Community health centers (CHCs) do not have the office systems in place to ensure that every eligible patient is offered colorectal cancer (CRC) screening. CHCs need evidence-based approaches to implementing office- system changes that take into account the substantial resource, staffing, and time constraints they face. Until this need is met, screening rates will likely remain low, putting thousands of minority, low-income, and uninsured patients at unnecessary risk. The long-term goal is to improve CRC screening rates in CHCs and in doing so, reduce cancer health disparities. The objective of this R21 application is to test the feasibility of an evidence-informed implementation strategy that combines an office-systems toolkit and outreach education. The rationale for the project, supported by preliminary data, is that CHCs want to increase CRC screening rates, but need evidence-based tools that-with training and technical assistance-they can implement and maintain more efficiently and effectively. Although the proposed implementation strategy is evidence-informed and promising, it is novel in the CHC setting and needs to be feasibility-tested in this challenging organizational context prior to larger-scale evaluation. This research study will pursue three specific aims: (1) assess the extent of implementation of office-system changes that promote CRC screening, using the CRC toolkit and outreach specialist;(2) estimate the costs of implementing and maintaining office-system changes, using the CRC toolkit and outreach specialist;(3) conduct a limited test of the office-system changes implemented, using the CRC toolkit and outreach specialist. For the first aim, interviews and surveys informed by a conceptual model of innovation implementation will be used to examine the number and type of office-system tools that CHCs implement, the amount and type of outreach support provided, and organizational factors predictive of implementation effectiveness. For the second aim, process maps, activity logs, and unit prices will be used to estimate the cost of implementing changes to the CRC screening process and calculate net benefit by comparing the costs and revenues of CRC screening processes pre- and post-implementation. For the third aim, changes in documented physician recommendation for screening and completed screenings will be assessed through chart audits pre- and post-implementation. This project is innovative in that it attempts to shift the current paradigm for making systems-based changes in CHCs from the quality improvement collaborative approach to one that promises greater feasibility given CHCs'resource constraints. The proposed research is significant because of its potential to improve public health by increasing CRC screening rates in minority, low income and insured populations and its contribution to scientific knowledge about how the office- systems approach works.
The proposed project is relevant to public health because an effective strategy for implementing office-system changes that uses fewer resources and achieves higher screening rates than current systems-based approaches could lead to the prevention or early detection of thousands of colorectal cancer cases annually among minority, low-income, and uninsured patients. Thus, the proposed research is relevant to the part of the NCI's mission to conduct and fund research that improves early detection and diagnosis and reduces cancer disparities.