Effectiveness and Implementation of mPATH-CRC: a Mobile Health System for Colorectal Cancer Screening

结直肠癌（CRC）是美国癌症死亡的第二大原因。CRC筛查 降低死亡率，并广泛推荐所有50岁以上的成年人使用，但超过35%的美国人 保持未筛选状态。为了解决CRC筛查的多重障碍（患者、临床医生和系统），我们 团队开发了mPATH-CRC（移动的健康-结直肠癌患者技术），一种患者友好的 个人在常规初级保健访问前使用的iPad程序。mPATH-CRC是CRC 帮助患者做出筛查决定的筛查决策辅助工具，允许患者“自行订购”CRC 筛选测试，并最大限度地减少供应商和系统的障碍。访问后，mPATH-CRC自动发送 选择在关键时刻接受筛查的患者， test.在我们最近完成的450例不同患者的随机对照试验（R 01 CA 178941）中，mPATH- CRC使完成CRC筛查的患者比例翻了一番。为了充分实现mPATH-CRC的 降低CRC死亡率的潜力，该计划现在必须在初级保健实践中实施， 鼓励日常和持续使用。然而，尽管数百种移动的健康（mHealth）工具 近年来，移动健康干预措施的实施和维护的最佳策略 在临床实践中尚不清楚。我们已经制定了一个“高接触”的移动健康实施战略， 在我们先前的研究基础上，并在技术接受模型和动态可持续性的指导下， 框架.我们的战略利用循证要素，包括诊所冠军，促进，定期 数据反馈、后续培训和适应。我们的团队现在建议比较“高”的结果， 使用III型混合研究设计并结合混合方法，将“接触”策略转换为“低接触”策略 在不同样本中评估mPATH-CRC的实施、维护和有效性， 基于社区的实践。该建议的具体目的是：1）在一个集群随机对照 28个初级保健诊所的试验，比较“高接触”循证的实施结果 移动健康实施策略与“低接触”实施策略; 2）在嵌套的前后研究中， 评估mPATH-CRC对在16周访视内完成CRC筛查的影响;以及3）确定 通过调查促进或阻碍mPATH-CRC等移动健康干预措施的维持的因素 并采访诊所工作人员和供应商作为混合方法分析的一部分。该项目可能会减少 通过将循证CRC筛查干预转化为社区，降低CRC发病率和死亡率 实践，直接解决健康人2020和国家癌症登月计划的目标。重要的是， 这些目标的完成将为成功实施其他技术提供重要信息， 在初级保健环境中进行调解干预，解决目前的知识差距。

Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States. Screening for CRC reduces mortality and is widely recommended for all adults starting at age 50, yet over 35% of Americans remain unscreened. To address the multiple barriers to CRC screening (patient, clinician, and system), our team developed mPATH-CRC (mobile PAtient Technology for Health-Colorectal Cancer), a patient-friendly iPad program used by individuals immediately before a routine primary care visit. mPATH-CRC is a CRC screening decision aid that helps patients make a screening decision, allows patients to “self-order” a CRC screening test, and minimizes provider and system barriers. After the visit, mPATH-CRC automatically sends patients who choose to be screened supportive text messages at key times to help them complete their chosen test. In our recently completed randomized controlled trial of 450 diverse patients (R01CA178941), mPATH- CRC doubled the proportion of patients who completed CRC screening. To fully realize mPATH-CRC's potential to decrease CRC mortality, the program now must be implemented in primary care practices in a way that encourages routine and sustained use. However, while hundreds of mobile health (mHealth) tools have been developed in recent years, the optimal strategies for implementing and maintaining mHealth interventions in clinical practice are unknown. We have developed a “high touch” mHealth implementation strategy based on our prior research and guided by the Technology Acceptance Model and the Dynamic Sustainability Framework. Our strategy leverages evidence-based elements including clinic champions, facilitation, regular data feedback, follow-up training, and adaptation. Our team now proposes to compare the results of the “high touch” strategy to a “low touch” strategy using a Type III hybrid study design and incorporating mixed methods to evaluate implementation, maintenance, and effectiveness of mPATH-CRC in a diverse sample of community-based practices. The Specific Aims of the proposal are to: 1) in a cluster-randomized controlled trial of 28 primary care clinics, compare the implementation outcomes of a “high touch” evidence-based mHealth implementation strategy with a “low touch” implementation strategy; 2) in a nested pre-post study, estimate the effect of mPATH-CRC on completion of CRC screening within 16 weeks of visit; and 3) determine the factors that facilitate or impede the maintenance of mHealth interventions like mPATH-CRC by surveying and interviewing clinic staff and providers as part of a mixed-methods analysis. This project could decrease CRC morbidity and mortality by translating our evidence-based CRC-screening intervention into community practice, directly addressing the goals of Healthy People 2020 and the National Cancer Moonshot. Importantly, completion of these aims will yield essential information for successful implementation of other technology- mediated interventions in primary care settings, addressing a current gap in knowledge.