Using the consolidated framework for implementation research to understand safety net health system efforts to increase colorectal cancer screening rates

Barriers to and facilitators of implementing colorectal cancer screening evidence-based interventions in federally qualified health centers: a qualitative study

BACKGROUND

There is an urgent need to increase colorectal cancer screening (CRCS) uptake in Texas federally qualified health centers (FQHCs), which serve a predominantly vulnerable population with high demands. Empirical support exists for evidence-based interventions (EBIs) that are proven to increase CRCS; however, as with screening, their use remains low in FQHCs. This study aimed to identify barriers to and facilitators of implementing colorectal cancer screening (CRCS) evidence-based interventions (EBIs) in federally qualified health centers (FQHCs), guided by the Consolidated Framework for Implementation Research (CFIR).

METHODS

We recruited employees involved in implementing CRCS EBIs (e.g., physicians) using data from a CDC-funded program to increase the CRCS in Texas FQHCs. Through 23 group interviews, we explored experiences with practice change, CRCS promotion and quality improvement initiatives, organizational readiness, the impact of COVID-19, and the use of CRCS EBIs (e.g., provider reminders). We used directed content analysis with CFIR constructs to identify the critical facilitators and barriers.

RESULTS

The analysis revealed six primary CFIR constructs that influence implementation: information technology infrastructure, innovation design, work infrastructure, performance measurement pressure, assessing needs, and available resources. Based on experiences with four recommended EBIs, participants described barriers, including data limitations of electronic health records and the design of reminder alerts targeted at deliverers and recipients of patient or provider reminders. Implementation facilitators include incentivized processes to increase provider assessment and feedback, existing clinic processes (e.g., screening referrals), and available resources to address patient needs (e.g., transportation). Staff buy-in emerged as an implementation facilitator, fostering a conducive environment for change within clinics.

CONCLUSIONS

Using CFIR, we identified barriers, such as the burden of technology infrastructure, and facilitators, such as staff buy-in. The results, which enhance our understanding of CRCS EBI implementation in FQHCs, provide insights into designing nuanced, practical implementation strategies to improve cancer control in a critical setting.

Guiding the Implementation of Wastewater-based Surveillance for Carceral Infection Control with Perspectives from People with Lived Experience of Incarceration during the COVID-19 Pandemic

Background

Little guidance exists on best practices for implementing and sustaining wastewater-based surveillance (WBS) for SARS-CoV-2 in carceral settings. To ensure alignment with priorities of stakeholders, we aimed to understand the perspectives of persons with lived experience (PLE) of jail who were incarcerated during the height of the COVID-19 pandemic on infection control.

Methods

We recruited two PLE at each of four jails: Cook County (IL), Fulton County (GA), Middlesex County (MA), and Washington DC. Focus Group Discussion (FGD) guides followed the Consolidated Framework for Implementation Research (CFIR). Two FGDs focusing on lived experience with jail infection control protocol and WBS were conducted, and six Key Informant (KI) interviews followed to gain insights on communicating WBS results. We used a combination of deductive thematic analysis based on CFIR constructs and inductive analysis to capture emergent themes.

Results

Themes from FGDs included: (1) variable experiences with COVID-19 infection control protocols including intake processes, individual testing, isolation and quarantine, (2) the perceived attitudes of fellow residents and staff surrounding COVID-19 mitigation in a carceral setting; and (3) perceived benefits and challenges involving WBS implementation and messaging. KIs emphasized 1) The importance of straightforward health messaging and trustworthiness in the communication of WBS results, 2) Support for enhanced health education around outbreaks, and 3) Receptiveness to WBS being used as a tool to measure common infectious agents (i.e., influenza) but hesitancy regarding its application to conditions such as HIV and illicit drug use. PLE articulated support of robust infection control programs and receptiveness to expanding WBS if conducted in a non-stigmatizing manner.

Conclusion

Perspectives from PLE can help shape the infection control programs for future outbreaks and inform the expansion of WBS implementation in carceral facilities. It will be important to consider the voices of current and former residents, as receivers of care, to promote an environment conducive to comprehensive infection control. In addition to having infection control programs consistently execute set protocols and educate all stakeholders, PLE identified collaboration between jail staff and residents, and clear communication around program expectations as priorities. Findings from this qualitative study can be shared with jail decision makers and the perceived engagement of stakeholders can be measured.

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation

BACKGROUND

Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

METHODS

In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

RESULTS

Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

CONCLUSIONS

Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Applications of implementation science frameworks, models and theories in disparities-focused cancer screening interventions: a scoping review protocol

BACKGROUND

Implementation science (IS) frameworks, models and theories (FMTs) have gained popularity in guiding the implementation and evaluation of evidence-based interventions (EBIs) for cancer screening. However, there are significant research gaps in understanding their applications in cancer health disparities contexts. This paper outlines a scoping review protocol designed to explore the utilisation of IS FMTs in cancer screening EBIs to inform intervention designs and adaptations.

METHODS AND ANALYSIS

This scoping review protocol adheres to Arksey and O'Malley's five-step methodological framework for conducting scoping studies. Search strategies were conducted in five bibliographic databases: Ovid MEDLINE, PubMed, Scopus, Web of Science and EMBASE. The search was run on 22 June 2023 with an English language filter and a date limit of 2001-current. Two reviewers will independently screen studies for inclusion and exclusion criteria. A third reviewer will be consulted, where appropriate at any of the review stages, to achieve consensus or resolve conflicts. Data will be collected, managed and analysed using Covidence. A narrative synthesis, based on Popay et al's methodology, will guide reporting and summarisation of results. The review will adhere to the PRISMA Extension for Scoping Reviews guidelines.

ETHICS AND DISSEMINATION

This scoping review is a novel approach for examining a growing corpus of research literature on IS FMT applications used in cancer screening EBIs. As a secondary analysis, this scoping review does not require approval from an institutional review board. We anticipate the review will produce insightful information (eg, challenges, key areas for future directions) on the applications of IS TMFs in designing, deploying and testing EBIs for populations experiencing cancer screening disparities. We will disseminate the results through journals and conferences targeting IS and cancer prevention researchers and practitioners.

Evaluation of COVID-19 vaccine implementation in a large safety net health system

Objectives

To evaluate rapid COVID-19 vaccine clinic implementation from January-April 2021 in the Los Angeles County Department of Health Services (LACDHS), the second-largest US safety net health system. During initial vaccine clinic implementation, LACDHS vaccinated 59,898 outpatients, 69% of whom were Latinx (exceeding the LA County Latinx population of 46%). LACDHS is a unique safety net setting to evaluate rapid vaccine implementation due to system size, geographic breadth, language/racial/ethnic diversity, limited health staffing resources, and socioeconomic complexity of patients.

Methods

Implementation factors were assessed through semi-structured interviews of staff from all twelve LACDHS vaccine clinics from August-November 2021 using the Consolidated Framework for Implementation Research (CFIR) and themes analyzed using rapid qualitative analysis.

Results

Of 40 potential participants, 25 health professionals completed an interview (27% clinical providers/medical directors, 23% pharmacist, 15% nursing staff, and 35% other). Qualitative analysis of participant interviews yielded ten narrative themes. Implementation facilitators included bidirectional communication between system leadership and clinics, multidisciplinary leadership and operations teams, expanded use of standing orders, teamwork culture, use of active and passive communication structures, and development of patient-centered engagement strategies. Barriers to implementation included vaccine scarcity, underestimation of resources needed for patient outreach, and numerous process challenges encountered.

Conclusion

Previous studies focused on robust advance planning as a facilitator and understaffing and high staff turnover as barriers to implementation in safety net health systems. This study found facilitators that can mitigate lack of advance planning and staffing challenges present during public health emergencies such as the COVID-19 pandemic. The ten identified themes may inform future implementations in safety net health systems.

Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives

BACKGROUND

In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic.

METHODS

Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis.

RESULTS

Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities.

CONCLUSIONS

Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Barriers and Facilitators to Knowledge Brokering Activities: Perspectives from Knowledge Brokers Working in Canadian Rehabilitation Settings

INTRODUCTION

Knowledge translation experts advocate for employing knowledge brokers (KBs) to promote the uptake of research evidence in health care settings. Yet, no previous research has identified potential barriers for KBs to promote the uptake of research evidence in rehabilitation settings. This study aimed to identify the barriers and facilitators for KBs in Canadian rehabilitation settings as perceived by individuals serving as KBs.

METHODS

Qualitative study using semistructured telephone interviews with individuals performing KB activities in rehabilitation settings across Canada. The interview topic guide was informed by the Consolidated Framework for Implementation Research (CFIR) and consisted of 20 questions covering three domains (characteristics of individuals, inner setting, and outer settings). We conducted qualitative descriptive analysis combining deductive coding guided by the CFIR.

RESULTS

Characteristics of individuals included having communication skills, clinical experience, research skills, and interpersonal features, in addition to being confident and motivated and receiving training. The inner setting domain included having constant networking with stakeholders and being aware of stakeholders' needs, in addition to resources availability, leadership engagement, knowledge accessibility, prioritizing brokering activities, and monitoring KBs' performance. Finally, the outer setting domain showed that KBs need to be connected to a community of practice to promote information exchange and avoid work duplications.

DISCUSSION

Factors likely to hinder or promote the optimal use of KBs within Canadian rehabilitation settings include skill sets and networking abilities; organizational culture, resources, and leadership engagement; and the need for specific training for KBs and for evaluation tools to monitor their performance.

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments

Background

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.

Materials and methods

Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.

Results

Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.

Discussion

Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.

Conclusion

This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Clinicians' perceptions of barriers to cervical cancer screening for women living with behavioral health conditions: a focus group study

Background

Women with behavioral health (BH) conditions (e.g., mental illness and substance abuse) receive fewer cervical cancer (CC) screenings, are diagnosed at more advanced cancer stages, and are less likely to receive specialized treatments. The aim of this study was to identify barriers that healthcare providers face in providing CC screening to women with BH conditions.

Methods

Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups in North Florida with 26 primary care and BH clinicians and staff to examine perceived barriers to CC screening among their patients with BH conditions to guide the future development of a tailored cervical cancer screening and follow-up intervention. Thematic analysis was used to analyze verbatim transcripts from audiotaped focus groups.

Results

Three main themes of barriers emerged from the data: 1) BH conditions related barriers included a history of trauma, stigma and discrimination, and uncontrolled comorbid conditions, 2) System level barriers related to lack of integration between BH and primary care, and 3) Similar barriers to the general population including lack of health insurance, insufficient processes to send out reminders, and challenges with communicating with patients.

Conclusions

Tailored CC screening interventions that address the unique needs of women with BH conditions are needed. Strategies that address improving trust between patients and healthcare providers, identifying avenues to improve receipt of screening during time-limited clinical visits, connecting BH and primary care providers, and addressing the social determinants of health have potential to improve CC screening rates for women with BH conditions.

Anal cancer screening among women with HIV: provider experiences and system-level challenges

Women living with HIV (WLWH) are at increased risk of anal cancer compared to women without HIV, often due to persistent human papillomavirus (HPV) infections. This paper describes current practices and challenges conducting anal cancer screening for WLWH at an urban integrated safety-net system and a non-profit community-based HIV clinic. We conducted 25 semi-structured interviews with clinical and administrative stakeholders to assess knowledge, clinic practices and procedures, and experiences with anal cancer screening. Interview transcripts and fieldnotes were thematically analyzed using an iterative deductive and inductive coding scheme. Findings were organized by the Consolidated Framework for Implementation Research (CFIR) domains and constructs. Provider-level barriers to conducting anal cancer screening included limited knowledge of guidelines. System-level barriers included: structural characteristics such as lack of coordination between clinics to discern provider roles and responsibilities; and limitations in available resources such as configuration of electronic health records and infrastructure to manage referrals of abnormal anal Pap results. We conclude that anal cancer screening and follow-up for WLWH requires organization and coordination between multiple care teams, updated clinical information systems to facilitate communication and support anal Pap ordering and result documentation, and infrastructure that includes policies and protocols for management of abnormal results.Trial registration: ClinicalTrials.gov identifier: NCT02135419.

Clinicians and individuals with acquired brain injury perspectives about factors that influence mobility: creating a core set of mobility domains among individuals with acquired brain injury

OBJECTIVES

To identify factors which may influence mobility and could be considered during the evaluation of mobility in individuals with acquired brain injury (ABI) following qualitative focus groups with both clinicians and individuals with ABI, to assess their needs and preferences in order to individualize their care management plans.

METHODS

Five focus groups were held, three with clinicians from 3 rehabilitation sites of CRIR (CRDM: n = 4; IURDPM: n = 3; JRH: n = 10) and two with individuals with ABI from one rehabilitation site (CRDM) (individuals with stroke: n = 5; individuals with TBI: n = 5). Focus group discussions were transcribed and analyzed using inductive and deductive thematic content approaches.

RESULTS

Four themes were identified: considering mobility holistically and individual needs, preferences, and unique experiences; assessment and intervention guidelines; support network; and uncertainty about symptoms and recovery. Using the ten-rule International Classification, Functioning, Disability, and Health framework linking process, codes were categorized into Body Functions Activity and Participation, and Environmental Factors exploring the prominent domains that mostly identify factors influencing mobility.

CONCLUSIONS

Comprehensive measurement of mobility remains an ongoing challenge owing to multiple contributing factors, ranging from personal and psychosocial factors to the influence of a myriad of environmental and community considerations. Preparing individuals with ABI for community mobility can be substantially improved if healthcare professionals employ communicative tools to facilitate shared decision making with patients and to deliver patient-centred rehabilitation care.

A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics

PURPOSE

To explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%.

METHODS

Using a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC-related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive-deductive approach.

RESULTS

Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower.

CONCLUSIONS

Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.

Facilitators and barriers to implement the family doctor contracting services in China: findings from a qualitative study

OBJECTIVE

To identify the facilitators and barriers to implement family doctor contracting services in China by using Consolidated Framework for Implementation Research (CFIR) to shed new light on establishing family doctor systems in developing countries.

DESIGN

A qualitative study conducted from June to August 2017 using semistructured interview guides for focus group discussions (FGDs) and individual interviews. CFIR was used to guide data coding, data analysis and reporting of findings.

SETTING

19 primary health institutions in nine provinces purposively selected from the eastern, middle and western areas of China.

PARTICIPANTS

From the nine sampled provinces in China, 62 policy makers from health related departments at the province, city and county/district levels participated in 9 FGDs; 19 leaders of primary health institutions participated in individual interviews; and 48 family doctor team members participated in 15 FGDs.

RESULTS

Based on CFIR constructs, notable facilitators included national reform involving both top-down and bottom-up policy making (Intervention); support from essential public health funds, fiscal subsidies and health insurance (Outer setting); extra performance-based payments for family doctor teams based on evaluation (Inner setting); and positive engagement of health administrators (Process). Notable barriers included a lack of essential matching mechanisms at national level (Intervention); distrust in the quality of primary care, a lack of government subsidies and health insurance reimbursement and performance ceiling policy (Outer setting); the low competency of family doctors and weak influence of evaluations on performance-based salary (Inner setting); and misunderstandings about family doctor contracting services (Process).

CONCLUSIONS

The national design with essential features including financing, incentive mechanisms and multidepartment cooperation, was vital for implementing family doctor contracting services in China. More attention should be paid to the quality of primary care and competency of family doctors. All stakeholders must be informed, be involved and participate before and during the process.

Mixed methods evaluation of implementation and outcomes in a community-based cancer prevention intervention

Background

Community-based educational programs can complement clinical strategies to increase cancer screenings and encourage healthier lifestyles to reduce cancer burden. However, implementation quality can influence program outcomes and is rarely formally evaluated in community settings. This mixed-methods study aimed to characterize implementation of a community-based cancer prevention program using the Consolidated Framework for Implementation Research (CFIR), determine if implementation was related to participant outcomes, and identify barriers and facilitators to implementation that could be addressed.

Methods

This study utilized quantitative participant evaluation data (n = 115) and quantitative and qualitative data from semi-structured interviews with program instructors (N = 13). At the participant level, demographic data (age, sex, insurance status) and behavior change intention were captured. Instructor data included implementation of program components and program attendance to create a 7-point implementation score of fidelity and reach variables. Degree of program implementation (high and low) was operationalized based on these variables (low: 0–4, high: 5–7). Relationships among degree of implementation, participant demographics, and participant outcomes (e.g., intent to be physically active or limit alcohol) were assessed using linear or ordinal logistic mixed effects models as appropriate. Interview data were transcribed and coded deductively for CFIR constructs, and constructs were then rated for magnitude and valence. Patterns between ratings of high and low implementation programs were used to determine constructs that manifested as barriers or facilitators.

Results

Program implementation varied with scores ranging from 4 to 7. High implementation was related to greater improvements in intention to be physically active (p <  0.05), achieve a healthy weight (p <  0.05), and limit alcohol (p <  0.01). Eight constructs distinguished between high and low implementation programs. Design quality and packaging, compatibility, external change agents, access to knowledge and information, and experience were facilitators of implementation and formally appointed internal implementation leaders was a barrier to implementation.

Conclusions

As higher implementation was related to improved participant outcomes, program administrators should emphasize the importance of fidelity in training for program instructors. The CFIR can be used to identify barriers and/or facilitators to implementation in community interventions, but results may be unique from clinical contexts.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7315-y) contains supplementary material, which is available to authorized users.

Efficacy of intestinal obstruction stent combined with laparoscopic surgery and neoadjuvant chemotherapy in patients with obstructive colorectal cancer

There is still controversy on the surgical treatment of obstructive colorectal cancer worldwide. No accurate research has been reported to propose which method is the most suitable for patients with obstructive colorectal cancer. Therefore, comparison of efficacy of intestinal stent and trans-anal ileus catheter combined with laparoscopic surgery and neoadjuvant chemotherapy respectively in patients with obstructive colorectal cancer was carried out to provide reference and guidance for the selection of surgical schemes for patients with obstructive colorectal cancer. In total 89 patients with obstructive colorectal cancer treated in the Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, from February 2016 to March 2017 were selected for retrospective analysis. Forty-nine cases treated with intestinal metal stent implantation combined with laparoscopic surgery and neoadjuvant chemotherapy were the stent group. The other 40 cases treated with trans-anal ileus catheter combined with laparoscopic surgery and neoadjuvant chemotherapy were the catheter group. The intestinal preparation time, surgical duration, intraoperative blood loss, open surgery rate, postoperative exhaust time and adverse reaction rate were compared between the two groups. All the patients were followed up with reexamination at 1 year in hospital to record the local recurrence rate and tumor implantation rate of incision. The intestinal preparation time in the stent group was shorter than that in the catheter group (P<0.001). The surgical duration in the stent group was longer than that in the catheter group (P<0.001). The intraoperative blood loss in the stent group was higher than that in the catheter group (P<0.001). However, there was no significant difference in open surgery rate, postoperative exhaust time, adverse reaction rate, local recurrence rate or incision tumor implantation rate between the two groups (all P>0.05). Therefore, intestinal metal stent implantation can effectively relieve intestinal obstruction, while trans-anal ileus catheter has higher safety in laparoscopic surgery. Their combination with neoadjuvant chemotherapy and laparoscopic surgery for obstructive colorectal cancer has high value and clinical effect. The best treatment plan should be selected according to the patient's condition.

Assessing Levels and Correlates of Implementation of Evidence-Based Approaches for Colorectal Cancer Screening: A Cross-Sectional Study With Federally Qualified Health Centers

Multiple evidence-based approaches (EBAs) exist to improve colorectal cancer screening in health clinics. The success of these approaches is tied to effective implementation. Therefore, the purpose of this study was to assess the implementation of EBAs for colorectal cancer screening and clinic-level correlates of implementation in federally qualified health centers (FQHCs). We conducted descriptive and cross-sectional analyses using data collected from FQHC clinics across seven states ( n = 51). A clinic representative completed electronic surveys about clinic characteristics (e.g., size, patient characteristics, and medical record system characteristics) and the implementation of Community Guide recommended EBAs (e.g., client reminders, small media, and provider assessment and feedback). We used bivariate Spearman correlations to assess clinic-level correlates with implementation outcomes. Most clinics were planning to implement, in the early implementation stages, or inconsistently implementing EBAs. No EBA was fully implemented by more than nine (17.6%) clinics. Clinic size variables were inversely related to implementation levels of one-on-one education; medical record variables were directly related to implementation levels of client and provider reminders as well as provider assessment and feedback; and rapid and timely feedback from clinic leaders was directly associated with implementation levels of four out of six EBAs. Given the varying levels of implementation, clinics need to assess current use of implementation strategies and improve effective program delivery to increase colorectal cancer screening among their patients. In addition, clinics should also consider how their characteristics may support or serve as a barrier to implementation in their respective settings.