Promoting follow-up of abnormal cancer screening tests using population-basedsystems to support stepped care multilevel intervention

项目摘要/摘要 虽然已经确定筛查可以降低乳腺癌、宫颈癌、结直肠癌和肺癌的特定死亡率 癌症，筛查的好处只有通过及时跟踪异常筛查结果才能实现。未能做到 接受适当的诊断测试破坏了筛查的好处，并违背了患者对 在他们的提供者和卫生系统中占有一席之地。癌症筛查通常在初级保健环境中启动，但 需要与执行测试或评估结果的其他提供者进行复杂的护理过渡。经常 从筛查到诊断评估的过渡需要在初级医生之间转移角色/责任 和专科护理。对异常癌症筛查试验的不完全跟踪是一个持续的挑战 初级保健提供者(PCP)在个人(患者、提供者)、团队和 卫生系统水平。我们建议制定、实施、评估和传播健康信息 以初级保健、mFOCUS(多层次)为基础的支持技术(IT)的多层次分级保健干预 癌症筛查的后续行动)，以促进对异常的乳房、子宫颈、结直肠和 肺部发现。我们将在40个初级保健诊所开发和实施mFOCUS，这些诊所隶属于三个 初级保健网络。MFOCUS的关键组成部分包括：系统设计以促进识别和 通过电子健康记录(EHR)与教育相结合的人口管理平台进行跟踪 围绕异常结果的管理促进文化变革；个别患者和PCP的使用 提醒和工具；随着接触强度的增加，逐步加强护理团队级别(即， 行政外展、患者导航)。一项4臂随机对照试验(RCT)，共6,400例 应对异常筛查结果进行随访的个人将允许对边缘进行检查 以及多级组件的累积有效性。我们的主要结果将是收到后续行动 根据癌症类型和异常情况预先定义的评估，在到期后120天内进行随访。 二次结果将评估多水平和跨水平的结果，例如患者报告的对其 测试结果和对随访的需求，以及对其初级保健医生提供的护理的满意度。最后，我们将研究 利用患者、提供者和卫生系统实现、采用、实施和维护mFOCUS 调查和定性数据，以检查障碍和促进者。MFOCUS直接建立在相关 概念模型和团队在全面癌症筛查和预防方面的先前经验， 初级保健人口管理、医疗IT支持的分步保健干预、患者导航和 我们被证明有能力将这类研究的结果转化为临床实践。这种类型的多层次 随着支付者和卫生系统通过以下途径承担人口健康责任，干预措施可能会增加 新的护理融资和提供模式。

Project Summary/ Abstract While it is established that screening reduces cancer-specific mortality for breast, cervical, colorectal and lung cancer, screening benefits are only realized through timely follow-up of abnormal screening results. Failure to receive appropriate diagnostic testing undermines the benefits of screening, and violates the trust that patients place in their providers and health systems. Cancer screening is often initiated in primary care settings but requires complex care transitions with other providers who either perform the test or evaluate the result. Often the transition from screening to diagnostic evaluation requires a transfer of role/ responsibility between primary and specialist care. Incomplete follow-up of abnormal cancer screening tests represents an ongoing challenge for primary care providers (PCPs) with barriers to follow-up at the individual (patient, provider), team, and health system levels. We propose to develop, implement, evaluate and disseminate a health information technology (IT)-enabled, multilevel, stepped care intervention grounded in primary care, mFOCUS (multilevel FOllowup of Cancer Screening), to promote appropriate follow-up of abnormal breast, cervical, colorectal and lung findings. We will develop and implement mFOCUS at 40 primary care practice sites affiliated with three primary care networks. Key mFOCUS components include: system design to promote identification and tracking through an electronic health record (EHR)-integrated population management platform with education to promote culture change around the management of abnormal results; use of individual patient and PCP reminders and tools; and a stepped-care team-level enhancement with increasing intensity of contact (i.e., administrative outreach, patient navigation). A 4-arm cluster randomized controlled trial (RCT) of 6,400 individuals who are due for follow-up of an abnormal screening result will allow examination of the marginal and cumulative effectiveness of the multilevel components. Our primary outcome will be receipt of follow-up evaluation, pre-defined by cancer type and abnormality, within 120 days of becoming due for follow-up. Secondary outcomes will assess multi- and cross-level outcomes, such as patient-reported knowledge of their test result and need for follow-up and satisfaction with the care provided by their PCP. Finally, we will study the reach, adoption, implementation and maintenance of mFOCUS using patient, provider and health system surveys and qualitative data to examine barriers and facilitators. mFOCUS builds directly upon relevant conceptual models and the team's prior experience in comprehensive cancer screening and prevention, primary care population management, health IT supported stepped care interventions, patient navigation, and our proven ability to translate the results of such research into clinical practice. This type of multilevel intervention will likely increase as payers and health systems take responsibility for population health through new care financing and delivery models.