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How does funding for EBIs impact EBI sustainability?

The bigger balancing loop (B3) highlights how EBI sustainability connects to funding stability. Once again, if an EBI is sustainable long-term, the clinic’s ability to effectively use EBIs increases,[[139]] and so does CRC screening.[[75, 201, 305, 332, 354, 407, 445]]

However, if overall clinic CRC screening increases, a clinic’s ability to document the need for funding to improve screening decreases. As a result, the clinic’s funding potential decreases along with the funding stability for EBIs.[[266]] A lack of funding stability for EBIs decreases their sustainability over time.[[114, 127, 153, 155]]

Diagram 2.0 Overview

Sustaining EBIs for Long-Term CRC Screening

Diagram 2.1

CRC Screening & EBI Sustainability

Diagram 2.2

Funding’s Role in EBI Sustainability

Diagram 2.3

Sustainability in Early EBI Implementation

Diagram 2.4

Factors Supporting Early EBI Sustainability

Diagram 2.5

EBI Selection, Implementation & Sustainability

Diagram 2.6

Key Relational Factors in EBI Sustainability

Diagram 2.7 Conclusion

Recommendations for Sustaining EBIs and EBI Impact

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Variables move in opposite directions

Variables move in the same direction

Research evidence supports relationship

Research team hypothesizes relationship

How does funding for EBIs impact EBI sustainability?

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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.

DeGroff A, Sharma K, Satsangi A, Kenney K, Joseph D, Ross K, Leadbetter S, Helsel W, Kammerer W, Firth R, Rockwell T, Short W, Tangka F, Wong F, Richardson L. Increasing Colorectal Cancer Screening in Health Care Systems Using Evidence-Based Interventions. Prev Chronic Dis. 2018 Aug 9;15:E100. doi: 10.5888/pcd15.180029. PMID: 30095405; PMCID: PMC6093266.

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114

Other frequently mentioned barriers [to EBI implementation] included getting approvals or arranging contracts with partner agencies and concerns about funding and sustainability.

Hannon PA, Maxwell AE, Escoffery C, Vu T, Kohn MJ, Gressard L, Dillon-Sumner L, Mason C, DeGroff A. Adoption and Implementation of Evidence-Based Colorectal Cancer Screening Interventions Among Cancer Control Program Grantees, 2009-2015. Prev Chronic Dis. 2019 Oct 10;16:E139. doi: 10.5888/pcd16.180682. PMID: 31603404; PMCID: PMC6795067.

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127

Few grantees provided reasons for discontinuing specific EBIs. Of those who did, a common reason given (especially in program year 6) was the end of funding to sustain the EBI.

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139

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.

Hohl SD, Melillo S, Vu TT, Escoffery C, DeGroff A, Schlueter D, Ross LW, Maxwell AE, Sharma KP, Boehm J, Joseph D, Hannon PA. Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics. Prev Chronic Dis. 2022 May 12;19:E25. doi: 10.5888/pcd19.210395. PMID: 35550244; PMCID: PMC9109642.

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153

Only 58% of clinics reported having good leadership support to maintain implementation of CRC screening EBIs, including mailed fecal testing. Fewer clinics reported having funding stability, organizational capacity, or the ability to adapt practices to ensure sustainability of EBI implementation. Although the CRCCP and other programs are designed with sustainability as a long-term goal, sustainability is an on-going challenge in clinics with limited resources and changing priorities that are reflected in budget changes.

Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.

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155

Over half of clinics (58%) reported having leadership support to a great/very great extent to sustain the implementation of EBIs after the CRCCP screening initiative ends, but only 29% reported having a great/very great extent of funding stability in place to do so (Table 7).

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201

Third, the effectiveness of these EBIs on CRC order and screening uptake was significant across all populations served and independent of insurance status.

Kim KE, Tangka FKL, Jayaprakash M, Randal FT, Lam H, Freedman D, Carrier LA, Sargant C, Maene C, Hoover S, Joseph D, French C, Subramanian S. Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago. Health Promot Pract. 2020 Nov;21(6):884-890. doi: 10.1177/1524839920954162. Epub 2020 Sep 29. PMID: 32990041; PMCID: PMC7894065.

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266

Initial investments may discontinue following short-term improvements to population health outcomes, after which implementation of evidence-based practices can diminish, resulting in loss of preliminary program gains (Birken et al., 2020; Buchanan et al., 2005; Stirman et al., 2012).

Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.

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305

All four priority EBIs were positively associated with clinic screening rates with statistical significance (Table 3).

Sharma KP, DeGroff A, Scott L, Shrestha S, Melillo S, Sabatino SA. Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations. Prev Med. 2019 Sep;126:105774. doi: 10.1016/j.ypmed.2019.105774. Epub 2019 Jul 15. PMID: 31319118; PMCID: PMC6904949.

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332

Overall, the average clinic-level screening rate increased by 11.7 percentage points from baseline (33.5%) to PY2 (45.2%).

Sharma KP, DeGroff A, Maxwell AE, Cole AM, Escoffery NC, Hannon PA. Evidence-Based Interventions and Colorectal Cancer Screening Rates: The Colorectal Cancer Screening Program, 2015-2017. Am J Prev Med. 2021 Sep;61(3):402-409. doi: 10.1016/j.amepre.2021.03.002. Epub 2021 May 14. PMID: 33994253; PMCID: PMC11008572.

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354

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.

Sharma KP, DeGroff A, Hohl SD, Maxwell AE, Escoffery NC, Sabatino SA, Joseph DA. Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program. Prev Med Rep. 2022 Jul 9;29:101904. doi: 10.1016/j.pmedr.2022.101904. PMID: 35864930; PMCID: PMC9294188.

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407

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.

Subramanian S, Tangka FKL, Hoover S. Role of an Implementation Economics Analysis in Providing the Evidence Base for Increasing Colorectal Cancer Screening. Prev Chronic Dis. 2020 Jun 25;17:E46. doi: 10.5888/pcd17.190407. PMID: 32584756; PMCID: PMC7316416.

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445

Screening uptake increased across all the sites during the implementation period, ranging from 7.1 to 18.9 % points.

Tangka FKL, Subramanian S, Hoover S, Lara C, Eastman C, Glaze B, Conn ME, DeGroff A, Wong FL, Richardson LC. Identifying optimal approaches to scale up colorectal cancer screening: an overview of the centers for disease control and prevention (CDC)'s learning laboratory. Cancer Causes Control. 2019 Feb;30(2):169-175. doi: 10.1007/s10552-018-1109-x. Epub 2018 Dec 14. PMID: 30552592; PMCID: PMC6382575.

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