Using Context to Improve Implementation of Evidenced-based Interventions for Colorectal Cancer Screening in Rural Primary Care (Precise CRC)

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PROJECT SUMMARY Candidate: Dr. Melinda Davis has a PhD in social developmental psychology and is a Research Assistant Professor in the Oregon Health & Science University (OHSU) School of Medicine (Department of Family Medicine) and Assistant Professor in the OHSU-PSU School of Public Health (Health Behavior). She is the Director of Community Engaged Research for the Oregon Rural Practice-based Research Network (ORPRN) at OHSU. This K07 builds upon her applied experience as a practice facilitator and participatory researcher, addresses critical gaps in scientific training, and provides pilot data for an R01 submission in year 3 in response to PAR-16-238. Guided by a multidisciplinary team of mentors, Dr. Davis will, through this K07, consolidate her skills in implementation science, mixed-methods, and cancer prevention and control. She will also secure her transition to research independence. Research Focus: Bridging the gap between knowledge of evidence based interventions (EBIs) and application in “real world” settings is a critical issue in cancer prevention and control research. Screening for colorectal cancer (CRC) saves lives, yet disparities exist for rural and low-income populations. Although direct mail (DM) programs can increase CRC screening rates by nearly 40%, this EBI is not yet routine practice. Moreover, implementation and intervention outcomes vary widely across settings. Research is needed to inform how best to scale DM programs and to support follow-up colonoscopy on positive fecal tests. Guided by the social ecological model and consolidated framework for implementation research we propose three aims: Aim 1: Identify factors associated with higher levels of primary care practice readiness to implement direct mail programs to increase colorectal cancer (CRC) screening. H1: Leadership culture and higher levels of adaptive reserve will be associated with readiness. Aim 2: Pilot test tailored implementation support for a direct mail program in four rural primary care practices clustered in one Medicaid Accountable Care Organization (ACO). Aim 3: Elucidate barriers, facilitators, and adaptations to direct mail program components and the associated impact on implementation and intervention outcomes. Training Goals: The training proposed fills critical gaps to enable Dr. Davis to conduct trials to improve the identification, adaptation, and implementation of EBIs to improve cancer prevention in rural primary care. The mentoring, training, and research aims ensure scientific growth in three areas: (1) Knowledge of advanced implementation science research methods; (2) Mixed methods research design and analysis; and (3) Leading multidisciplinary teams in cancer prevention and control. Environment: The OHSU Department of Family Medicine provides institutional support for this K07. Research and training activities also utilize the robust infrastructure of the Oregon Rural Practice-based Research Network (ORPRN), Oregon Clinical and Translational Research Institute (OCTRI), Knight Cancer Institute, and the Kaiser Permanente Northwest Center for Health Research. Methods: We will use an intervention mixed method design with embedded convergent and sequential components. To achieve Aim 1, we will conduct a multimodal (email, phone, in-person) survey of ORPRN practices (N~190), which are spread across Oregon's 16 Medicaid ACOs. We use generalized linear mixed models to identify factors associated with higher levels of readiness. To achieve Aim 2, we will use practice facilitation informed by the Getting to Outcomes™ approach, an evidence-based model that uses 10 steps to help organizations implement EBIs, to implement DM programs into four rural primary care clinics clustered in one Medicaid ACO (PacificSource Health Plans). We will assess the number of eligible patients reached (implementation outcomes) and the impact on CRC screening (intervention outcomes) and use a merging approach to cross-tabulate findings from clinic performance data with qualitative themes from observation visits and a baseline assessments of adaptive reserve and practice-readiness. In Aim 3, we will interview key informants from each practice (N~20) to identify DM program adaptations and elucidate barriers and facilitators to implementation. Outcomes: The training and research activities in this K07 fill critical gaps in scientific training for Dr. Davis. Findings provide essential pilot data on practice readiness, implementation strategies, and intervention adaptations which will inform an R01 submission in year 3 in response to PAR-16-238 to scale DM programs across rural clinics served by Oregon's Medicaid ACOs in a two arm pragmatic clinical trial. Findings address NCI agency priorities to implement EBIs and study multilevel interventions, help address long-standing CRC screening disparities, and propel Dr. Davis to research independence.