Improving Access to Gastrointestinal Endoscopy in the Covid-19 Recovery Phase and Beyond

背景：确保获得资源有限的专科护理是VHA面临的持续挑战，也是 VHA、VISN和设施领导权优先。新冠肺炎疫情只会加剧这一挑战， 特别是在程序服务方面。高容量胃肠道(GI)内窥镜检查的积压工作现在越来越多 结肠镜检查等手术是VHA高度成功的结直肠癌(CRC)的核心组成部分 预防计划。因此，人们担心对下游结果的不利影响，例如 及时诊断和治疗结直肠癌。因此，迫切需要有系统的战略，以确保 在大流行后继续接受结肠镜检查。替代普通风险筛查结肠镜检查 以粪便为基础的筛查(即粪便免疫化学检测，FIT)是循证实践(EBP) 在不影响质量的情况下改善内窥镜检查通道的最大潜力。这些测试是指导性的- 推荐的，非常有效的，但没有得到充分利用。尽管2020年3月VACO指令要求 在大流行期间优先使用FIT而不是结肠镜进行中等风险结直肠癌筛查，许多VHA 设施未能有效地实施和/或维持这一EBP。我们假设造物主， 部署和促进使用实施《行动手册》--多层次实施简编 战略-将优化和维持基于FIT的结直肠癌筛查的设施级采用，并全面改善 结肠镜检查通道。在此启动计划中，我们将与VISN 10合作开发和部署 《行动手册》，确定实施的障碍和促进者，并改进衡量和评估 监控EBP使用和跟踪持续绩效所需的框架和相关工具。这项工作将 为全面的PII提案奠定坚实的基础，重点是该EBP的多站点传播和评估，如 一种改善整体内窥镜检查通道的机制。 意义/影响：优化和持续采用基于适合度的筛查不仅有助于VHA解决 COVID后恢复期的程序积压，但更重要的是将帮助VHA解决 通过减少结肠镜检查需求和改善整体内窥镜检查途径来应对慢性接入挑战。 具体目标：目标1：共同设计执行《行动手册》--促进 基于FIT的CRC筛查的最优化和可持续性。目标2：在第2阶段试行实施“剧本” VISN 10内窥镜设备，并完善评估、数据收集、分析和报告计划。 方法：在目标1中，我们将与2个VISN 10设施合作，共同设计和改进实施 《攻略》--一个交互式在线工具库，用于促进基于FIT的优化和可持续发展 放映。项目组将通过定期会议促进和鼓励这一进程，从而产生 针对患者、提供者和系统级别的工具概要，由公认的 实施战略。在目标2中，我们将在两个VISN 10站点试行实施《行动手册》，以进一步 改进和调整干预措施，并找出实施的潜在障碍和促进者。每个人 作为该试点的一部分，启动设施将在每个级别实施一个或多个工具。此外，我们将完善我们的 衡量和评价框架，包括开发评价和报告工具(例如， 访谈指南、针对具体设施的反馈报告)，为计划中的完整QUERI VISN PII提案做准备。 实施/下一步：本启动计划中提出的活动将为全面 QUERI PII提案侧重于多地点传播和评估这一EBP，作为一种机制 改善整体内窥镜检查通道。这笔赠款的产品将包括：(1)执行《行动手册》， VA设施可以用来提高基于FIT的筛查的接受度，减少结肠镜检查的需求；(2) 监测EBP吸收和可持续性的评价和报告工具；以及(3)衡量和评价 支持传播和评估干预措施的框架，以增强整体内窥镜检查的可及性。

Background: Ensuring access to resource-limited specialty care is an ongoing challenge for VHA, and a top priority of VHA, VISN and facility leadership. The COVID-19 pandemic has only exacerbated this challenge, particularly for procedural services. Backlogs are now growing for high-volume gastrointestinal (GI) endoscopic procedures such as colonoscopy, a central component of VHA’s highly successful colorectal cancer (CRC) prevention program. As a result, there are concerns about adverse impacts on downstream outcomes, such as timely diagnosis and treatment of CRC. Thus, there is an urgent need for systematic strategies to ensure ongoing access to colonoscopy in the wake of the pandemic. Replacing average-risk screening colonoscopy with stool-based screening (i.e., fecal immunochemical testing, FIT) is the evidence-based practice (EBP) with the greatest potential to improve endoscopy access without compromising quality. Such tests are guideline- recommended and highly effective, yet underutilized. Despite a March 2020 VACO directive mandating preferential use of FIT over colonoscopy for average-risk CRC screening during the pandemic, many VHA facilities have failed to effectively implement and/or sustain this EBP. We hypothesize that creation, deployment, and facilitated use of an implementation “playbook”—a compendium of multi-level implementation strategies—will optimize and sustain facility-level uptake of FIT-based CRC screening and improve overall colonoscopy access. In this startup proposal, we will partner with VISN 10 to develop and deploy this “playbook,” identify barriers and facilitators to implementation, and refine the measurement and evaluation framework and associated tools necessary to monitor EBP use and track ongoing performance. This work will lay a solid foundation for the full PII proposal focused on multi-site dissemination and evaluation of this EBP as a mechanism to improve overall endoscopy access. Significance/Impact: Optimizing and sustaining uptake of FIT-based screening will not only help VHA address procedural backlogs during the post-COVID recovery period, but more importantly will help VHA to tackle chronic access challenges by decreasing colonoscopy demand and improving overall endoscopy access. Specific Aims: Aim 1: Co-design an implementation “playbook” -- a compendium of strategies to promote optimization and sustainability of FIT-based CRC screening. Aim 2: Pilot the implementation “playbook” at 2 VISN 10 endoscopy facilities, and refine evaluation, data collection, analysis, and reporting plans. Methodology: In Aim 1, we will collaborate with 2 VISN 10 facilities to co-design and refine an implementation “playbook” — an interactive online repository of tools to promote optimization and sustainability of FIT-based screening. The project team will facilitate and encourage the process through periodic meetings, resulting in a compendium of tools targeting the patient-, provider-, and system-levels informed by recognized implementation strategies. In Aim 2, we will pilot the implementation “playbook” at two VISN 10 sites to further refine and adapt the intervention and to identify potential barriers and facilitators to implementation. Each startup facility will implement one or more tools at each level as part of this pilot. Additionally, we will refine our measurement and evaluation framework, including development of evaluation and reporting tools (e.g., interview guides, facility-specific feedback reports) in preparation for the planned full QUERI VISN PII proposal. Implementation/Next Steps: The activities proposed in this startup proposal will lay the foundation for a full QUERI PII proposal focused on multi-site dissemination and evaluation of this EBP as a mechanism to improve overall endoscopy access. Products of this grant will include: (1) An implementation “playbook” that VA facilities can use to enhance uptake of FIT-based screening and decrease colonoscopy demand; (2) evaluation and reporting tools to monitor EBP uptake and sustainability; and (3) a measurement and evaluation framework to support dissemination and evaluation of the intervention to enhance overall endoscopy access.