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。结直肠癌筛查 降低死亡率，被广泛推荐给50岁开始的所有成年人，但超过35%的美国人 保持无筛查状态。为了解决结直肠癌筛查的多重障碍(患者、临床医生和系统)，我们的 团队开发了mPATH-CRC(移动健康患者技术-结直肠癌)，一种患者友好的 个人在例行初级保健访问之前使用的iPad程序。MPATH-CRC是一种CRC 帮助患者做出筛查决定的筛查决策辅助工具，允许患者自行订购结直肠癌 筛选测试，并最大限度地减少供应商和系统障碍。访问后，mPATH-CRC自动发送 选择在关键时间筛查支持性短信以帮助他们完成选择的患者 测试。在我们最近完成的450名不同患者的随机对照试验(R01CA178941)中，mPATH- CRC使完成CRC筛查的患者比例翻了一番。充分实现mPATH-CRC 有可能降低CRC死亡率，现在必须在初级保健实践中以某种方式实施该计划 这鼓励了常规和持续的使用。然而，尽管数百种移动健康(MHealth)工具 是近年来开发的，实施和维护移动健康干预的最佳战略 在临床实践中都是未知的。我们已经制定了一项基于以下内容的高接触移动健康实施战略 以技术接受模型和动态可持续发展为指导的前人研究 框架。我们的战略利用循证要素，包括临床冠军、促进、常规 数据反馈、后续培训和适应。我们的团队现在建议比较“高潮”的结果 使用III型混合研究设计，并结合混合方法，将“接触”策略转变为“低接触”策略 在不同的样本中评估mPATH-CRC的实施、维护和有效性 基于社区的实践。该方案的具体目标是：1)在集群中-随机控制 对28家初级保健诊所进行试验，比较“高接触”循证医学的实施结果 移动健康实施战略和“低接触”实施战略；2)在嵌套的事前研究中， 评估mPATH-CRC对就诊后16周内完成结直肠癌筛查的影响；以及3)确定 通过调查促进或阻碍mPATH-CRC等mHealth干预措施的维持 并采访诊所工作人员和提供者，作为混合方法分析的一部分。这个项目可能会减少 将我们的循证结直肠癌筛查干预措施转化为社区的结直肠癌发病率和死亡率 实践，直接涉及2020年健康人目标和国家癌症登月计划。重要的是 完成这些目标将为其他技术的成功实施提供必要的信息- 调解初级保健环境中的干预措施，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.