Abstract
BackgroundFew studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Our qualitative study explored viewpoints of multilevel stakeholders before, during, and after implementation of a centralized outreach program. Program implementation was part of a broader quality-improvement initiative.MethodsDuring 2008–2010, we conducted semi-structured, open-ended individual interviews and focus groups at Kaiser Permanente Northwest (KPNW), a not-for-profit group model health maintenance organization using the practical robust implementation and sustainability model to explore external and internal barriers to CRC screening. We interviewed 55 stakeholders: 8 health plan leaders, 20 primary care providers, 4 program managers, and 23 endoscopy specialists (15 gastroenterologists, 8 general surgeons), and analyzed interview transcripts to identify common as well as divergent opinions expressed by stakeholders.ResultsThe majority of stakeholders at various levels consistently reported that an automated telephone-reminder system to contact patients and coordinate mailing fecal tests alleviated organizational constraints on staff’s time and resources. Changing to a single-sample fecal immunochemical test (FIT) lessened patient and provider concerns about feasibility and accuracy of fecal testing. The centralized telephonic outreach program did, however, result in some screening duplication and overuse. Higher rates of FIT completion and a higher proportion of positive results with FIT required more colonoscopies.ConclusionsAddressing barriers at multiple levels of a health system by changing the delivery system design to add a centralized outreach program, switching to a more accurate and easier-to-use fecal test, and providing educational and electronic support had both benefits and problematic consequences. Other health care organizations can use our results to understand the complexities of implementing centralized screening programs.
Highlights
Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs
Primary care providers expressed that they received a “mixed-message” from the organization by being allowed to refer patients to colonoscopy to screen for CRC in average-risk patients, but were not always supported by health plan leaders or specialists for doing so
Success was due in large part to the activation of three different domains within the practical robust implementation and sustainability model (PRISM) framework: changing the delivery system design through centralizing screening efforts; switching to a more accurate and feasible fecal test; and providing educational and electronic support
Summary
Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Recommended CRC screening modalities for average-risk patients include annual fecal occult blood testing (FOBT) or colonoscopy every 10 years, or flexible sigmoidoscopy every 5 years, with or without interval FOBT [5]. As a result of improved test performance and usability, in 2008, multiple professional societies endorsed the use of four types of fecal immunochemical tests (FIT) to replace guaiac FOBT for CRC screening [6]. Population-based screening programs that employ patient-screening reminders [8,9,10,11], provision of stool tests to complete at home [12], and provider feedback are effective for improving uptake of CRC screening [13]. There are few studies [15] on system-level challenges, or on determinants of success, encountered in the process of implementing such programs
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