Abstract
BackgroundCancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients’ cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system’s goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes.MethodsIn a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR.ResultsBased on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements.ConclusionsPre-implementation changes to CDS may help meet healthcare systems’ evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems.Trial registrationNCT02986230.
Highlights
Cancer is a leading cause of death in the United States
We attended a pilot clinic primary care Primary care providers (PCPs) section meeting, where we presented on the cancer prevention clinical decision support (CDS) and shared decision-making tools (SDMT) under development, which influenced their design
Primary care leadership and registered nurses gave positive feedback on this role continuing with the cancer prevention CDS
Summary
Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. A Healthy People 2020 goal aims to reduce cancer incidence, morbidity, and mortality, including through supporting evidence-based recommendations made by the U.S Preventive Services Task Force (USPSTF), which regularly updates prevention recommendations for common cancers [1] This is relevant in primary care, where patients are most likely to receive a variety of cancer prevention recommendations [2]. Clinical decision support (CDS) systems can be used to inform patients of potential benefits and risks of evidence-based treatment options, providing decision support as envisioned in the Chronic Care Model [10]. CDS systems can identify patients eligible for cancer prevention and screening They can provide decision aids, such as shared decision-making tools (SDMT). Typical cancer prevention SDMT feature an introduction, risks and benefits of available screening modalities, supplementary information like risk calculators, and statements or questions aimed at helping patients decide among available options [15]
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