Health Care Systems for Tracking Colorectal Cancer Screening Tests
We developed our dissemination plan based largely on AHRQ's Dissemination Planning Tool (Carpenter, et al., 2005). The key components of this tool are:
- Content: What we intend to disseminate: the project findings and the redesign intervention tools that we have found to be useful or effective.
- End users: The intended targets of our dissemination efforts; those whom we will target to adopt and implement or otherwise use what we disseminate.
- Dissemination partners: Those with whom we will partner to help us disseminate our findings and encourage the spread and adoption of our redesign intervention.
- Communication: Our strategy for reaching our intended end users; the communication channels we will use to reach these end users.
- Evaluation: How we intend to assess the effectiveness of our dissemination effort.
Our dissemination efforts have two components: a SATIS-PHI/CRC intervention implementation toolkit and material and efforts beyond the toolkit. The primary component is the toolkit. Through it, we intend to inform potential new users and adopters about the SATIS-PHI/CRC intervention and our experiences implementing it. To facilitate the spread of the intervention, we will provide tools, guidelines, and tips for implementing SATIS-PHI/CRC based on the lessons learned reported here and on what we found effective and useful in our implementation efforts. To encourage the intervention's spread, the toolkit provides evidence of the intervention's effectiveness and reasons for its adoption. We describe the toolkit in greater detail below.
In addition to and beyond the toolkit, we will disseminate various elements of our project findings and various elements of the intervention. In particular, as part of our efforts beyond the toolkit, we will disseminate our analytical findings from the practice surveys and focus groups and report them at professional meetings and in professional publications. Similarly, we will report the full details of our intervention study (implementation process and outcomes) at professional meetings and in professional publications. We will also report summaries of our intervention and assessment in trade publications and to relevant professional associations and consortia of cancer care providers.
Topics for analysis and dissemination include:
- Overall effectiveness of the intervention to increase CRC screening rates.
- Evaluation of the intervention effort using the PRISM and RE-AIM frameworks.
- Assessment of clinician beliefs and behaviors related to CRC screening (based on the survey and focus groups).
- Assessment of patient attitudes regarding the CRC screening process (based on the focus groups).
- Estimation of the extent of "ineligible eligibles"—patients whom the initial electronic record review identified as eligible but whom we deemed to be ineligible based on the SEA form, chart reviews, and subsequent electronic record review—in our data.
We envision two kinds of end users for our dissemination efforts. The first are potential adopters of our intervention. These primarily include integrated delivery systems, independent practice associations or foundations, insurers owned or operated by delivery systems, insurers not owned or operated by delivery systems, and State, county, or municipal public health agencies and related entities. They are the principal target of the toolkit.
The second group of users includes those who are not firstline new adopters but who may be able to inform and influence potential new users. It also includes people who may be interested in our intervention and findings for purposes of conducting followup research, incorporating our intervention elements into other CRC screening efforts, or developing next generation versions of the intervention. They are the principal target of our dissemination efforts beyond the toolkit.
These types of end users, the target of the toolkit, include the following in rough priority order of planned targets for our dissemination efforts:
- The remaining LVPHO/EPICNet primary care practices that did not participate as intervention practices in the SATIS-PHI/CRC intervention study.
- Delivery systems affiliated with Thomas Jefferson University (TJU) through Jefferson Health System or other collaborative arrangements.
- Delivery systems, insurers, and public health agencies throughout Pennsylvania.
- Delivery systems in the current CNA Health ACTION Team network.
- Delivery systems in other ACTION partnerships.
Influencers of Potential Adopters
These types of end users, the target of our efforts beyond the toolkit, include the following, in rough priority order:
- Pennsylvania Cancer Control Consortium (PAC3).
- Agency for Healthcare Research and Quality (AHRQ): staff members affiliated with the Prevention and Care Management research portfolio (and possibly the Health Information Technology research portfolio) and with the Center for Primary Care, Prevention, and Clinical Partnerships.
- Centers for Disease Control and Prevention (CDC): staff members affiliated with the Division of Cancer Prevention and Control of the National Center for Chronic Disease Prevention and Health Promotion in the Coordinating Center for Health Promotion, including the CDC State Cancer Control Plans.
- National Colorectal Cancer Roundtable (NCCRT).
- American Cancer Society (ACS).
- American Academy of Family Physicians (AAFP).
- American College of Physicians (ACP).
- America's Health Insurance Plans (AHIP).
Our primary dissemination team consists of members of the CNA Health ACTION Team who participated on this Task Order: (1) CNA; (2) Thomas Jefferson University, including its School of Population Health, Department of Family and Community Medicine, and Department of Medical Oncology; and (3) LVHN, including the LVPHO and the Department of Family Medicine. In addition to our efforts, we will work with AHRQ and CDC to help package and disseminate information about our intervention and the availability of our intervention implementation toolkit.
We also plan to investigate the possibility of enlisting one or more of our type 2 end users (PAC3, NCCRT, ACS, AAFP, ACP, AHIP) to become a dissemination partner. We will work through contacts that team members already have established with PAC3, NCCRT, ACS, and AAFP. We will seek to make new contacts with ACP, AHIP, and other type 2 end users that we subsequently identify.
We will communicate our intervention implementation toolkit to potential new users and adopters through direct and mediated contact. We will directly disseminate it through the LVPHO to Lehigh Valley primary care practices, through TJU to members of the Jefferson Health System, and through CNA to other members of our ACTION partnership. We will work with AHRQ to disseminate it more broadly to other ACTION partnerships. In addition, we will work with both AHRQ and CDC, as well as our other targeted dissemination partners, to disseminate it beyond that. Our final toolkit will undergo remediation so that it can be compliant with Section 508 of the Rehabilitation Act and therefore made available on the AHRQ Web site. This posting will help disseminate the toolkit to both type 1 and 2 users.
We will also communicate information about the intervention and the findings of our assessment to type 1 and type 2 end users, as well as to the broader professional clinical and research communities. This communication will include writing articles for professional journals and trade publications, presenting papers and posters at professional and trade meetings, informing professional and trade associations, and using the dissemination capabilities of CNA and its partners on this ACTION Task Order.
Since the dissemination effort is being conducted at the end of this Task Order and will extend beyond it, we cannot evaluate its success within the scope of the Task Order. Such effort exceeds the Task Order's statement of work, period of performance, and funding. Still, we have an interest in evaluating our effort and plan to monitor response to it as best we can. One way we will gather data for our dissemination evaluation will be to seek feedback from our dissemination partners regarding their perception of the intervention and the toolkit and their experience helping to disseminate information about it. We will also seek feedback from participants at the professional meetings where we present our study findings.
Our Dissemination Toolkit includes the following three components: (1) introduction to the toolkit and its contents, (2) background information about the intervention and our study findings—including supporting evidence about the effectiveness of the intervention, and (3) intervention steps and tools. We delivered the toolkit to AHRQ and CDC as a companion deliverable document to this final report in satisfaction of our task order contract. Others wanting a copy may request one from CNA by E-mailing the CNA Health ACTION Partnership at CHAP@CNA.org.
The introduction to the toolkit contains a brief statement of the purpose of the dissemination toolkit, its intended users, and ways the toolkit can help users. It include a brief overview of the need for CRC screening (including the prevalence and natural history of the disease) and a brief summary of the current research literature regarding screening programs and the need for the kind of intervention we developed and implemented. It also provides a general overview of the contents of the toolkit and its structure.
In the background section, we briefly describe the Task Order project and the system redesign intervention that is the basis for this dissemination effort. We also provide descriptions of the intervention setting. We describe the applicability of this intervention to other users that are most conducive to successfully implementing the intervention or using the tools. Last, we briefly describe the assessment of the intervention, noting general evidence in support of its overall effectiveness and usefulness as well as that of various tools contained in the toolkit. We describe the assessment in the context of why a user would want to try to adopt our intervention and its components.
Intervention Steps and Tools
In the intervention protocol and steps section, we describe each of the six main intervention steps and then describe the optional assessment step. For each of the intervention and assessment steps, we describe what it entails, provide instructions for implementing it, and offer tips for implementing it based on lessons learned from our implementation experience, including pitfalls to avoid and how to avoid them. We also identify possible alternative ways of carrying out various steps and point out what would be required to make such alternatives practical. In addition, we point out where various steps may be considered optional and under what circumstances a user may or may not want to apply one of those steps.
After describing each intervention step, we include the appropriate corresponding intervention tools (forms, letters to patients, academic detailing material, etc.). The tools are based on the materials we used for our intervention. However, users can tailor and revise them as appropriate for their organizations and settings.
Current Dissemination Activities
We are currently disseminating our intervention and its findings across multiple outlets, including research conferences, statewide clinical and policy working groups, peer-reviewed and trade manuscripts, and the World Wide Web.
Upon completion of this Task Order, AHRQ will post our final toolkit on their Web site, and it will also be linked from the CDC Web site. This posting will allow the toolkit to be accessible to both the clinical and research communities. The toolkit will undergo remediation to be accessible to all populations. In addition, we plan to disseminate the toolkit to our ACTION partners and throughout each primary care practice in the LVHN community. We also plan on posting it on the PAC3 Portal, a statewide network working to reduce cancer in Pennsylvania.
Clinical and Policy Working Groups
Steering Group members have become involved in various panels and working groups through which they will continue to spread and disseminate the findings from the intervention. Below is a summary of some of these activities:
- Pennsylvania Improving Performance in Practice (IPIP) Project. Steering Group members have been invited to participate as expert faculty in the Pennsylvania IPIP project. This 3-year effort was started by the Governor's Office of Healthcare Reform to move practices to the medical home concept and improve the management of chronic disease through participation in primary care collaboratives across the State. Starting in June 2010, Steering Group members planned to make statewide Web presentations to primary care practices throughout Pennsylvania. In some of the Web seminars, they included the content and findings from our study's intervention, such as lessons learned from the practice survey and focus groups in the Lehigh Valley, and tools to help increase CRC screening.
- Pennsylvania CRC screening Project. The Commonwealth of Pennsylvania has been selected by CDC to receive State grant funding to increase CRC screening in the low-income uninsured population. Steering Group members will also serve as expert faculty on this project, working with the 10 public health centers in the city and their points of referral.
- National Colorectal Cancer Roundtable. Steering Group members planned to attend the National Colorectal Cancer Roundtable meeting in November 2010 to report the findings of our intervention.
- Lehigh Valley Health Network Research Day. Steering Group members will present the intervention and study findings at the LVHN Research Day.
- Lehigh Valley Patient Centered Medical Home. LVHN is working toward implementing the patient-centered medical home concept in their practices, and they are looking at including CRC screening as one of the key elements of the medical home. Steering Group members are working with LVHN to incorporate elements of our CRC screening intervention in their medical home efforts.
Study findings have and will be disseminated at several key research conferences. For example, some of our baseline study findings about primary care practice involvement with CRC screening activities and the utility of health information technology for population-based screening were disseminated at the North American Primary Care Research Group (NAPCRG) Conference in November 2009 and AcademyHealth Annual Research Meeting (ARM) in June 2010. We also planned to disseminate additional findings at the American Public Health Association (APHA) Annual Meeting in November 2010. This presentation focused on our baseline findings of clinician attitudes and behaviors associated with CRC screening.
The conference sessions included:
- "Colorectal Cancer Screening Responsibilities in Primary Care Practice," NAPCRG, November 2009, poster session.
- "Ineligible Eligibles: Incorrect Information in Electronic Health Data Affecting Intervention Implementation Research: A Report From the CNA Health ACTION Team," AcademyHealth, June 2010, poster session.
- "Primary Care and Colorectal Cancer (CRC): Attitudes and Behavior Associated With Performing Preventative Screening and Followup: A Report From the CNA Health ACTION Team," AcademyHealth, June 2010, poster session.
- "From AHRQ ACTION: Colorectal Cancer Screening Steps Reported by Primary Care Practices," APHA, November 2010, poster session.
We will draft and submit at least one peer-reviewed manuscript and one trade journal manuscript to the appropriate publications. The peer-reviewed manuscript will describe the intervention, research methods, and study results. The trade journal manuscript will focus on the process of implementing the intervention and will be geared more toward clinical entities that may be interested in implementing our intervention. In addition to these two publications, Steering Group members will be involved with publishing other elements of the results, such as how findings from our baseline practice survey align with the patient-centered medical home concept.