Multilevel health system intervention to increase surveillance colonoscopy for high-risk colorectal polyps

项目摘要/摘要 每年，147,950名美国人被诊断为结直肠癌(CRC)，并导致超过 美国有53,200人死亡。CRC筛查的基础是检测和去除 癌前病变结肠和直肠息肉，可降低结直肠癌发病率和死亡率。一百万美国人 每年在结肠镜检查中被诊断为高危肿瘤(HRN)的特定亚组 与随后的HRN、CRC和死亡风险增加2-5倍相关的大肠息肉 来自中国铁路总公司。清除HRN可预防癌症并挽救生命。因此，专业医学会 建议HRN患者在HRN后3年再次进行结肠镜检查 诊断。虽然许多研究努力都集中在增加对中等风险美国人的结直肠癌筛查，但很少有研究 研究解决了这一高危人群的低监测率问题。 在HRN诊断后缺乏监测是由于多种因素，包括患者(例如，没有 知识监控)、提供者(例如任务过载、结肠镜检查和病理学的解释 )，以及医疗制度(例如，3年后不跟踪或召回HRN患者)障碍。因此，在 为了提高HRN监测率，我们建议实施和评估一项多层次的技术-- 辅助干预，自动可靠地识别HRN患者，提示患者和 当应进行监测时，还可为结肠镜检查的转诊和日程安排提供便利。干预措施将是 在加州大学洛杉矶分校健康中心实施，这是一个拥有超过15,100次筛查的大型学术综合医疗服务网络 每年进行结肠镜检查，诊断出约1,810例HRN。它利用了 代表临床医学、卫生服务研究、医疗信息学、 自然语言处理(NLP)、人口健康、经济学和实施科学。具体的 建议的R01的目的是：1)获取利益相关者对我们建议的多层次干预的观点，以及 评估接受监视结肠镜检查的潜在障碍和促进者；以及2)进行混合型 1有效性-实施集群-评估有效性、实施和成本的随机试验 旨在提高HRN患者的结肠镜监测率的多水平干预。这个 拟议的研究填补了结直肠癌预防方面的一个重要空白，并将重点放在了已经 在CRC研究中基本上被忽视了。此外，这种方法有可能改变临床实践，是 便于携带，用于处理其他类型的息肉和监测间隔，并可适用于其他类型的息肉 面临识别和召回结直肠癌高风险患者的类似挑战的卫生系统。

Project Summary/Abstract Each year, colorectal cancer (CRC) is diagnosed in 147,950 Americans and is responsible for over 53,200 deaths in the United States (U.S). The foundation of CRC screening is the detection and removal of precancerous colon and rectal polyps, which reduces CRC incidence and mortality. One million Americans are diagnosed with high-risk neoplasia (HRN) during screening colonoscopy every year, a specific subgroup of colorectal polyps that are associated with a 2- to 5-fold increased risk for subsequent HRN, CRC, and death from CRC. HRN removal prevents CRCs and saves lives. Consequently, professional medical societies recommend that individuals with HRN undergo surveillance with repeat colonoscopy 3 years after HRN diagnosis. While many research efforts focus on increasing CRC screening for average-risk Americans, few studies address low surveillance rates in this high-risk group. Lack of surveillance after a HRN diagnosis is due to multiple factors, including patient (e.g., no knowledge surveillance is due), provider (e.g. task overload, interpretation of colonoscopy and pathology findings), and healthcare system (e.g., no tracking or recall of HRN patients at 3 years) barriers. Therefore, in order to increase HRN surveillance rates, we propose to implement and evaluate a multilevel, technology- assisted intervention that automatically and reliably identifies patients with HRN, prompts patients and providers when surveillance is due, and facilitates colonoscopy referral and scheduling. The intervention will be implemented in UCLA Health, a large academic integrated health delivery network with over 15,100 screening colonoscopies performed and approximately 1,810 HRN diagnosed annually. It harnesses the strengths of a multidisciplinary research team representing clinical medicine, health services research, medical informatics, natural language processing (NLP), population health, economics and implementation science. The specific aims of the proposed R01 are: 1) to gain stakeholder perspectives on our proposed multilevel intervention and assess potential barriers and facilitators to receipt of surveillance colonoscopy; and 2) to conduct a hybrid type 1 effectiveness-implementation cluster-randomized trial to assess the effectiveness, implementation, and cost of a multilevel intervention aimed to improve colonoscopy surveillance rates for patients with HRN. The proposed study fills an important gap in CRC prevention and focuses on a high-risk group that has been largely neglected in CRC research. Furthermore, this approach has the potential to change clinical practice, is easily portable for addressing other types of polyps and surveillance intervals, and can be adapted for other health systems that face the similar challenge of identifying and recalling patients at elevated risk for CRC.