System Dynamics Affecting the Cost and Cost-Effectiveness of EBI Implementation
This diagram visualizes the complex interactions and factors influencing resource use and efficiency of EBI implementation and sustainment to support CRC screening. This causal loop diagram illustrates the challenges and opportunities for clinics to maximize efficiency when implementing CRC screening EBIs in resource-constrained settings.
Understanding the diagram:
- S (Same): Arrows marked with “S” indicate that the two connected variables move in the same direction. For example, if one variable increases, the other also increases.
- O (Opposite): Arrows marked with “O” suggest that the variables move in opposite directions. If one variable increases, the other decreases.
- Solid Lines: These lines represent direct relationships or influences between variables.
- Dotted Lines: Dotted lines indicate indirect relationships or feedback loops that may require additional steps to influence the connected variables.
The diagram serves as a roadmap for understanding how various factors interact to influence clinics’ ability to implement EBIs that are cost-effective. By examining these loops, we can gain insights into the dynamics that clinics face in supporting their CRC screening strategies in the context of limited funding and other constraints.
Cited references for this diagram
During interviews, respondents discussed benefiting from increasing use of automated patient messaging systems while responding to COVID-19 to disseminate CRC screening reminders and establishing or streamlining FIT kit standing orders to reduce burden on heavily strained clinic staff.
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
A key lesson learned was the importance of having high-quality electronic systems in place that can support tracking patients in real time to avoid the need for large amounts of staff time to manually track patients for CRC screening programs. In this study, FQHCs with efficient tracking processes were able to implement client reminders that are likely to be highly cost-effective.
Conn ME, Kennedy-Rea S, Subramanian S, Baus A, Hoover S, Cunningham C, Tangka FKL. Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia. Health Promot Pract. 2020 Nov;21(6):891-897. doi: 10.1177/1524839920954164. Epub 2020 Sep 29. PMID: 32990048; PMCID: PMC7894066.
Additionally, given that these are rural FQHCs serving small populations (all but one FQHC provided FIT kits to less than 1,000 patients during the study), we would anticipate that their costs would be generally higher than high-volume centers, as they are unable to reap benefits from economies of scale (Subramanian et al., 2017; Trogdon et al., 2014)
Conn ME, Kennedy-Rea S, Subramanian S, Baus A, Hoover S, Cunningham C, Tangka FKL. Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia. Health Promot Pract. 2020 Nov;21(6):891-897. doi: 10.1177/1524839920954164. Epub 2020 Sep 29. PMID: 32990048; PMCID: PMC7894066.
Several grantees also discussed electronic health records as a facilitator for EBIs that involved sending information to clients and for the provider-oriented EBIs.
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.
However, most measures did not explicitly evaluate resources available as part of assessing capacity, a concept important in resource-limited settings, particularly FQHCs involved in the CRCCP.
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.
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.
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.
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.
Joseph DA, DeGroff A. The CDC Colorectal Cancer Control Program, 2009-2015. Prev Chronic Dis. 2019 Dec 5;16:E159. doi: 10.5888/pcd16.190336. PMID: 31808418; PMCID: PMC6896829.
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]]
Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis. 2022 May 19;19:E26. doi: 10.5888/pcd19.210258. PMID: 35588522; PMCID: PMC9165474.
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.
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.
Team-based care delivery models also supported sustainability. Team-based care has been shown to improve efficiency, effectiveness, value of care, and patient and provider experiences (Jesmin et al., 2012; Schottenfeld et al., 2016).
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.
Respondents noted the importance of planning for sustainability from initiation of CRCCP implementation by allocating funding to integrate EBIs into FQHC practices. Respondents reported that FQHCs were encouraged to apply funding in ways that directly supported sustainability, such as building infrastructure and long-term FQHC practices (e.g., EHR assessments, quality improvement [QI] efforts, and workflow adaptations) versus funding staff positions (e.g., patient navigators) requiring new funding sources once CRCCP funding ends.
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.
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.
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.
Programmatically, because EBIs can be resource-intensive to implement irrespective of the clinic size, our results support targeting larger clinics, when feasible and appropriate, where greater impact can be achieved.
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.
This most recent study adds further support to the analysis by the Community Preventive Services Task Force demonstrating that multicomponent interventions led to greater increases in CRC screening.[[13]] Increasing the number of EBIs may be accomplished through the integration of some EBIs such as provider reminders, patient reminders, and provider assessment and feedback into electronic health record systems. Although an upfront investment of time and resources may be needed to accomplish this, resource needs would then diminish, and the sustainability of the EBIs would be enhanced.
Sharma KP, Leadbetter S, DeGroff A. Characterizing clinics with differential changes in the screening rate in the Colorectal Cancer Control Program of the Centers for Disease Control and Prevention. Cancer. 2021 Apr 1;127(7):1049-1056. doi: 10.1002/cncr.33325. Epub 2020 Dec 10. PMID: 33301173; PMCID: PMC9242539.
The study findings support that clinics may choose to implement strategies best suited for their unique circumstances and availability of resources.
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.
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.
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.
EHR systems, a reservoir of patient information, were also found to be an important component of information sharing to support integrated implementation. Although investing in functional EHR systems can be costly, these systems are recognized as essential to enable optimal, integrated, patient-centered care because they allow for the abstraction of accurate clinical information.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
Participants discussed programs providing braided funding—a process that involves coordinating separate funding streams from multiple programs, such as CRCCP and NBCCEDP—to pay for common activities such as patient navigation across programs, provider reminders, and patient reminders (e.g., reminders for breast, cervical, and CRC screening).
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
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.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
Participants indicated that the clinic staff, particularly patient navigators and care coordinators, rely on the availability of accurate EHR reports to identify patients for screening and/or diagnostics for multiple chronic disease conditions. The clinic staff emphasized that the utility of the EHR data in supporting integrated implementation is contingent on data accuracy.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
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.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
The indirect overarching component (which is included in the total non-clinical cost) was about $475–$793 per person served for both types of programs. These costs are likely to decrease if programs expand to cover a large cohort of individuals as economies of scale are achieved.
Subramanian S, Tangka FKL, Hoover S, Royalty J, DeGroff A, Joseph D. Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening. Eval Program Plann. 2017 Jun;62:73-80. doi: 10.1016/j.evalprogplan.2017.02.007. Epub 2017 Feb 7. PMID: 28190597; PMCID: PMC5863533.
The total number of people screened had some effect on the direct clinical cost per person; programs with large populations screened had $292 lower costs than programs with small populations screened.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
Our findings expand on our prior analysis and use 5 years of data to quantify the presence of economies of scale — programs that screen a larger number of people had lower cost per person than programs that screen a smaller number of people.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
Our analysis of the activity-based cost data across 5 years of the CRCCP reveals potential economies of scale: programs with larger screening volume incurred a lower cost per person served than smaller-volume programs. Therefore, encouraging partnerships to foster large-scale programs could be more efficient than funding multiple small screening programs.
Subramanian S, Tangka FKL, Hoover S, Cole-Beebe M, Joseph D, DeGroff A. Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program. Prev Chronic Dis. 2019 Apr 25;16:E50. doi: 10.5888/pcd16.180338. PMID: 31022371; PMCID: PMC6513474.
In general, the cost per person screened at FQHCs participating in our study tended to be lowest in those with large target populations. All interventions have fixed implementation costs; therefore, the greater the number of persons screened because of the intervention, the lower the cost per person screened.
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.
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.
Subramanian S, Tangka FKL, Hoover S, DeGroff A. Integrated interventions and supporting activities to increase uptake of multiple cancer screenings: conceptual framework, determinants of implementation success, measurement challenges, and research priorities. Implement Sci Commun. 2022 Oct 5;3(1):105. doi: 10.1186/s43058-022-00353-8. PMID: 36199098; PMCID: PMC9532830.
In addition, prior studies of cancer programs have shown that these programmatic costs have significant economies of scale and, as program increase in size, the programmatic cost per person serves decreases substantially (Subramanian, Ekwueme, Gardner, Bapat, & Kramer, 2008; Trogdon, Ekwueme, Subramanian, & Crouse, 2014).
Tangka FKL, Subramanian S, Hoover S, Royalty J, Joseph K, DeGroff A, Joseph D, Chattopadhyay S. Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP). Eval Program Plann. 2017 Jun;62:67-72. doi: 10.1016/j.evalprogplan.2016.12.008. Epub 2016 Dec 12. PMID: 27989647; PMCID: PMC5840873.
As in previous evaluations of the cost of cancer screening programs,[[11, 12]] there appears to be some economies of scale associated with the cost of implementing the interventions. Specifically, Health Systems with larger numbers of patients were likely able to distribute fixed costs associated with the interventions across more patients. In other words, the interventions are effective in all settings but may be more costly to implement in smaller clinics based on their number of patients.
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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