Implementing Cancer Prevention Using Patient - Provider Clinical Decision Support

 描述(由申请人提供)：数百万美国成年人和青少年没有接受关键的循证预防护理服务。农村人口尤其处境不利，存在多种医疗保健差距，导致一级和二级癌症预防干预率较低。该项目的目标是实施和评估一个复杂的基于Web的、与电子健康记录(EHR)相关的临床决策支持(CDS)系统的有效性，该系统旨在改善初级和继发性癌症预防护理。为了实现这一目标，我们在一个安全的网站中将电子病历数据与循证癌症预防算法联系起来，以：(A)在护理点识别所有未更新癌症预防干预措施的符合条件的患者；以及(B)向患者和初级保健提供者(PCP)和/或初级保健团队的关键成员、认证医务助理(CMA)、适当的循证初级癌症预防干预措施和癌症筛查选项提供护理点。癌症预防-CDS将侧重于为50-74岁的女性进行乳腺癌筛查，为50-75岁的男女进行结直肠癌筛查，为21-65岁的妇女进行宫颈癌筛查，为11-26岁的男女接种人乳头瘤病毒疫苗，以及为所有18岁及以上的成年人转介体重控制和戒烟。疗效的评估是通过将30家初级保健诊所的大约285名PCP和153,000名符合研究条件的患者随机分成三种实验条件之一进行的：第一组：以PCP为重点的CDS干预，其中PCP触发CDS系统的使用，并使患者参与适当的癌症预防策略。第2组：以CMA为重点的CDS干预，CMA触发CDS系统的使用，并在看到他们的PCP之前与患者互动，让他们参与适当的癌症预防策略，PCP将批准或与他们的患者讨论该计划。第三组诊所提供常规护理，没有与癌症预防相关的干预活动。每项研究有10家诊所、95名初级保健医生和51,000名潜在符合条件的患者，这项研究将正式检验这一假设，即在18个月的随访期内，第1组和第2组在以下方面优于第3组：(A)根据美国预防服务工作组的定义，乳腺癌、宫颈癌和结直肠癌的适当筛查率显著更高；(B)11-26岁的男性和女性的人类乳头瘤病毒(HPV)疫苗接种率显著更高。我们进一步假设，第1组和第2组的短期医疗成本高于第3组，但长期成本效益高于第3组。实施研究综合框架(CFIR)和RE-AIM概念框架将用于指导大型农村医疗保健系统干预的实施规划、组织、实施和影响评估。该项目将使那些在接受初级和二级癌症预防方面存在巨大医疗差距和差距的农村人口参与进来。研究结果将推动传播和实施研究方法，以减少医疗服务不足地区数百万人的健康差距并改善医疗保健。

 DESCRIPTION (provided by applicant): Millions of U.S. adults and adolescents do not receive key evidence-based preventive care services. Rural populations are especially disadvantaged with multiple healthcare disparities, resulting in lower rates of primary and secondary cancer prevention interventions. The objective of this project is to implement and evaluate the effectiveness of a sophisticated Web-based, electronic health record (EHR)-linked clinical decision support (CDS) system designed to improve primary and secondary cancer preventive care. To achieve this objective, we link EHR data to evidence-based cancer prevention algorithms in a secure Web site to: (a) identify at the point of care all eligible patients not up o date on their cancer prevention interventions; and (b) present to both patient and primary care provider (PCP) and/or a key member of the primary care team, certified medical assistant (CMA), appropriate evidence-based primary cancer prevention interventions and cancer screening options at the point of care. The Cancer Prevention-CDS will focus on breast cancer screening in women aged 50-74, colorectal cancer screening for both sexes aged 50-75, cervical cancer screening for women aged 21-65, human papilloma virus (HPV) vaccination for both sexes aged 11-26, and referrals for weight management and smoking cessation in all adults aged 18 and older. Effectiveness is assessed by cluster-randomizing 30 primary care clinics with roughly 285 PCPs and 153,000 study-eligible patients into one of three experimental conditions: Group 1: PCP-focused CDS intervention in which the PCP triggers use of the CDS system and engages patients in appropriate cancer prevention strategies. Group 2: CMA-focused CDS intervention in which the CMA triggers use of the CDS system and interacts with the patient to engage them in appropriate cancer prevention strategies before seeing their PCP, who will approve or discuss the plan with their patient. Group 3 clinics provide usual care with no intervention-related activity related to cancer prevention. With 10 clinics, 95 PCPs, and 51,000 potentially eligible patients per study arm, this study will formally test the hypothesis tht Groups 1 and 2 are superior to Group 3 over an 18-month follow-up period with respect to: (a) significantly higher rates of appropriate screening for breast, cervix, and colorectal cancer, as defined by the United States Preventive Services Task Force; and (b) significantly higher rates of human papillomavirus (HPV) vaccination in males and females aged 11-26 years. We further posit that Groups 1 and 2 will have higher short-term health care costs but better long-term cost-effectiveness than Group 3. The Consolidated Framework for Implementation Research (CFIR) and RE-AIM conceptual frameworks will be used to guide implementation planning, organization, conduct, and impact evaluation of the intervention in a large rural healthcare system. This project will engage a rural population with substantial healthcare disparities and gaps in the receipt of primary and secondary cancer prevention. Results will advance dissemination and implementation research methods that can reduce health disparities and improve healthcare for millions in medically underserved areas.