Cited references for this diagram
Early results from our PY1 evaluation, including changes in screening rates, suggest the CRCCP is working; program reach was measurable and substantial, clinics enhanced EBIs in place or implemented new ones in clinics, and we observed an increase in the overall average screening rate.
To assist public health organizations in correctly implementing EBIs, it is critical to offer intervention-specific guidance in addition to general instructions on how to use evidence as suggested by the Interactive Systems Framework.14
Although there is fairly moderate use of EBIs among the grantees, greater adoption and quality implementation of these strategies may be realized through training and individualized TA provided by CDC, other cancer-focused national organizations, and cancer experts.
Meeting grantees’ training and TA needs is important, as their capacity to implement EBIs will be crucial for meeting the program goal of increasing levels of CRC screening population-wide.
A large proportion of CRCCP grantees expressed the need for training with regards to specific EBIs, especially system-level EBIs and provider-directed EBIs to promote CRC screening. Grantees rated these EBIs as more difficult to implement than client-oriented EBIs and fewer grantees reported use of these EBIs.
Individualized TA can provide more in-depth information on how to implement a specific strategy and also address unique contextual factors (e.g., organizational systems such as paper records or electronic medical records, staffing, resources). These combinations of prevention support reported by grantees match the common strategies found in other studies that promote the adoption of EBIs such as in person training and TA,29,30 packaged materials or recommendations,31,32 and conference calls.33 These prevention supports have been proven to increase adoptions of evidence-based prevention strategies.31,32,34
Many grantees also noted that working with providers was difficult given challenges in changing their systems or practice patterns and that they are often overburdened and have limited time.
Overall, more grantees used small media and client reminders, and rated these EBIs easier to implement than interventions to reduce structural barriers, provider reminders, or provider assessment and feedback, which have been shown to have greater impact on improving screening rates than either small media or client reminders.13
Grantees were most likely to implement small media (96%) and client reminders (75%) and also rated these as easier to implement than the other strategies (Table 2).
Adoption and implementation of the provider-oriented EBIs (provider reminders, provider assessment and feedback) and reduction of structural barriers was more gradual, with a few new grantees adopting these EBIs each year. There was also more turbulence in terms of implementation for these EBIs, with several grantees discontinuing them before 2015. Notable reasons for discontinuing EBIs were lack of resources, partners’ priorities, and ending of funding. These less-frequently implemented and sustained EBIs may have more potential to affect screening rates.15,16,21) However, provider-oriented EBIs are more complex, which can reduce implementation.22
We found that grantees’ reasons for discontinuing an EBI most often related to capacity issues. Context also may be an important factor. For instance, electronic health records systems were identified as a barrier to EBI implementation. This suggests that sustainability in clinic settings may be challenged when electronic health records systems cannot support integration of client and provider reminder systems as well as provider assessment and feedback reports.
Across EBIs, many grantees mentioned successful partnerships as key facilitators to implementation. In many cases, grantees’ partners led implementation activities; in others, they provided connections, materials, or staff time.
We found that most grantees adopted and implemented small media and client reminders early in the study period; most grantees also maintained these 2 EBIs through 2015. These client-oriented EBIs are often considered simpler to implement than the provider-oriented EBIs because they do not necessarily require partnerships with health systems or modifications to electronic health records.
The EBIs listed above vary in terms of complexity and partnerships required. The client-oriented EBIs could be implemented directly by grantees or by their clinical or community partners. The provider-oriented EBIs may be more complex from the perspective of a typical grantee organization because they require 1 or more clinic or health system partners. In addition, implementing provider reminders or provider assessment and feedback may require working with or adapting electronic health records.
Implementation readiness — an organization’s combined capacity, commitment, and willingness to implement a new program, policy, or practice — facilitates implementation success.16–18 Because public health resources are limited, identifying a clinic’s readiness to successfully implement and sustain interventions, as well as gaps in clinic resources or practices that need to be addressed before implementation, is critical. Such assessment practices can guide clinics to select interventions with the greatest potential for long-term sustainability, and in turn help maximize the impact of public health spending, optimize clinic success, reduce cancer disparities, and improve population health.
Key informants who represented current and previous recipients generally said that mixed-methods assessments conducted before implementation prepared them to use results to inform development of tailored action plans for EBI implementation and technical assistance with partners.
Program planners should carefully consider the potential reach and infrastructure costs of direct CRC screening services given available sources of funding, the size of the potential target population relative to the capacity and funding of program implementers, the selection of EBIs that maximize program effects while minimizing costs, and the ability of program implementers to leverage the resources of other public and nonpublic health organizations to facilitate implementation.
The authors found that most grantees implemented and maintained client-oriented EBIs such as client reminders and small media. Grantees considered these EBIs easier to implement than provider-oriented EBIs or reduction of structural barriers.
Third, we found that grantees allocated a disproportionate amount of their awards toward interventions with limited evidence for their effectiveness (eg, mass media), and grantees found client-oriented interventions, such as client reminders and small media, easier to implement.
Second, each EBI was modified to fit the needs and staffing model for this health system, which may have improved efficiency and impact.
This study demonstrates that EBIs to increase CRC screening may be effective in clinics with fewer resources that serve populations who have poor access to or under-utilize health care services. Tailoring the EBIs to the needs and capacity of participating clinics may have been key to their effectiveness.
Using a participatory implementation approach, a pre-implementation assessment was conducted to assess readiness for implementation of EBIs in order to increase CRC screening uptake.
First, the pre-implementation process allowed the awardee to determine the infrastructure needs and their capacity to implement EBIs.
Third, the effectiveness of these EBIs on CRC order and screening uptake was significant across all populations served and independent of insurance status.
Findings from these surveys help in understanding and prioritizing the needs of public health agencies and their community partners in implementing evidence-based approaches to increase CRC screening. These needs might best be met by a multilevel approach that includes developing systems to help practice agencies promote long-lasting protective interventions (ie, screening), using effective and audience-specific information and education.17
National programs like CRCCP must balance the desire for a common campaign identity with the need to help state and local agencies customize resources to best serve their local mix of constituents. For example, CRCCP leaders and their partners must choose specific types of small media and client reminders and adapt them for different settings and populations.
Another explanation is that some EBIs and SAs can be integrated into clinical practice through clinics’ electronic health records systems. For example, by using data from electronic health records, patient reminder letters can be generated and personalized with each patient’s name and address, preferred language, the name of the patient’s primary care provider, and their history of CRC screening (eg, type and time of most recent test). Although it takes resources to program electronic health records and to set up these strategies initially, clinic health information technology and automated calling and texting systems can support implementation.27,28
Uptake may be facilitated through technical and financial support provided by CRCCP awardees and integration of these strategies into clinic electronic health records systems.
Among clinics that had EBIs and SAs in place by the end of each year, most considered those EBIs and SAs fully integrated into health systems or clinic operations and sustainable with or without CRCCP resources, especially in years 2 and 3 (Table 4).
Sustainability and integration into clinic operations during the 3-year period increased most for activities that largely focused on providers, such as provider reminder systems, an increase of 14 percentage points from 79% in year 1 to 93% in year 3. Similarly, full integration of provider assessment and feedback increased 27 percentage points, from 69% to 96% of clinics; full integration of professional development or provider education increased by 16 percentage points, from 76% to 92% of clinics, followed by full integration of small media for an increase of 11 percentage points from 81% to 92% of clinics.
Specifically, CRCCP grantees were twice as likely as nongrantees to use small media and 3 to 4 times more likely to use client reminders to increase community awareness of CRC screening guidelines and to increase community demand for CRC screening. The frequent use of small media and client reminders may be due to their ease of implementation and the fact that the CRCCP grantees are able to take the lead on the implementation of these activities.
CRCCP grantees and nongrantees similarly rated the ease or difficulty of implementing Community Guide-recommended interventions. On a 5-point scale (1= very difficult, 2 = somewhat difficult, 3 = neutral, 4 = somewhat easy, 5 = very easy), patient-directed interventions were rated from 3.2 (reducing structural barriers) to 3.8 (small media), and provider-directed interventions were rated from 3.1 (provider assessment and feedback) to 3.5 (provider reminders) for all organizations combined.
Fewer grantees used interventions directed at health care providers, such as provider assessment and feedback and provider reminders, which usually require collaboration with a partner organization.
Given the limited nature of public health funding cycles, it is critical that health systems change efforts not only work to achieve population health outcomes but also dedicate time and resources to integrating effective strategies for increased likelihood of long-term sustainability. Integrating EBIs and SAs into existing FQHC processes proved essential to CRCCP sustainability.
Awardees also provided ongoing support to overcome the complexity of many EHR systems, a challenge among FQHCs that stalled their ability to optimize data management and reporting features.
Effective EHR use is foundational for institutionalizing EBIs and SAs and supports high-quality data management and reporting, thereby making continued implementation more feasible.
Study results support the need for awardees and implementation partners to provide health systems and clinics with tailored TA for their specific EHR system throughout the funding cycle to support EHR optimization for CRC screening, including avoiding common pitfalls (e.g., improper data entry, overly complex systems, changing EHRs) in ever-changing health care environments.
Respondents in this study largely discussed the utility of integration within existing team-based care structures. Clinics without team-based structures in place prior to implementing a CRC health systems change effort may require additional support as they adjust to providing integrated services.
Respondents described aspects of FQHC communication and culture that bolstered early implementation, including the importance of identifying champions from varied roles (e.g., QI expert, physician) during FQHC recruitment or early implementation who could help prioritize CRC screening within FQHCs.
Whether champions served in leadership or other FQHC staff roles, their ongoing promotion of EBIs and SAs, and clear and consistent leadership support, was paramount to prioritize these efforts. CRC screening champions have been associated with increased CRC screening rates and higher overall clinic performance.
Integrating evidence-based processes into multiple aspects of clinic operations—including funding allocation, staff training, care delivery models, and EHR systems—can be complex but improve the prospect of sustainability.
Our findings highlight the essential role of awardees in using readiness assessment findings to “meet clinics where they are” and mobilize strength-based partnerships—a critical tenet of public health service—to identify opportunities to integrate EBIs and SAs into existing clinic protocols.
A key theme across all awardees was the essential nature of coordinating EBIs and SAs with existing FQHC practices to expand reach of clinics’ prevention efforts and increase efficiency.
Respondents from three awardees described working with FQHCs to formally assess their implementation readiness during the application process or initial site visits. Although the scope of assessments and definitions of “readiness” varied, awardees generally examined: (a) CRC burden and risk, (b) CRC screening practices, (c) experience implementing similar EBIs and SAs, (d) effectively engaging partners, (e) current EHR systems, including problems with EHRs related to EBI implementation or measuring CRC screening rates, and (f) CRC screening rates. FQHC staff, in collaboration with awardees, used assessment results to inform selection of EBIs and SAs for implementation and address EHR issues.
That non-FQHC clinics had higher screening rates than FQHCs may highlight the fact that the latter serve patients who are more disadvantaged with lower screening rates than other populations included in this study. Similarly, our finding that clinics with larger patient populations had higher screening rates suggests availability of resources and clinic capacity may underlie their performance.
All four priority EBIs were positively associated with clinic screening rates with statistical significance (Table 3).
Clinic champions, also found to be more common in Q4 clinics, can play an important role in facilitating EBI implementation.
The EBIs used in the CRCCP can be implemented differently, and practitioners can benefit from ensuring that the interventions are appropriate for their unique clinic population and context.
The study findings support that clinics may choose to implement strategies best suited for their unique circumstances and availability of resources.
This combined variable indicates that if a clinic directed any additional resources toward a specific EBI, regardless of whether the EBI was already in place or implemented new, then screening rates increased.
Having a clinic CRC screening champion was among the most important program components associated with increased CRC screening both in this analysis and in the earlier analysis.10 The literature supporting the importance of champions in public health program effectiveness continues to grow.23 Champions may be critical to improving CRC screening practice by promoting and prioritizing screening efforts, supporting sustained practice improvements guided by a vision and commitment, and making sure that individual practice changes fit together into a meaningful whole.2
Overall, the average clinic-level screening rate increased by 11.7 percentage points from baseline (33.5%) to PY2 (45.2%).
To determine appropriate EBIs and ensure clinic capacity to implement them, programs can conduct readiness assessments of clinics prior to implementation. However, clinics may lack resources to implement all available interventions, and may strategically choose EBIs that are less resource intensive.
A study of the first CRCCP from 2009 to 2015 found that many clinics were more likely to put in place EBIs that were easier to implement, and thus opportunities may exist to further increase screening uptake by facilitating implementation of other EBIs. (Hannon et al., 2013)
Average clinic CRC screening rates generally increased when clinics implemented or enhanced any number EBIs or SAs compared to clinics that did not newly implement or enhance any EBIs/SAs.
The ability to access and share accurate patient information, including EHR data, was identified as another factor supporting readiness for integrated implementation of CRC screening.
Similarly, data sharing among quality improvement (QI) teams promotes a collective understanding of where clinics stand on the delivery of health promotion activities that can foster understanding of opportunities to potentially improve these metrics through integrated implementation.
At the clinic level, a team-based approach was found to support staff ability to integrate implementation of EBIs and supporting activities to promote CRC screening with other patient care activities.
Across all interventions and multicomponent interventions, increases in the overall FQHC screening uptake ranged from 4.9 to 26.7 percentage points. Each FQHC implemented interventions that increased CRC screening among its low-income population.
Third, staff turnover was seen as a major barrier to both implementation success and sustainability. The burden consists of the need to train new staff, the loss of institutional knowledge, and the need to rebuild informal communication channels that are often required for coordination of multilevel interventions and supporting activities.
Fifth, the capacity and capabilities of the electronic medical records to support cancer screening by quickly identifying patients due for screening, tracking screening completion, and generating provider-level summary screening uptake were seen as critical for successful implementation and maintenance.
The key determinants of successful implementation [of integrating EBIs across cancer screening] that were deemed to have the most impact (average score of 3.0) were complexity of the intervention, implementation cost, overall implementation climate, and ensuring appropriate individuals were involved in the implementation process. Higher levels of complexity and cost were negatively related to implementation success.
We found that the complexity of the intervention, cost of delivering the intervention and supporting activities, implementation climate at the clinic, and engaging appropriate team members in the implementation process were key determinants of implementation success.
Given the large variation across grantees on screening promotion interventions, a systematic assessment of needs matched with promotion activities, and their impact on screening rates, could provide better guidance on optimal resource allocation.
Small media was often used at the initiation of the program, and this could be due to the availability of small media materials20 and tools that grantees could easily tailor.
Across the 5 years, grantees allocated more resources to small media in the first year of the program. Small media might be easier to implement while other interventions might require more planning; CDC and other organizations provide small media materials that grantees can easily tailor to implement targeted campaigns.
Integrating CRC interventions into the standard operating procedures and work flow processes of health systems, when possible, will contribute to sustainability (e.g., incorporating client reminders into the electronic health record system so that reminders are automated).
Screening uptake increased across all the sites during the implementation period, ranging from 7.1 to 18.9 % points.
According to ID-DHW stakeholders, there were several program elements that facilitated the initiation of cancer screening prevention integration after their planning phase. The first of these elements was a pre-implementation checklist for health clinics to determine their capacity for implementing each type of cancer screening and undertake specific enhancements for coordinated and integrated screenings to be initiated.
Grantees also reported a moderate need for training regarding many aspects of EBI implementation, from identifying EBIs and assessing organizational capacity to implement selected EBIs to conducting a process and outcome evaluation.
