CRCCP Workgroup Update

CPCRN Annual MeetingOctober 4, 2013

Workgroup leaders: Peggy Hannon, Cam Escoffery, & Annette Maxwell

OverviewCRCCP & CPCRN workgroup

2012 Grantee Survey

Projects in progressIn-depth interviews2013 survey

2013-14 work-plan

Colorectal Cancer Control Program (CRCCP)Goal: Increase CRC screening to 80% by 2014

Provide screening to un/underinsured

Promote screening population-wide

CRCCP Grantees

Community Guide Strategies

5 strategies* to promote CRC screening:

Client-orientedSmall mediaClient remindersReducing structural barriers

Provider-orientedProvider remindersProvider assessment and feedback

*One-on-one education was added in 2012

Opportunity for CPCRNMission: Accelerate evidence-based intervention (EBI) adoption

Shift in CDC’s approach from NBCCEDP to CRCCP

Grantees urged to use Guide-recommended EBIs

CRCCP Workgroup GoalsStudy EBI adoption, implementation, maintenance

Implement Annual Grantee Survey 2011-2014

Develop additional studies

Annual Grantee Survey Goals

1. Understand how grantees are implementing CDC’s Colorectal Cancer Control Program (CRCCP)

2. Establish a baseline to assess how implementation changes each year

3. Collect information related to technical assistance and training needs

D&I Frameworks Guiding Survey

RE-AIM with focus on Adoption, Implementation and Maintenance of 5 Community Guide strategies

Interactive Systems Framework for Dissemination and Implementation

Prevention Support System (training and technical assistance)

ANNETTE’S SLIDES STARTING HERE

Grantees & Unfunded Sites

2012 Survey

Methods

Survey completed by person responsible for day-to-day management of the CRCCP or the BCCEDP

Grantee Sample (2011, 2012, 2013, 2014): 29 CRCCPs (25 states and 4 tribes) across the U.S.

Unfunded Sample (2012): 33 BCCEDPs

Design: Online survey administered annually

2012 Survey Administration & Participation

Survey administered via Web, Sep 28 to Dec 10, 2012

29 CRCCP Grantees completed the survey (100%)

24 of 33 Unfunded states and tribes completed the Unfunded Survey (73%). NBCCEDP grantees were approached for completion of the Unfunded Survey.

Respondents of both surveys were similar with respect to their role in the organization and level of experience.

Screening Promotion

EBI Use by CRCCP Grantees

2011 & 2012 – small changes

Small media

Client re

minders

Reduc

ing stru

ctura

l barrie

rs

Provid

er remind

ers

Provid

er ass

ess/f

eedba

ck0%

20%

40%

60%

80%

100%

120%

96%

75%

50%

32%

50%

97%

76%

59%

38%45%

2011 (N=28)2012 (N=29)

2012: Grantees Use More EBIs than Unfunded Sites

Small media

Client re

minders

Reduc

ing stru

ctura

l barrie

rs

Provid

er remind

ers

Provid

er ass

ess/f

eedba

ck0%

20%

40%

60%

80%

100%

120%

97%

76%

59%

38%45%50%

21% 25%17% 12%

Grantees (N=29)Unfunded Sites (N=24)

Use of Patient Navigators to promote CRC screening

Most common navigator activitiesPatient educationScheduling appointmentsReminder calls for bowel prep or appointments

2011: 18/28 grantees used PN to promote screening (64%)2012: 21/29 grantees used PN to promote screening (72%)

2012: 4/24 unfunded organizations used PN to promote screening (17%)

Screening Provision

CRC Screening ProvisionGrantees

(N=29)

Unfunded Organizations

(N=24)

N % N %Offered Any CRC Screening Test

29 100% 12 50%

Primary Screening Test Offered

Colonoscopy 13 45% 8 33%

Fecal occult blood test 5 17% 4 17%

Fecal immunochemical test 10 35% 0 0%

Sigmoidoscopy 1 3% 0 0%

• All of the grantees but only half of the unfunded sites offered any CRC screening test.

• About half of the grantees offered FOBT/FIT, while the majority of unfunded sites (8/12=67%) offered colonoscopy.

Patient Recruitment for Screening Provision

Grantees conduct more clinic in-reach activities to provide information and education about CRC screening than unfunded organizations.

Grantees (N=29) Unfunded (N=24)

N % N %

What clinic in-reach activities are conducted to provide information and education about screening provision?

Distribution of brochures about CRC screening

25 86% 13 54%

Tailored letters or communication from health care provider

10 34% 3 13%

Flyers and information about CRC posted in clinic/hospital/health care center

24 83% 10 42%

Pre-reviewing records/charts to identify patients eligible for screening

14 48% 5 21%

Other 10 34% 4 17%None 1 3% 9 38%

Providing Treatment of Patients diagnosed

with CRC via CRC screening provision

More Grantees have resources to support treatment for diagnosed patients than unfunded organizations.

Grantees (N=29) Unfunded (N=24)

N % N %How easy or difficult has it been to secure treatment for diagnosed patients (1=very difficult, 5=very easy), M, SD *

3.21 1.47 2.46 1.41

Are the partners/resources currently supporting treatment for diagnosed patients?

Yes 26 90% 12 50%No 0 0% 2 8%N/A – No patients diagnosed yet 3 10% 10 42%

Desire for Training depends on EBI

Both Grantees and Unfunded Organizations have the greatest need for training and technical assistance with respect to provider assessment and feedback, reducing structural barriers and provider reminders. In addition, almost half of the Unfunded Organizations need TA for small media.

Grantees (N=29) Unfunded (N=24)

N % N %

Would like training or technical assistance

Provider assessment and feedback 20 69% 16 67%Reducing structural barriers 16 55% 13 54%Provider reminders 12 41% 10 42%Patient reminders 6 21% 8 33%Small media 2 7% 11 46%None 5 17% 6 25%

Professional Development & Quality Assurance related to CRC Screening Provision

More Grantees engage in professional development and quality assurance related to CRC screening provision than unfunded organizations.

Grantees (N=29) Unfunded (N=24)

N % N %Does your organization provide CME opportunities? 13 33% 4 17%Does your organization distribute or provide physician education materials?

21 72% 5 21%

Does your organization conduct education outreach visits or webcasts?

15 52% 3 13%

Does your organization distribute clinical guidelines? 26 90% 7 29%Does your organization provide academic detailing as part of screening provision?

6 21% 3 13%

Does your organization collect and monitor clinical data other than the required CCDE for screening or patient navigation?

13 45% 8 33%Does your organization produce performance monitoring reports, and share them with partners?

15 52% 6 25%

Summary2012 Grantee Survey provided a lot of information on• integration with other programs • program implementation • TA needs

• Grantees continue to use more heavily patient-oriented strategies (small media, client reminders) than provider-focused strategies (provider reminders, provider assessment and feedback).

• Patient navigation remains a prominent strategy among CRCCP Grantees.

• Much more activity regarding screening promotion, screening provision and professional development and quality assurance among grantees than among unfunded organizations. Differences in type of screening test offered.

• Results are being disseminated to grantees via annual CRCCP “Grantee Highlights Report” and webinars.

CURRENT CRCCP PROJECTS

In-depth Interview Study

2013 Grantee Survey

Current CRCCP Workgroup Projects

Purpose of the Qualitative Study• Describe the CRCCP grantees’ screening promotion goals• Describe grantees’ experience transitioning from primarily

providing screening services (like in B/C) to integrating population-level promotion activities

• Describe the grantee’s implementation of EBIs (e.g., EBI used, implementation strategy, barriers and facilitators to implementation)

• Explore engagement of partners to promote CRC cancer screening

• Describe efforts to leverage organizational-level policy change

• Identify technical assistance needs for use of EBIs and screening promotion

Interview Instrument

Topic Sample QuestionsUse of EBIs Prioritize probing about systems and organizational

level/policy EBIs first (in this order): reducing structural barriers, provider assessment and feedback, provider reminders, patient reminders, group/1 on 1 education, small media, patient navigation]  Key ComponentsWhat are the key components of the intervention? Or what does it include? Describe how you are implementing [each EBI]? Who have been the main people/groups implementing the activity? Where are you implementing the activity?

Interview InstrumentTopic Sample Questions

Facilitators What factors facilitated using this [EBI]? (e.g., previous experience, partner expertise, a training they attended on the EBI)What technical assistance or other resources did you use, to assist you with implementing [EBI]? Is there additional assistance or other resources that would have helped you plan and implement [EBI]? What are those?

Partnerships If any, what new partnerships have you formed since the beginning of the CRCCP program to promote population-based screening? How would you characterize the effectiveness of these partnerships?What partnerships have you tried to foster but have been unsuccessful?

Interview InstrumentTopic Sample Questions

Policy Change Think about the policy that you view to be the most successful, or that has the potential for most impact. • What was the organization that implemented the policy?• What was the new or revised policy?•Why was this policy adopted?•Who were the players involved in creating or revising the policy? •What process did you undertake to create or revise this policy? •What facilitated the process?• What were some barriers that arose, if any? How did you overcome that/those barrier(s)?•Do you have plans to evaluate the impact of that policy? If so, how?•Do you think this policy will be maintained, why or why not?

Theoretical Frameworks

ISF CFIRCoalition

ActionTheory

EBI Use

ISF=Interactive Systems FrameworkCFIR = Consolidated Framework for Implementation Research

Methods• Sample: Interview at least half of grantees who

adopt many EBIs and those who have organizational/systems changes

• Semi structured guide (~ 1 ½ hr)• Analysis

– Codebook– Thematic analysis in Nvivo– Case stories of successful EBI implementation

or partnerships/policy changes• Emory IRB approval with interviewers added from

UNC and Univ of Co• Pilot interviews conducted in early summer (4

sites)

Preliminary Results

• 14 of 29 grantees interviewed (12 states, 2 tribes)

• Goals– Focused on population level promotion of

screening– A small proportion focused provider

education/prof. development

• Facilitators of EBIs– Data integration (e.g., electronic records)– Collaboration with partners– Integration with other cancer programs

(NBCCEDP, comprehensive cancer)

Shift to Screening Promotion• What helped with the transition?

Well, the infrastructure of the breast and cervical program is from [state] and I think the credibility of that program has made it pretty easy for us to do the work that we’ve in this program.

Well, the initial year it was a shock to have the program shift from the screening program to 30% of it or so screening and the rest of the population focus…Once we got over that we became very excited about doing the population work. It energized staff to spend some time thinking about messaging, health messaging that would really motivate people to get screened…It was also nice to be able to think about how we could add colorectal education for lay health workers.

Policy Change• We have a program called the [state] Cancer

Consortium Challenge that focused on organizational policies for breast, cervical and colorectal cancer screening. I think we had 8 total organizations participate and review their polices for employees around breast, cervical and colorectal cancer screening…We told them we would promote their work and give them an award.

• We asked them to work with their insurance vendor to get an aggregate screening rate for their employees before they started the challenge…and that was the biggest barrier trying to figure out how to do that with them working with their insurance vendor.

Affordable Care Act• To promote population level screening rates, [stat e]

grantee is working to "bridge a partnership with our Medicaid, especially as they start expanding and what not with the new exchange in market place.”

• Although you’ve had healthcare reform in your state, how is the ACA affecting the current one coming out nationally

• Female Respondent. Yes. It’s changing the context a little bit in terms of the availability of the exchange, because we’ve had an exchange for many years. So this will expand the exchange. And it will also, we also have elected to expand Medicaid…So that provision, there will be additional people that will now be eligible for Medicaid that may have only been eligible for safety net or something like that in the past

ACA, cont.• I will so however that we are just starting, and this

is very, very recent, when people call the program to inquire about screening availability, or when we talk to people about the program, we are starting to incorporate more information, as much as we have available, on Affordable Care Act, and encouraging people to, and trying to channel people into the marketplace, so that they can get insurance.

2013 Survey: Grantees Only2013 survey launched 9/17/13

In the field now

New questions Assess EBI reach ACA impact

Collaboration with CRCCP Program Evaluation TeamDevelop Annual Grantee Survey & additional studies

Data collection, analysis, and interpretation

Integrate survey findings with other evaluation activities

Feedback to grantees (highlights report, webinars)

Broader dissemination

Papers and PresentationsPapersGrantees’ use of EBIs, AJPM, in press

Grantees’ use of patient navigation, under review

Comparison of grantees and unfunded sites, in development Presentations (national meetings)2011 National Colorectal Cancer Roundtable

2012 CDC Cancer Conference

2013-14 WORK-PLAN OBJECTIVES

Projects & Products

2013-14 Workplan Objectives

Projects

Analyze in-depth interview data

Complete & analyze 2013 survey

Prepare & field 2014 survey

Collaborate with CDC and others on emerging project and/or training opportunities

Example: NBCCEDP survey

ProductsPapers & conference presentations

Next 6 months:

2012 comparison

Training/TA

Additional topics:

In-depth interview study

Trends in EBI use over time

Screening provision

Discussion

Peggy Hannon Cam Escoffery Annette Maxwellpeggyh@uw.edu cescoff@emory.edu amaxwell@ucla.edu