A total of 12 CAB members in Kentucky and 10 in Ohio were recruited to the project, and to date, we have held four CAB meetings: in January 2019 (Kentucky), March 2019 (Ohio), May 2019 (Kentucky), and August 2019 (Ohio). Meetings provided CAB members with the opportunity to offer input and recommendations on the proposed objectives and processes of Phase I of ACCSIS Appalachia. Topics for CAB meetings included an overview of the initiative and themes reflected in key informant interviews, summary of clinic and community intervention activities, and requests for feedback on telephone survey materials, as well as suggestions for increasing community participation and engagement at future events.
Key Informant Interviews
We conducted interviews with 24 community members (n=13 in Kentucky, n=11 in Ohio) and 51 clinical stakeholders (n=20 in Kentucky, n=31 in Ohio) in the 12 intervention counties between February and May 2019. On average, the interviews took 45–60 minutes. Key informant interviews identified strengths such as providers encouraging CRC screening among patients and positive and strong community connections, among others. Common CRC screening barriers were described at the A) patient-level (e.g., serious competing priorities, fear of screening procedure and test results, financial concerns); B) provider-level (e.g., time, competing priorities); C) clinic-level (e.g., lack of reminder or tracking system, staff burden); and D) community-level (e.g., cultural issues, societal norms, transportation) (14, 36). Opportunities included having a prevention-focused message with CRC screening options and using acceptable communication channels (e.g., social media, faith community, low literacy print materials) that would leverage the importance of staying healthy for individuals’ families. Lastly, reported threats included negative anecdotal stories, loss of health insurance due to unemployment related to a cancer diagnosis, patient issues related to insurance copayments, incongruence of screening modality suggestions by providers, and ongoing clinic issues with EHR capabilities.
Ultimately, the qualitative findings guided the research team’s decision to create a menu of multilevel (i.e., provider/clinic, patient, community), evidence-based strategies for clinics to choose from to implement in the Year One pilot. In addition, pilot community events held in Year One focused on provision of CRC and screening education in a creative and engaging manner at a well-regarded community location. For example, in Kentucky, the ACCSIS team partnered with a federally qualified health center (FQHC) and cooperative extension to host a community luncheon that included an expert speaker (i.e., nurse practitioner) and tours of an inflatable colon. Subsequent discussions of community-level approaches focused on the need to raise community awareness via multiple communication methods, including health fairs and mass communication mediums (e.g., newspapers, billboards), that CRC is both preventable and treatable.
Pilot Project Implementation
After formative evaluation activities were complete, Year One pilot project activities commenced in two clinics/communities (i.e., one in Kentucky and one in Ohio). Project staff and clinic champions conducted in-person implementation meetings with clinic staff and providers, project team members, and any other interested stakeholders with the goal of reviewing relevant national and local CRC statistics, discussing themes identified in the key informant interviews and environmental scans, reviewing baseline CRC screening rates based on EHR reports, describing the levels of implementation on which to focus, and highlighting possible strategies for each level. In Ohio, the pilot clinic chose patient education (patient-level), provider education (provider-level), and improving EHR reports and alerts and creating a written pathway to care for CRC screening (clinic-level) as strategies to improve CRC screening in their patient population. In Kentucky, the pilot clinic champion, in consultation with clinic staff, selected patient education and fecal immunochemical testing (FIT) reminders/follow-up (patient-level), feedback/assessment and provider education (academic detailing), and developing a screening protocol and improving EHR reporting to increase annual wellness visits (AWVs) (clinic-level). Specific details about each intervention level are described below.
The Ohio pilot clinic implementation team chose Healthy Colon, Healthy Life as the patient-level EBI to implement in their clinic because it offered the potential to reach those patients who do not present in clinic at regular intervals (37). Components included: 1) a phone call from clinic staff to the patient to confirm eligibility, identify stage of change, and provide barrier counseling for CRC screening (i.e., counseling about how to reduce barriers to screening); 2) a mailed fecal occult blood test (FOBT) accompanied by CRC screening educational brochure and a letter from their provider encouraging them to complete the at-home screening test; and 3) a follow-up phone call from clinic staff to the patient if the FOBT was not returned for processing. Adaptations implemented by clinic staff included using the FIT instead of the FOBT and using a Centers for Disease Control and Prevention (CDC) Screen for Life brochure instead of the educational brochure used in the sentinel study. Clinic staff also opted to display CDC Screen for Life posters in their clinic space to facilitate conversation around CRC screening and begin to increase knowledge of the importance of CRC screening. Similarly, the Kentucky clinic chose to provide patient education using Screen for Life materials. They chose to focus their patient-level education on improving distribution and return of FIT. Specifically, they mailed FIT reminder birthday postcards to patients due for annual FIT, and a clinic nurse created a demonstration video on how to complete FIT and Cologuard, which was subsequently publicized on the clinic’s social media pages.
At the provider level, the Ohio clinic chose to implement a provider education EBI that focused on follow-up of abnormal CRC screening tests, consistent with the clinic’s goal of 100% follow-up (38). Components included two small group provider education sessions on CRC and barriers to complete diagnostic evaluation (offered six months apart), a pre-post survey to assess change in knowledge, printed provider education materials, a tailored letter and phone call from the trainer to the provider, a practice-specific report about CRC screening, and an education session evaluation. The clinic adapted this EBI to focus provider education not only on follow-up of abnormal CRC screening, but also education about strategies to increase initial CRC screening. The education was provided by OSU researchers who conducted the hour-long session at the clinic during the clinic lunch break (September 2019). Eight clinic/health system providers and staff members attended. Pre- and post-knowledge data were obtained from the providers: prior to the education session, they averaged 15.3±1.8 CRC knowledge questions correct out of 20 which improved to an average of 18.4±1.5 correct following the education session (p = 0.003).
Similarly, an intervention kickoff event was held by UK researchers in November 2019 to present clinic staff details of their chosen EBIs, which included scheduled biannual expert speakers to provide detail on high-level, pertinent CRC screening topics for providers. The kickoff presentation concluded with an educational session to assist providers with motivating patients to complete CRC screening. However, in previous discussions, the clinic indicated that provider knowledge of screening modalities and guidelines was excellent and should not be the focus of any provider education EBI sessions. Citing patient adherence as a primary factor in low screening rates, the Kentucky clinic chose to implement a provider education EBI that focused on communication strategies providers could utilize to motivate both willing and reluctant patients to complete CRC screening. The education session was provided by UK researchers with expertise in CRC research and communication strategies.
The pilot clinics in Kentucky and Ohio selected clinic-level EBIs they felt would increase CRC screening and were best suited to their needs. The Ohio clinic fine-tuned their use of eClinicalWorks (eCW) to identify patients in need of CRC screening and follow-up and created a written pathway to clinical care for CRC screening and follow-up of abnormal tests. The written pathway documented the combination of the chosen EBIs and how their respective components were assimilated into their existing clinic operations. It also specified the process of identifying patients eligible for screening, ensuring that patients received a CRC screening recommendation (either in-person or via mail), tracking completion of CRC screening in eCW and referral follow-up, monitoring progress and making improvements, as needed.
The Kentucky clinic also developed a CRC screening protocol to ensure implementation fidelity, and they decided to focus on increasing the number of patients who visit the clinic for annual wellness visits (AWV). In making this decision to leverage AWVs to increase CRC screening rates, the clinic pointed out the limited time that providers have to discuss CRC with patients during acute care visits, and also that AWVs are underutilized by patients. AWVs provide the best opportunity and time for providers to discuss CRC and other screenings with patients in detail and use motivational communication techniques to encourage patients to follow through and complete screening. To implement this strategy, the clinic decided on a two-pronged approach: 1) at the patient level, the clinic will send birthday card reminders to patients encouraging them to schedule AWVs; and 2) at the provider/clinic level, the clinic will set goals and provide incentives for providers and staff who increase their respective AWV numbers.
The pilot clinics in both states chose to use the “inflatable colon” (39) to educate community members about polyps, potential symptoms, and the importance of regular CRC screening. In Guernsey County, Ohio, the pilot clinic partnered with a local regional medical center to raise awareness about CRC and related screening (40). Between May and July 2019, an inflatable walk-through colon exhibit was set up at two community events including a local farmer’s market and a festival. This interactive format included guided tours of the colon exhibit by health care professionals to educate 70 lay community members about prevention and early detection of CRC. The participants received a card with CRC cancer screening recommendations and contact information for free or reduced cost screening available in their county. Local media coverage of these events included local radio station and newspaper, along with a video of a guided tour of the colon exhibit posted on Facebook.
A similar event was held in Lewis County, Kentucky in May 2019. The outreach event was held in conjunction with the local county extension office. The event included a presentation from a clinic provider on how to complete FIT and Cologuard tests, a healthy cooking demonstration, a testimonial from a community member about her personal colonoscopy experience, and guided tours of the inflatable colon. Forty-six community members attended the event. Additionally, to help reach patients who may not visit the clinic regularly, members of the Kentucky CAB in the pilot county decided to use mass media to deliver a message that CRC is “preventable, treatable, and beatable.” To that end, a billboard was collaboratively designed with input from Kentucky ACCSIS project team members, clinic staff, and university marketing staff. The billboard was erected in December 2019 in a high-visibility location along a main highway, and it included the aforementioned simple message; the logos of the university, project, and local clinic; a contact phone number for community members to inquire about screening; and a photo of a known practitioner from the clinic.