Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial

Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design

Background

Asthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungs^SM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungs^SM intervention into primary care.

Methods

Implementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance).

Discussion

We anticipate that a tailored implementation of Coach McLungs^SM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition.

Trial Registration: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www.clinicaltrials.gov/ct2/show/NCT05059210

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02030-1.

Adaptation of a Mailed-FIT Kit and Patient Navigation Intervention to Increase Colorectal Cancer (CRC) Screening Among Spanish-Speaking Hispanic/Latino Patients

BACKGROUND

Hispanic/Latino populations experience significant barriers to colorectal cancer (CRC) screening. ProCRCScreen is a multicomponent CRC screening program that can help primary care clinics improve CRC screening rates, but it needs adaptation to better meet the health care needs of Spanish-speaking Hispanic/Latino populations.

METHODS

We conducted four focus groups with 22 Spanish-speaking Latino patients and used inductive qualitative content analysis to identify potential program adaptations.

RESULTS

We identified lack of social support for CRC screening and confusion about completing stool-based testing as important barriers to CRC screening. Participants recommended increased specificity of the fecal immunochemical test (FIT) instructions to increase the likelihood of successful test completion, especially for first-time screening. They also endorsed patient navigation for support in completing CRC screening.

DISCUSSION

We adapted the informational materials and workflows for the ProCRCScreen program. Future research to test the adapted program is needed.

Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods

BACKGROUND

Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors.

OBJECTIVES

As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program.

DESIGN

Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program.

MAIN MEASURES

We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model.

KEY RESULTS

FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present.

CONCLUSIONS

Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.

Is Theory Guiding Our Work? A Scoping Review on the Use of Implementation Theories, Frameworks, and Models to Bring Community Health Workers into Health Care Settings

Community health workers (CHWs) are becoming a well-recognized workforce to help reduce health disparities and improve health equity. Although evidence demonstrates the value of engaging CHWs in health care teams, there is a need to describe best practices for integrating CHWs into US health care settings. The use of existing health promotion and implementation theories could guide the research and implementation of health interventions conducted by CHWs. We conducted a standard 5-step scoping review plus stakeholder engagement to provide insight into this topic. Using PubMed, EMBASE, and Web of Science, we identified CHW intervention studies in health care settings published between 2000 and 2017. Studies were abstracted by 2 researchers for characteristics and reported use of theory. Our final review included 50 articles published between January 2000 and April 2017. Few studies used implementation theories to understand the facilitators and barriers to CHW integration. Those studies that incorporated implementation theories used RE-AIM, intervention mapping, cultural tailoring, PRECEDE-PROCEED, and the diffusion of innovation. Although most studies did not report using implementation theories, some constructs of implementation such as fidelity or perceived benefits were assessed. In addition, studies that reported intervention development often cited specific theories, such as the transtheoretical or health belief model, that helped facilitate the development of their program. Our results are consistent with other literature describing poor uptake and use of implementation theory. Further translation of implementation theories for CHW integration is recommended.

Evaluation of a shared decision-making intervention for pediatric patients with asthma in the emergency department

BACKGROUND

Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation.

METHODS

The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study.

DISCUSSION

To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.

The Effects of the Nurse Navigation Program in Promoting Colorectal Cancer Screening Behaviors: a Randomized Controlled Trial

Although screening programs are known and recommended for the early detection of colorectal cancer (CRC), the screening rates for the fecal occult blood test (FOBT) and colonoscopy are very low among adult individuals. Navigation programs, also known as individualized counseling, have recently begun to be used for increasing screening rates. The purpose of this study was to compare the efficacy of the Nurse Navigation Program versus usual care on CRC screening participation and movement in stage of adoption for CRC screening and to examine perceived benefits of and barriers to CRC screening. This study was designed in line with a pre- and posttest two-group methodology. A total of 110 participants (55 nurse-navigated and 55 non-navigated patients) were studied. Data were collected using the following three tools: a sociodemographic information form, the Harvard Colorectal Cancer Risk Assessment Tool, and Instruments to Measure Colorectal Cancer Screening Benefits and Barriers. Following the Nurse Navigation Program, the FOBT (82 and 84%, respectively) and colonoscopy completion rates (15 and 22%, respectively) were significantly higher in the nurse-navigated group than in the non-navigated group at 3 and 6 months follow-up. Following the program, the benefit perceptions of the nurse-navigated group about CRC screening were improved, and their barrier perceptions were reduced. The results showed that the Nurse Navigation Program had significant effects on CRC screening behavior and health-related beliefs concerning CRC screening. Further assessment of the Nurse Navigation Program in different groups should be performed to observe its effects.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

Importance

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

Objective

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

Design, Setting, and Participants

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

Interventions

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

Main Outcomes and Measures

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

Results

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

Conclusions and Relevance

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

Trial Registration

clinicaltrials.gov Identifier: NCT02054598.

Race/Ethnicity and Primary Language: Health Beliefs about Colorectal Cancer Screening in a Diverse, Low-Income Population

Colorectal cancer (CRC) is an important cause of cancer death in adults in the U.S.; screening is effective but underutilized, particularly among minorities. The purpose of this paper was to explore whether health belief model (HBM) constructs pertaining to CRC screening differ by race/ethnicity and primary language. Data were from the baseline surveys of 933 participants (93.5%) in a randomized trial promoting CRC screening in San Francisco. Composite scores for each construct were created from multiple items, dichotomized for analysis, and analyzed using multivariate logistic regression. Most participants were Asian (29.7%) or Hispanic (34.3%), and many were non-English speakers. Non-English speaking Hispanics (p<.001) and English-speaking Asians (p=.002) reported lower perceived susceptibility than non-Hispanic Whites (NHW). Non-English speaking Hispanics reported more and non-English speaking Asians fewer perceived barriers (psychological and structural) than NHW. Understanding how different populations think about CRC screening may be critical in promoting screening in diverse populations.

Who is a community health worker? - a systematic review of definitions

BACKGROUND

Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common understanding among policy makers, programme planners, and researchers.

OBJECTIVE

To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers.

DESIGN

A systematic review of peer-reviewed papers and grey literature.

RESULTS

We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre-service training. These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried.

CONCLUSIONS

This review provides a categorisation of CHWs that may be useful for health policy formulation, programme planning, and research.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions

INTRODUCTION

Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits.

STUDY DESIGN

RCT with data collected from patients at baseline and immediately after the provider encounter.

SETTING/PARTICIPANTS

Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015).

INTERVENTION

Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter.

MAIN OUTCOME MEASURES

CRC screening-related knowledge, discussion, intent, test preferences, and test ordering.

RESULTS

The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%).

CONCLUSIONS

Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02054598.