Bridging the gap: Delivering Equitable Colorectal Cancer Screening

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Summary Colorectal cancer (CRC) is the third most common cause of cancer and cancer mortality in the U.S., with significant differences in outcomes in historically marginalized populations. Black individuals have the highest mortality rate for CRC; half of the disparity has been associated with lower screening rates. CRC screening is recommended by the United States Preventative Services Task Force for adults age 45-75. Patient navigation is an evidence-based strategy to increase screening rates among racial and ethnic minorities. While patient navigation is an evidence-based approach to improve screening, there is a gap in understanding the multi-level influences on implementation of such programs across primary care practices, particularly using a health- equity focused, stakeholder-centered approach. Our long-term goal is to promote health equity through understanding contextual factors including system and interpersonal racism and implementation strategies needed to implement patient navigation across primary care settings with diverse racial and ethnic populations. We propose mixed methods along with an advisory board comprised of community organizations to iteratively adapt the patient navigation intervention to consider the patient population, the clinical workflows and staffing, and the community context. Guided by the Practical, Robust Implementation and Sustainability Model (PRISM) and core health and racial equity principles, we aim to increase reach of patient navigation and show effectiveness through improvement in the percentage of Black and Hispanic patients completing CRC screening. We will also utilize longitudinal tracking of implementation strategies to better track implementation or intervention adaptations navigation delivery in order to inform future scale up. We will conduct a stepped- wedged, randomized trial to roll out patient navigation and patient and provider reminders across 15 clinics (3 clinics per step, 5 six-month steps). Implementation strategies will include assessing for readiness, audit and feedback, building a community coalition, engaging consumers, modifying referral tracking, and training and educating clinical stakeholders. We will use the electronic health record data with consideration for the Observational Medical Outcomes Partnership (OMOP) Common Data Model, additional patient-reported data, and study tracking logs to measure reach, effectiveness, adoption, implementation (fidelity, feasibility, acceptability, appropriateness), and will use qualitative measures and site observations to document contextual factors, including examination of discrimination in patient experiences and provider referral patterns that may influence intervention delivery or CRC screening completion. Partnership with the National Committee on Quality Assurance (NCQA) will further allow us to examine sustainability of a community-engaged model for delivery of evidence-based interventions.