Promoting follow-up of abnormal cancer screening tests using population-basedsystems to support stepped care multilevel intervention

项目概要/摘要 虽然已经确定筛查可以降低乳腺癌、宫颈癌、结肠直肠癌和肺癌的特定死亡率， 对于癌症，只有通过及时跟踪异常筛查结果才能实现筛查效益。未能 接受适当的诊断测试破坏了筛查的好处，并违反了患者的信任， 在他们的供应商和卫生系统。癌症筛查通常在初级保健机构开始， 需要与执行测试或评估结果的其他提供者进行复杂的护理转换。经常 从筛查到诊断评估的过渡需要在主要的 和专科护理。对异常癌症筛查试验的不完全随访是一个持续的挑战 对于在个人（患者、提供者）、团队和 卫生系统水平。我们建议制定、实施、评估和传播一项健康信息 技术（IT）支持的，多层次的，以初级保健为基础的阶梯式护理干预，mFOCUS（多层次 癌症普查的跟进工作），以促进对乳腺癌、子宫颈癌、结直肠癌和 肺部发现。我们将开发和实施mFOCUS在40个初级保健实践网站隶属于三个 初级保健网络。关键的mFOCUS组件包括：系统设计，以促进识别和 通过电子健康记录（EHR）进行跟踪-带有教育的综合人口管理平台 促进围绕异常结果管理的文化变革;个体患者和PCP的使用 提醒和工具;以及随着接触强度的增加而增强的分级护理团队水平（即， 管理外展、患者导航）。一项纳入6，400例受试者的4组随机对照试验（RCT） 对异常筛查结果进行随访的个人将允许检查边缘 和多层次组成部分的累积效力。我们的主要结果将是收到后续行动 根据癌症类型和异常预先定义的评估，在随访到期后120天内进行。 次要结局将评估多水平和跨水平结局，例如患者报告的对他们的 检查结果和随访需求以及对初级保健医生提供的护理的满意度。最后，我们将研究 利用患者、提供者和卫生系统覆盖、采用、实施和维护mFOCUS 调查和定性数据，以审查障碍和促进因素。mFOCUS直接建立在相关 概念模型和团队在全面癌症筛查和预防方面的先前经验， 初级保健人口管理，卫生IT支持的阶梯式护理干预，患者导航，以及 我们有能力将这些研究成果转化为临床实践。这种多层次 随着支付者和卫生系统通过以下方式承担起人口健康的责任， 新的保健筹资和提供模式。

Project Summary/ Abstract While it is established that screening reduces cancer-specific mortality for breast, cervical, colorectal and lung cancer, screening benefits are only realized through timely follow-up of abnormal screening results. Failure to receive appropriate diagnostic testing undermines the benefits of screening, and violates the trust that patients place in their providers and health systems. Cancer screening is often initiated in primary care settings but requires complex care transitions with other providers who either perform the test or evaluate the result. Often the transition from screening to diagnostic evaluation requires a transfer of role/ responsibility between primary and specialist care. Incomplete follow-up of abnormal cancer screening tests represents an ongoing challenge for primary care providers (PCPs) with barriers to follow-up at the individual (patient, provider), team, and health system levels. We propose to develop, implement, evaluate and disseminate a health information technology (IT)-enabled, multilevel, stepped care intervention grounded in primary care, mFOCUS (multilevel FOllowup of Cancer Screening), to promote appropriate follow-up of abnormal breast, cervical, colorectal and lung findings. We will develop and implement mFOCUS at 40 primary care practice sites affiliated with three primary care networks. Key mFOCUS components include: system design to promote identification and tracking through an electronic health record (EHR)-integrated population management platform with education to promote culture change around the management of abnormal results; use of individual patient and PCP reminders and tools; and a stepped-care team-level enhancement with increasing intensity of contact (i.e., administrative outreach, patient navigation). A 4-arm cluster randomized controlled trial (RCT) of 6,400 individuals who are due for follow-up of an abnormal screening result will allow examination of the marginal and cumulative effectiveness of the multilevel components. Our primary outcome will be receipt of follow-up evaluation, pre-defined by cancer type and abnormality, within 120 days of becoming due for follow-up. Secondary outcomes will assess multi- and cross-level outcomes, such as patient-reported knowledge of their test result and need for follow-up and satisfaction with the care provided by their PCP. Finally, we will study the reach, adoption, implementation and maintenance of mFOCUS using patient, provider and health system surveys and qualitative data to examine barriers and facilitators. mFOCUS builds directly upon relevant conceptual models and the team's prior experience in comprehensive cancer screening and prevention, primary care population management, health IT supported stepped care interventions, patient navigation, and our proven ability to translate the results of such research into clinical practice. This type of multilevel intervention will likely increase as payers and health systems take responsibility for population health through new care financing and delivery models.