Protocol for an interview-based method for mapping mental models using causal-loop diagramming and realist interviewing

Causal-loop diagramming, a method from system dynamics, is increasingly used in evaluation to describe individuals' understanding of how policies or programs do or could work ("mental models"). The use of qualitative interviews to inform model development is common, but guidance for how to design and conduct these interviews to elicit causal information in participant mental models is scant. A key strength of semi-structured qualitative interviews is that they let participants speak freely; they are not, however, designed to elicit causal information. Moreover, much of human communication about mental models-particularly larger causal structures such as feedback loops-is implicit. In qualitative research, part of the skill and art of effective interviewing and analysis involves listening for information that is expressed implicitly. Similarly, a skilled facilitator can recognize and inquire about implied causal structures, as is commonly done in group model building. To standardize and make accessible these approaches, we have formalized a protocol for designing and conducting semi-structured interviews tailored to eliciting mental models using causal-loop diagramming. We build on qualitative research methods, system dynamics, and realist interviewing. This novel, integrative method is designed to increase transparency and rigor in the use of interviews for system dynamics and has a variety of potential applications.

"It's Like Finding Your Way Through the Labyrinth": a Qualitative Study of Veterans' Experiences Accessing Healthcare

BACKGROUND

The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans.

OBJECTIVE

To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans.

DESIGN

Qualitative descriptive design.

PARTICIPANTS

United States (US) Veterans in Northwestern states engaged in VA and/or community care.

APPROACH

Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis.

KEY RESULTS

We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation.

CONCLUSIONS

Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans-especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare.

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

PURPOSE

Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion.

METHODS

We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes.

FINDINGS

We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift.

CONCLUSIONS

These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.

METHODS

SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.

DISCUSSION

Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Primary Care Providers Experiences Implementing Low-Dose Computed Tomography Recommendations for Lung Cancer Screening

PURPOSE

Describe primary care providers' (PCPs) barriers and facilitators to implementation of lung cancer screening programs in rural settings.

METHODS

We conducted qualitative interviews with PCPs practicing in rural Oregon from November 2019 to September 2020. The interview questions and analytic framework were informed by the 2009 Consolidated Framework for Implementation Research. We used inductive and deductive approaches for analysis.

RESULTS

We interviewed 15 key participants from 12 distinct health care systems. We identified several Consolidated Framework for Implementation Research factors affecting lung cancer screening implementation. 1) Most PCPs did not have workflows to assist in discussing screening and relied on their memory and knowledge of the patient's history to prompt discussions. PCPs supported screening and managed the patient throughout the process. 2) PCPs reported several patient-level barriers, including geographic access to lung cancer screening scans and out-of-pocket cost concerns. 3) PCPs reported that champions are necessary to create opportunities for local practices to adopt lung cancer screening programs.

CONCLUSIONS

Rural-practicing PCPs were supportive of lung cancer screening, however workflow processes, time challenges, and patient-reported barriers remain impediments to improved screening in their clinics. We identified several areas for improvement in lung cancer screening implementation in rural primary care practices, ranging from designing clinic workflows and processes to designating clinic staff to support referral, screening, and follow-up care for patients.

Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation

BACKGROUND

Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees.

OBJECTIVES

To address disparities, we used a modified community engagement approach, Boot Camp Translation (BCT). Research partners, an advisory board, and the rural community informed messaging about CRC outreach and a mailed fecal immunochemical test program.

METHODS

Eligible rural patients (English-speaking and ages 50-74) and clinic staff involved in patient outreach participated in a BCT conducted virtually over two months. We applied qualitative analysis to BCT transcripts and field notes.

RESULTS

Key themes included: the importance of directly communicating about the seriousness of cancer, leveraging close clinic-patient relationships, and communicating the test safety, ease, and low cost.

CONCLUSIONS

Using a modified version of BCT delivered in a virtual format, we were able to successfully capture community input to adapt a CRC outreach program for use in rural settings. Program materials will be tested during a pragmatic trial to address rural CRC screening disparities.

Engaging stakeholders in the use of an interactive simulation tool to support decision-making about the implementation of colorectal cancer screening interventions

PURPOSE

We aimed to understand how an interactive, web-based simulation tool can be optimized to support decision-making about the implementation of evidence-based interventions (EBIs) for improving colorectal cancer (CRC) screening.

METHODS

Interviews were conducted with decision-makers, including health administrators, advocates, and researchers, with a strong foundation in CRC prevention. Following a demonstration of the microsimulation modeling tool, participants reflected on the tool's potential impact for informing the selection and implementation of strategies for improving CRC screening and outcomes. The interviews assessed participants' preferences regarding the tool's design and content, comprehension of the model results, and recommendations for improving the tool.

RESULTS

Seventeen decision-makers completed interviews. Themes regarding the tool's utility included building a case for EBI implementation, selecting EBIs to adopt, setting implementation goals, and understanding the evidence base. Reported barriers to guiding EBI implementation included the tool being too research-focused, contextual differences between the simulated and local contexts, and lack of specificity regarding the design of simulated EBIs. Recommendations to address these challenges included making the data more actionable, allowing users to enter their own model inputs, and providing a how-to guide for implementing the simulated EBIs.

CONCLUSION

Diverse decision-makers found the simulation tool to be most useful for supporting early implementation phases, especially deciding which EBI(s) to implement. To increase the tool's utility, providing detailed guidance on how to implement the selected EBIs, and the extent to which users can expect similar CRC screening gains in their contexts, should be prioritized.

System dynamics modeling for cancer prevention and control: A systematic review

Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.

Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost.

METHODS

PROMPT was a pragmatic, stepped-wedge, cluster-randomized effectiveness trial of mailed FIT outreach. Participants in the standard condition were mailed a FIT and received live telephone reminders to return it. Participants in the enhanced condition also received a tailored advance notification (text message or live phone call) and two automated phone call reminders. The primary outcome was 6-month FIT completion; secondary outcomes were any colorectal cancer screening completion at 6 months, implementation, and program costs.

RESULTS

The study included 27,585 participants (80% ages 50-64, 82% Hispanic/Latino; 68% preferred Spanish). A higher proportion of enhanced participants completed FIT at 6 months than standard participants, both in intention-to-treat [+2.8%, 95% confidence interval (CI; 0.4-5.2)] and per-protocol [limited to individuals who were reached; +16.9%, 95% CI (12.3-20.3)] analyses. Text messages and automated calls were successfully delivered to 91% to 100% of participants. The per-patient cost for standard mailed FIT was $10.84. The enhanced program's text message plus automated call reminder cost an additional $0.66; live phone calls plus an automated call reminder cost an additional $10.82 per patient.

CONCLUSIONS

Adding advance notifications and automated calls to a standard mailed FIT program boosted 6-month FIT completion rates at a small additional per-patient cost.

IMPACT

Enhancements to mailed FIT outreach can improve colorectal cancer screening participation. Future research might test the addition of educational video messaging for screening-naïve adults.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making

INTRODUCTION

Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making.

METHODS

We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach.

RESULTS

Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate.

CONCLUSIONS

Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans

BACKGROUND

The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes.

OBJECTIVE

To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery.

DESIGN

Phenomenological qualitative study.

PARTICIPANTS

Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest.

APPROACH

Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis.

KEY RESULTS

We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services.

CONCLUSIONS

Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.

Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative

BACKGROUND

Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative.

METHODS

We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation.

RESULTS

ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs.

CONCLUSIONS

Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.

Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies.

METHODS

We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations).

RESULTS

One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation.

CONCLUSION

Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.

Before and During Pandemic Telemedicine Use: An Analysis of Rural and Urban Safety-Net Clinics

INTRODUCTION

Differences in face-to-face and telemedicine visits before and during the COVID-19 pandemic among rural and urban safety-net clinic patients were evaluated. In addition, this study investigated whether rural patients were as likely to utilize telemedicine for primary care during the pandemic as urban patients.

METHODS

Using electronic health record data from safety-net clinics, patients aged ≥18 years with ≥1 visit before or during the COVID-19 pandemic, March 1, 2019-March 31, 2021, were identified, and trends in face-to-face and telemedicine (phone and video) visits for patients by rurality using Rural‒Urban Commuting Area codes were characterized. Multilevel mixed-effects regression models compared service delivery method during the pandemic by rurality.

RESULTS

Included patients (N=1,015,722) were seen in 446 safety-net clinics: 83% urban, 10.3% large rural, 4.1% small rural, and 2.6% isolated rural. Before COVID-19, little difference in the percentage of encounters conducted face-to-face versus through telemedicine by rurality was found. Telemedicine visits significantly increased during the pandemic by 27.2 percentage points among patients in isolated rural areas to 52.3 percentage points among patients in urban areas. Rural patients overall had significantly lower odds of using telemedicine for a visit during the pandemic than urban patients.

CONCLUSIONS

Despite the increased use of telemedicine in response to the pandemic, rural patients had significantly fewer telemedicine visits than those in more urban areas. Equitable access to telemedicine will depend on continued reimbursement for telemedicine services, but additional efforts are warranted to improve access to and use of health care among rural patients.

Assessing Intersectional Disparities in Cervical Cancer Screening by Disability Status, Race, and Ethnicity

Introduction

Separate bodies of research have studied disparities by disability status and by race or ethnicity in receipt of cervical cancer screening. Much less is known about how these disparities intersect. The purpose of this study was to evaluate disparities in compliance with the U.S. Preventive Services Task Force guidelines for Pap testing in age-eligible women at the intersection of disability and race or ethnicity.

Methods

We conducted cross-sectional analyses of the Medical Expenditure Panel Survey Household Component deidentified public data files pooled for years 2007-2016, using a modified Poisson regression analysis to compute prevalence ratios for being up to date with Pap testing by disability status and race or ethnicity. We also calculated predicted marginal proportions adjusting for demographic and socioeconomic covariates.

Results

The analytic sample included 68,507 women with nonmissing covariates; 15.6% had a disability. Overall, the proportion current with Pap testing was significantly lower among women with disabilities than among those without disabilities (82.1% vs 88.6%, p<0.0001). Furthermore, within each racial and ethnic group, women with disabilities were less likely than those without disabilities to be current with Pap testing. In adjusted analyses, prevalence ratios for White women with disabilities (adjusted prevalence ratio=0.94; 95% CI=0.92, 0.96) and other race women with and without disabilities (adjusted prevalence ratio=0.91; 95% CI=0.86, 0.95 and adjusted prevalence ratio=0.91; 95% CI=0.89, 0.95, respectively) were significantly below those for the reference group of White women without disabilities. Hispanic women with disabilities did not differ significantly from White women without disabilities, and Black women with disabilities had significantly higher adjusted prevalence ratios than White women without disabilities (adjusted prevalence ratio=1.07; 95% CI=1.05, 1.09). When taking covariates into account, the proportion of Black women with disabilities current with screening was only slightly lower than the estimated proportion for Black women without disabilities (92% vs 93%). The gap in screening between White women with and without disabilities narrowed somewhat (from 9 percentage points to 4 percentage points) but remained significant.

Conclusions

Our results extend previous research focused separately on disability or race and ethnicity. Women with disabilities in all racial and ethnic groups fell short of Healthy People 2020 goals for cervical cancer screening.

Primary Care Research Is Hard to Do During COVID-19: Challenges and Solutions

Conducting research in primary care during the COVID-19 pandemic is hard, due to baseline stresses on primary care, which have been compounded by the pandemic. We acknowledge and validate primary care researchers' frustrations. Using our experience on over 15 individual projects during the pandemic we identify 3 key challenges to conducting primary care research: (1) practice delivery trickle-down effects, (2) limited/changing resources and procedures for research, and (3) a generally tense milieu in US society during the pandemic. We present strategies, informed by a set of questions, to help researchers decide how to address these challenges observed during our studies. In order to overcome and grow from these challenging times we encourage normalization and self-compassion, and encourage researchers and funders to embrace pragmatic and adaptive research designs as the circumstances with COVID-19 evolve over time.

"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

Assessing the impact of multicomponent interventions on colorectal cancer screening through simulation: What would it take to reach national screening targets in North Carolina?

Healthy People 2020 and the National Colorectal Cancer Roundtable established colorectal cancer (CRC) screening targets of 70.5% and 80%, respectively. While evidence-based interventions (EBIs) have increased CRC screening, the ability to achieve these targets at the population level remains uncertain. We simulated the impact of multicomponent interventions in North Carolina over 5 years to assess the potential for meeting national screening targets. Each intervention scenario is described as a core EBI with additional components indicated by the "+" symbol: patient navigation for screening colonoscopy (PN-for-Col+), mailed fecal immunochemical testing (MailedFIT+), MailedFIT+ targeted to Medicaid enrollees (MailedFIT + forMd), and provider assessment and feedback (PAF+). Each intervention was simulated with and without Medicaid expansion and at different levels of exposure (i.e., reach) for targeted populations. Outcomes included the percent up-to-date overall and by sociodemographic subgroups and number of CRC cases and deaths averted. Each multicomponent intervention was associated with increased CRC screening and averted both CRC cases and deaths; three had the potential to reach screening targets. PN-for-Col + achieved the 70.5% target with 97% reach after 1 year, and the 80% target with 78% reach after 5 years. MailedFIT+ achieved the 70.5% target with 74% reach after 1 year and 5 years. In the Medicaid population, assuming Medicaid expansion, MailedFIT + forMd reached the 70.5% target after 5 years with 97% reach. This study clarifies the potential for states to reach national CRC screening targets using multicomponent EBIs, but decision-makers also should consider tradeoffs in cost, reach, and ability to reduce disparities when selecting interventions.

Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming

Background

Rural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy influences. Federal policies over the last decade have relaxed requirements for some veterans to receive primary care services from community providers through their VA benefits, known as community care.

Methods

We used a participatory systems mapping approach involving causal-loop diagramming to identify interrelationships between variables underlying challenges to veteran access to primary care and potential opportunities for change—known as leverage points in systems science. Our methods involved a secondary analysis of semi-structured qualitative interviews with rural veterans, VA staff, non-VA clinic staff and providers who serve rural veterans, and veteran service officers (VSOs) in the Northwest region of the US, followed by a two-part participatory modeling session with a study advisory board. We then applied Meadows’s leverage point framework to identify and categorize potential interventions to improve rural veteran access to primary care.

Results

The final model illustrated challenges at the veteran, clinic, and system levels as experienced by stakeholders. Main components of the diagram pertained to the choice of VA or non-VA primary care, veteran satisfaction with the VA, enrollment in VA benefits and other insurance, community care authorization, reimbursement of non-VA care, referrals to specialty care, record sharing and communication between VA and non-VA providers, institutional stability of the VA, and staffing challenges. Fourteen interventions, including administrative and communications changes, were identified by analyzing the model using the leverage points framework.

Conclusions

Our findings illustrate how challenges rural veterans face accessing health care are interconnected and persist despite recent changes to federal law pertaining to the VA health care system in recent years. Systems mapping and modeling approaches such as causal-loop diagramming have potential for engaging stakeholders and supporting intervention and implementation planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08318-2.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study

Background

Unhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care.

Methods

ANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center—state leaders in Medicaid health system transformation—SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework.

Discussion

This study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

BACKGROUND

Markov models are used in health research to simulate health care utilization and disease states over time. Health phenomena, however, are complex, and the memoryless assumption of Markov models may not appropriately represent reality. This tutorial provides guidance on the use of Markov models of different orders and stratification levels in health decision-analytic modeling. Colorectal cancer (CRC) screening is used as a case example to examine the impact of using different Markov modeling approaches on CRC outcomes.

METHODS

This study used insurance claims data from commercially insured individuals in Oregon to estimate transition probabilities between CRC screening states (no screen, colonoscopy, fecal immunochemical test or fecal occult blood test). First-order, first-order stratified by sex and geography, and third-order Markov models were compared. Screening trajectories produced from the different Markov models were incorporated into a microsimulation model that simulated the natural history of CRC disease progression. Simulation outcomes (e.g., future screening choices, CRC incidence, deaths due to CRC) were compared across models.

RESULTS

Simulated CRC screening trajectories and resulting CRC outcomes varied depending on the Markov modeling approach used. For example, when using the first-order, first-order stratified, and third-order Markov models, 30%, 31%, and 44% of individuals used colonoscopy as their only screening modality, respectively. Screening trajectories based on the third-order Markov model predicted that a higher percentage of individuals were up-to-date with CRC screening as compared with the other Markov models.

LIMITATIONS

The study was limited to insurance claims data spanning 5 y. It was not possible to validate which Markov model better predicts long-term screening behavior and outcomes.

CONCLUSIONS

Findings demonstrate the impact that different order and stratification assumptions can have in decision-analytic models.

HIGHLIGHTS

This tutorial uses colorectal cancer screening as a case example to provide guidance on the use of Markov models of different orders and stratification levels in health decision-analytic models.Colorectal cancer screening trajectories and projected health outcomes were sensitive to the use of alternate Markov model specifications.Although data limitations precluded the assessment of model accuracy beyond a 5-y period, within the 5-y period, the third-order Markov model was slightly more accurate in predicting the fifth colorectal cancer screening action than the first-order Markov model.Findings from this tutorial demonstrate the importance of examining the memoryless assumption of the first-order Markov model when simulating health care utilization over time.

Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial

Background

Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer Moonshot^SM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees.

Methods

Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities.

Discussion

This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

Trial registration

Registered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.

Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff

PURPOSE

Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program.

METHODS

We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates.

RESULTS

We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back- or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors.

CONCLUSIONS

Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs.

An observational study of workflows to support fecal testing for colorectal cancer screening in primary care practices serving Medicaid enrollees

Abstract

Background

Screening supports early detection and treatment of colorectal cancer (CRC). Provision of fecal immunochemical tests/fecal occult blood tests (FIT/FOBT) in primary care can increase CRC screening, particularly in populations experiencing health disparities. This study was conducted to describe clinical workflows for FIT/FOBT in Oregon primary care practices and to identify specific workflow processes that might be associated (alone or in combination) with higher (versus lower) CRC screening rates.

Methods

Primary care practices were rank ordered by CRC screening rates in Oregon Medicaid enrollees who turned age 50 years from January 2013 to June 2014 (i.e., newly age-eligible). Practices were recruited via purposive sampling based on organizational characteristics and CRC screening rates. Data collected were from surveys, observation visits, and informal interviews, and used to create practice-level CRC screening workflow reports. Data were analyzed using descriptive statistics, qualitative data analysis using an immersion-crystallization process, and a matrix analysis approach.

Results

All participating primary care practices (N=9) used visit-based workflows, and four higher performing and two lower performing used population outreach workflows to deliver FIT/FOBTs. However, higher performing practices (n=5) had more established workflows and staff to support activities. Visit-based strategies in higher performing practices included having dedicated staff identify patients due for CRC screening and training medical assistants to review FIT/FOBT instructions with patients. Population outreach strategies included having clinic staff generate lists and check them for accuracy prior to direct mailing of kits to patients. For both workflow types, higher performing clinics routinely utilized systems for patient reminders and follow-up after FIT/FOBT distribution.

Conclusions

Primary care practices with higher CRC screening rates among newly age-eligible Medicaid enrollees had more established visit-based and population outreach workflows to support identifying patients due for screening, FIT/FOBT distribution, reminders, and follow up. Key to practices with higher CRC screening was having medical assistants discuss and review FIT/FOBT screening and instructions with patients. Findings present important workflow processes for primary care practices and may facilitate the implementation of evidence-based interventions into real-world, clinical settings.

Early Lessons and Strategies from Statewide Efforts to Integrate Community Health Workers into Medicaid

The 2010 Affordable Care Act provided new impetus and funding opportunities for state Medicaid agencies to integrate community health workers (CHWs) into their health systems. Community health workers are trusted community members who participate in training so they can promote health in their own communities. This qualitative study shares lessons and strategies from Oregon's early efforts to integrate CHWs into Medicaid with concomitant financing, policy, and infrastructure issues. Key informant interviews were conducted with 16 Coordinated care organizations (CCO) and analyzed using an iterative, immersion-crystallization approach. Coordinated care organizations found CHW integration a supportive factor for Medicaid-enrolled members navigating health and social services, educating members about disease conditions, and facilitating member engagement in primary care. Barriers to CHW integration included a lack of understanding about CHW roles and their benefits to health systems, as well as a need for more intensive guidance and support on financing and integrating CHW services.

Integration of Improvement and Implementation Science in Practice-Based Research Networks: a Longitudinal, Comparative Case Study

BACKGROUND

Implementation science (IS) and quality improvement (QI) inhabit distinct areas of scholarly literature, but are often blended in practice. Because practice-based research networks (PBRNs) draw from both traditions, their experience could inform opportunities for strategic IS-QI alignment.

OBJECTIVE

To systematically examine IS, QI, and IS/QI projects conducted within a PBRN over time to identify similarities, differences, and synergies.

DESIGN

Longitudinal, comparative case study of projects conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019.

APPROACH

We reviewed documents and conducted staff interviews. We classified projects as IS, QI, IS/QI, or other using established criteria. We abstracted project details (e.g., objective, setting, theoretical framework) and used qualitative synthesis to compare projects by classification and to identify the contributions of IS and QI within the same project.

KEY RESULTS

Almost 30% (26/99) of ORPRN's projects included IS or QI elements; 54% (14/26) were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and setting. Over half of the IS and IS/QI projects used randomized designs and theoretical frameworks, while no QI projects did. Projects displayed an upward trend in complexity over time. Project used a similar number of practice change strategies; however, projects classified as IS predominantly employed education/training while all IS/QI and most QI projects used practice facilitation. Projects including IS/QI elements demonstrated the following contributions: QI provides the mechanism by which the principles of IS are operationalized in order to support local practice change and IS in turn provides theories to inform implementation and evaluation to produce generalizable knowledge.

CONCLUSIONS

Our review of projects conducted over a 12-year period in one PBRN demonstrates key synergies for IS and QI. Strategic alignment of IS/QI within projects may help improve care quality and bridge the research-practice gap.

A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program

Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.

Employment Changes Following Breast Cancer Diagnosis: The Effects of Race and Place

The financial implications of breast cancer diagnosis may be greater among rural and black women. Women with incident breast cancer were recruited as part of the Carolina Breast Cancer Study. We compared unadjusted and adjusted prevalence of cancer-related job or income loss, and a composite measure of either outcome, by rural residence and stratified by race. We included 2435 women: 11.7% were rural; 48.5% were black; and 38.0% reported employment changes after diagnosis. Rural women more often reported employment effects, including reduced household income (43.6% vs 35.4%, two-sided χ2 test P = .04). Rural white, rural black, and urban black women each more often reported income reduction (statistically significant vs. urban white women), although these groups did not meaningfully differ from each other. In multivariable regression, rural differences were mediated by socioeconomic factors, but racial differences remained. Programs and policies to reduce financial toxicity in vulnerable patients should address indirect costs of cancer, including lost wages and employment.

Consolidated Framework for Collaboration Research derived from a systematic review of theories, models, frameworks and principles for cross-sector collaboration

Cross-sector collaboration is needed to address root causes of persistent public health challenges. We conducted a systematic literature review to identify studies describing theories, models, frameworks and principles for cross-sector collaboration and synthesized collaboration constructs into the Consolidated Framework for Collaboration Research (CFCR). Ninety-five articles were included in the review. Constructs were abstracted from articles and grouped into seven domains within the framework: community context; group composition; structure and internal processes; group dynamics; social capital; activities that influence or take place within the collaboration; activities that influence or take place within the broader community; and activities that influence or take place both in the collaboration and in the community. Community engagement strategies employed by collaborations are discussed, as well as recommendations for using systems science methods for testing specific mechanisms of how constructs identified in the review influence one another. Researchers, funders, and collaboration members can use the consolidated framework to articulate components of collaboration and test mechanisms explaining how collaborations function. By working from a consolidated framework of collaboration terms and using systems science methods, researchers can advance evidence for the efficacy of cross-sector collaborations.

Improvement Science and Implementation Science in Cancer Care: Identifying Areas of Synergy and Opportunities for Further Integration

Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.

Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees

INTRODUCTION

This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates.

METHODS

Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing).

RESULTS

Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening.

CONCLUSIONS

Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.

Barriers and Facilitators of Dental Care in African-American Seniors: A Qualitative Study of Consumers' Perspective

Objective

To identify African-American seniors' perceptions of the barriers and facilitators to their dental care.

Materials and Methods

In this cross-sectional qualitative study, we conducted in-depth interviews with 16 community-based, self-identified African-American seniors from March 2017 to August 2017 in Oregon. We coded data in ATLAS. ti and used thematic analysis to identify emergent themes within the social ecological framework and a cross-case comparative analysis to explore variation by participant characteristics.

Results

Regardless of dental insurance status, cost and perceived urgency of treatment were the primary drivers of participant's ability and interest in seeking dental care. Participants identified four solutions to improve oral health care in African-American seniors: affordable/free care and vouchers for dental work, better oral health education at a younger age, onsite community dental services, and navigators who can educate patients about insurance and dental providers who see low-income patients.

Conclusions

Oral health decisions by African-American seniors were primarily driven by cost and perceived urgency irrespective of insurance coverage. Affordable dental care, early intervention, on-site services, and navigation may help to address key barriers and reduce oral health disparities faced by African-Americans.

Initiation of Colorectal Cancer Screening Among Medicaid Enrollees

INTRODUCTION

Few studies have explored how individual- and practice-level factors influence colorectal cancer screening initiation among Medicaid enrollees newly age eligible for colorectal cancer screening (i.e., turning 50 years). This study explored colorectal cancer screening initiation among newly age-eligible Medicaid enrollees in Oregon.

METHODS

Medicaid claims data (January 2013 to June 2015) were used to conduct multivariable logistic regression (in 2018 and 2019) to explore individual- and practice-level factors associated with colorectal cancer screening initiation among 9,032 Medicaid enrollees.

RESULTS

A total of 17% of Medicaid enrollees initiated colorectal cancer screening; of these, 64% received a colonoscopy (versus fecal testing). Colorectal cancer screening initiation was positively associated with turning 50 years in 2014 (versus 2013; OR=1.21), being Hispanic (versus non-Hispanic white; OR=1.41), urban residence (versus rural; OR=1.23), and having 4 to 7 (OR=1.90) and 8 or more (OR=2.64) primary care visits compared with 1 to 3 visits in the year after turning 50 years. Having 3 or more comorbidities was inversely associated with initiation (OR=0.75). The odds of screening initiation were also higher for practices with 3 to 4 (OR=1.26) and 8 or more (OR=1.34) providers compared with 1 to 2 providers, and negatively associated with percentage of Medicaid panel age eligible for colorectal cancer screening (OR=0.92).

CONCLUSIONS

Both individual- and practice-level factors are associated with disparities in colorectal cancer screening initiation among Oregon Medicaid enrollees. Future work promoting colorectal cancer screening might focus on additional barriers to the timely initiation of colorectal cancer screening and explore the effect of practice in-reach and population outreach strategies.

Access to Primary, Mental Health, and Specialty Care: a Comparison of Medicaid and Commercially Insured Populations in Oregon

OBJECTIVE

To describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.

DESIGN

Cross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).

PARTICIPANTS

420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015.

OUTCOME

Presence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.

RESULTS

Relative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.

CONCLUSIONS

This cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.

Estimating the impact of insurance expansion on colorectal cancer and related costs in North Carolina: A population-level simulation analysis

Although screening is effective in reducing incidence, mortality, and costs of treating colorectal cancer (CRC), it remains underutilized, in part due to limited insurance access. We used microsimulation to estimate the health and financial effects of insurance expansion and reduction scenarios in North Carolina (NC). We simulated the full lifetime of a simulated population of 3,298,265 residents age-eligible for CRC screening (ages 50-75) during a 5-year period starting January 1, 2018, including polyp incidence and progression and CRC screening, diagnosis, treatment, and mortality. Insurance scenarios included: status quo, which in NC includes access to the Health Insurance Exchange (HIE) under the Affordable Care Act (ACA); no ACA; NC Medicaid expansion, and Medicare-for-all. The insurance expansion scenarios would increase percent up-to-date with screening by 0.3 and 7.1 percentage points for Medicaid expansion and Medicare-for-all, respectively, while insurance reduction would reduce percent up-to-date by 1.1 percentage points, compared to the status quo (51.7% up-to-date), at the end of the 5-year period. Throughout these individuals' lifetimes, this change in CRC screening/testing results in an estimated 498 CRC cases averted with Medicaid expansion and 6031 averted with Medicare-for-all, and an additional 1782 cases if health insurance gains associated with ACA are lost. Estimated cost savings - balancing increased CRC screening/testing costs against decreased cancer treatment costs - are approximately $30 M and $970 M for Medicaid expansion and Medicare-for-all scenarios, respectively, compared to status quo. Insurance expansion is likely to improve CRC screening both overall and in underserved populations while saving money, with the largest savings realized by Medicare.

Mailed FIT (fecal immunochemical test), navigation or patient reminders? Using microsimulation to inform selection of interventions to increase colorectal cancer screening in Medicaid enrollees

Colorectal cancer (CRC) can be effectively prevented or detected with guideline concordant screening, yet Medicaid enrollees experience disparities. We used microsimulation to project CRC screening patterns, CRC cases averted, and life-years gained in the population of 68,077 Oregon Medicaid enrollees 50-64 over a five year period starting in January 2019. The simulation estimated the cost-effectiveness of five intervention scenarios - academic detailing plus provider audit and feedback (Detailing+), patient reminders (Reminders), mailing a Fecal Immunochemical Test (FIT) directly to the patient's home (Mailed FIT), patient navigation (Navigation), and mailed FIT with Navigation (Mailed FIT + Navigation) - compared to usual care. Each intervention scenario raised CRC screening rates compared to usual care, with improvements as high as 11.6 percentage points (Mailed FIT + Navigation) and as low as 2.5 percentage points (Reminders) after one year. Compared to usual care, Mailed FIT + Navigation would raise CRC screening rates 20.2 percentage points after five years - averting nearly 77 cancer cases (a reduction of 113 per 100,000) and exceeding national screening targets. Over a five year period, Reminders, Mailed FIT and Mailed FIT + Navigation were expected to be cost effective if stakeholders were willing to pay $230 or less per additional year up-to-date (at a cost of $22, $59, and $227 respectively), whereas Detailing+ and Navigation were more costly for the same benefits. To approach national CRC screening targets, health system stakeholders are encouraged to implement Mailed FIT with or without Navigation and Reminders.

Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey

Some cancer survivors report spending 20% of their annual income on medical care. Undue financial burden that patients face related to the cost of care is referred to as financial hardship, which may be more prevalent among rural cancer survivors. This study examined contrasts in financial hardship among 1419 rural and urban cancer survivors using the 2011 Medical Expenditure Panel Survey supplement - The Effects of Cancer and Its Treatment on Finances. We combined four questions, creating a measure of material financial hardship, and examined one question on financial worry. We conducted multivariable logistic regression analyses, which produced odds ratios (OR) for factors associated with financial hardship and worry, and then generated average adjusted predicted probabilities. We focused on rural and urban differences classified by metropolitan statistical area (MSA) designation, controlling for age, education, race, marital status, health insurance, family income, and time since last cancer treatment. More rural cancer survivors reported financial hardship than urban survivors (23.9% versus 17.1%). However, our adjusted models revealed no significant impact of survivors' MSA designation on financial hardship or worry. Average adjusted predicted probabilities of financial hardship were 18.6% for urban survivors (Confidence Interval [CI]: 11.9%-27.5%) and 24.2% for rural survivors (CI: 15.0%-36.2%). For financial worry, average adjusted predicted probabilities were 19.9% for urban survivors (CI: 12.0%-31.0%) and 18.8% for rural survivors (CI: 12.1%-28.0%). Improving patient-provider communication through decision aids and/or patient navigators may be helpful to reduce financial hardship and worry regardless of rural-urban status.

Parental Mental Health Associated With Child Overweight and Obesity, Examined Within Rural and Urban Settings, Stratified by Income

PURPOSE

Rural areas experience greater childhood obesity compared with urban areas. Differences in reported physical activity and dietary intake do not fully explain the disparity. The purpose of this study was to examine the association between parental mental health and childhood obesity within urban and rural areas.

METHODS

We used data from the National Survey of Children's Health, 2016, subset to children age 10-17 with available weight data. We stratified the sample by rural and urban settings and examined whether maternal or paternal mental health was associated with child overweight or obesity, accounting for income stratum (low-income: ≤200% federal poverty line; high-income: >200% federal poverty line). We used multivariable analyses to test if associations remained after including covariates of food security, physical activity, and screen time.

FINDINGS

For the 14,733 children 10-17 years of age in our sample, family income but not rurality was associated with overweight or obesity. Among high-income families, positive mental health of either the mother or the father was associated with lower odds of overweight or obesity. In multivariable models, the association between positive maternal mental health and lower odds of child overweight/obesity persisted after adjustment for family food security, child physical activity, and child screen time. For paternal mental health, the association was not significant after adjusting for these covariates.

CONCLUSIONS

After stratification by income, there were no differences in childhood overweight/obesity by rurality. Both maternal and paternal mental health are associated with children's weight, though only the maternal association remains after adjusting for covariates.

Key Collaborative Factors When Medicaid Accountable Care Organizations Work With Primary Care Clinics to Improve Colorectal Cancer Screening: Relationships, Data, and Quality Improvement Infrastructure

Purpose

Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success.

Methods

We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening — one incentivized performance metric.

Results

ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics’ reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO–clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue.

Conclusion

Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.

Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies

BACKGROUND

Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening.

METHODS

We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010-2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation.

RESULTS

We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010-2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation.

DISCUSSION

The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.

Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?

BACKGROUND

Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA.

METHODS

Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs).

RESULTS

A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs.

CONCLUSIONS

Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.

Adverse Childhood Experiences (ACE) among American Indians in South Dakota and Associations with Mental Health Conditions, Alcohol Use, and Smoking

OBJECTIVES

To assess the prevalence of Adverse Childhood Experiences (ACEs) and their association with behavioral health in American Indian (AI) and non-AI populations in South Dakota.

METHODS

We included the validated ACE questionnaire in a statewide health survey of 16,001 households. We examined the prevalence of ACEs and behavioral health conditions in AI and non-AI populations and associations between ACEs and behavioral health.

RESULTS

Compared with non-AIs, AIs displayed higher prevalence of ACEs including abuse, neglect, and household dysfunction and had a higher total number of ACEs. For AIs and non-AIs, having six or more ACEs significantly increased the odds for depression, anxiety, PTSD, severe alcohol misuse, and smoking compared with individuals with no ACEs.

CONCLUSIONS

American Indians in South Dakota experience more ACEs, which may contribute to poor behavioral health. Preventing and mitigating the effects of ACEs may have a significant impact on health disparities in AI populations.

Participatory Research to Advance Colon Cancer Prevention (PROMPT): Study protocol for a pragmatic trial

BACKGROUND

Colon cancer is the second leading cause of cancer deaths in the United States. The Participatory Research to Advance Colon Cancer Prevention (PROMPT) study is a collaboration between two research institutions and a federally qualified health center (FQHC). The study seeks to raise colon cancer screening rates using a direct-mail fecal immunochemical testing (FIT) and reminder program in an FQHC serving a predominantly Latino population in California.

METHODS

PROMPT is a pragmatic trial enrolling 16 clinics. The study will test automated and live prompts (i.e., alerts, reminders) to a direct-mail FIT program in two phases. In Phase I, we tailored and defined intervention components for the pilot using a community-based participatory research approach called boot camp translation. We then plan to conduct a three-arm patient-randomized comparative effectiveness trial in two pilot clinics to compare 1) automated prompts, 2) live prompts, and 3) a combination of automated plus live prompts to alert and remind patients to complete screening. In Phase II, the adapted best practice intervention will be spread to additional clinics within the FQHC (estimated population 27,000) and assessed for effectiveness. Patient and staff interviews will be conducted to explore receptivity to the program and identify barriers to implementation.

DISCUSSION

This pragmatic trial applies innovative approaches to engage diverse stakeholders and will test the effectiveness and spread of a direct-mail plus reminder program. If successful, the program will provide a model for a cost-effective method to raise colon cancer screening rates among Latino patients receiving care in FQHCs.

TRIAL REGISTRATION

National Clinical Trial (NCT) Identifier NCT03167125.

Participatory implementation science to increase the impact of evidence-based cancer prevention and control

It is critical to accelerate the integration of evidence-based programs, practices, and strategies for cancer prevention and control into clinical, community, and public health settings. While it is clear that effective translation of existing knowledge into practice can reduce cancer burden, it is less clear how best to achieve this. This gap is addressed by the rapidly growing field of implementation science. Given that context influences and is influenced by implementation efforts, engaging stakeholders in the co-production of knowledge and solutions offers an opportunity to increase the likelihood that implementation efforts are useful, scalable, and sustainable in real-world settings. We argue that a participatory implementation science approach is critical, as it supports iterative, ongoing engagement between stakeholders and researchers to improve the pathway between research and practice, create system change, and address health disparities and health equity. This article highlights the utility of participatory implementation science for cancer prevention and control research and addresses (a) the spectrum of participatory research approaches that may be of use, (b) benefits of participatory implementation science, and