Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation.

BACKGROUND: Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees. OBJECTIVES: To address disparities, we used a modified community engagement approach, Boot Camp Translation (BCT). Research partners, an advisory board, and the rural community informed messaging about CRC outreach and a mailed fecal immunochemical test program. METHODS: Eligible rural patients (English-speaking and ages 50-74) and clinic staff involved in patient outreach participated in a BCT conducted virtually over two months. We applied qualitative analysis to BCT transcripts and field notes. RESULTS: Key themes included: the importance of directly communicating about the seriousness of cancer, leveraging close clinic-patient relationships, and communicating the test safety, ease, and low cost. CONCLUSIONS: Using a modified version of BCT delivered in a virtual format, we were able to successfully capture community input to adapt a CRC outreach program for use in rural settings. Program materials will be tested during a pragmatic trial to address rural CRC screening disparities.

Protocol for an interview-based method for mapping mental models using causal-loop diagramming and realist interviewing.

Causal-loop diagramming, a method from system dynamics, is increasingly used in evaluation to describe individuals' understanding of how policies or programs do or could work ("mental models"). The use of qualitative interviews to inform model development is common, but guidance for how to design and conduct these interviews to elicit causal information in participant mental models is scant. A key strength of semi-structured qualitative interviews is that they let participants speak freely; they are not, however, designed to elicit causal information. Moreover, much of human communication about mental models-particularly larger causal structures such as feedback loops-is implicit. In qualitative research, part of the skill and art of effective interviewing and analysis involves listening for information that is expressed implicitly. Similarly, a skilled facilitator can recognize and inquire about implied causal structures, as is commonly done in group model building. To standardize and make accessible these approaches, we have formalized a protocol for designing and conducting semi-structured interviews tailored to eliciting mental models using causal-loop diagramming. We build on qualitative research methods, system dynamics, and realist interviewing. This novel, integrative method is designed to increase transparency and rigor in the use of interviews for system dynamics and has a variety of potential applications.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas.

BACKGROUND: Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings. METHODS: SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up. DISCUSSION: Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. TRIAL REGISTRATION: Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Primary Care Providers Experiences Implementing Low-Dose Computed Tomography Recommendations for Lung Cancer Screening.

PURPOSE: Describe primary care providers' (PCPs) barriers and facilitators to implementation of lung cancer screening programs in rural settings. METHODS: We conducted qualitative interviews with PCPs practicing in rural Oregon from November 2019 to September 2020. The interview questions and analytic framework were informed by the 2009 Consolidated Framework for Implementation Research. We used inductive and deductive approaches for analysis. RESULTS: We interviewed 15 key participants from 12 distinct health care systems. We identified several Consolidated Framework for Implementation Research factors affecting lung cancer screening implementation. 1) Most PCPs did not have workflows to assist in discussing screening and relied on their memory and knowledge of the patient's history to prompt discussions. PCPs supported screening and managed the patient throughout the process. 2) PCPs reported several patient-level barriers, including geographic access to lung cancer screening scans and out-of-pocket cost concerns. 3) PCPs reported that champions are necessary to create opportunities for local practices to adopt lung cancer screening programs. CONCLUSIONS: Rural-practicing PCPs were supportive of lung cancer screening, however workflow processes, time challenges, and patient-reported barriers remain impediments to improved screening in their clinics. We identified several areas for improvement in lung cancer screening implementation in rural primary care practices, ranging from designing clinic workflows and processes to designating clinic staff to support referral, screening, and follow-up care for patients.

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity.

PURPOSE: Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion. METHODS: We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes. FINDINGS: We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift. CONCLUSIONS: These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

"It's Like Finding Your Way Through the Labyrinth": a Qualitative Study of Veterans' Experiences Accessing Healthcare.

BACKGROUND: The 2014 Veterans Choice Act and subsequent 2018 Veteran's Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks Act (MISSION Act) are legislation which clarified Veteran access to healthcare provided by non-VA clinicians (community care). These policies are of particular importance to Veterans living in rural areas, who tend to live farther from VA medical facilities than urban Veterans. OBJECTIVE: To understand Veterans' experiences of the MISSION Act and how it impacted their access to primary care to inform future interventions with a focus on reaching rural Veterans. DESIGN: Qualitative descriptive design. PARTICIPANTS: United States (US) Veterans in Northwestern states engaged in VA and/or community care. APPROACH: Semi-structured interviews were conducted with a purposive sample of Veterans between August 2020 and September 2021. Interview domains focused on barriers and facilitators of healthcare access. Transcripts were analyzed using thematic analysis. KEY RESULTS: We interviewed 28 Veterans; 52% utilized community care as their primary source of care and 36% were from rural or frontier areas. Three main themes emerged: (1) Veterans described their healthcare experiences as positive but also frustrating (billing and prior authorization were noted as top frustrations); (2) Veterans with medical complexities, living far from healthcare services, and/or seeking women's healthcare services experienced additional frustration due to increased touch points with VA systems and processes; and (3) financial resources and/or knowledge of the VA system insulated Veterans from frustration with healthcare navigation. CONCLUSIONS: Despite provisions in the MISSION Act, Veteran participants described persistent barriers to healthcare access. Patient characteristics that required increased interaction with VA processes exacerbated these barriers, while financial resources and VA system knowledge mitigated them. Interventions to improve care coordination or address access barriers across VA and community care settings could improve access and reduce health inequities for Veterans-especially those with medical complexities, those living far from healthcare services, or those seeking women's healthcare.

Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science.

Introduction: Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods: We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results: All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion: In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.

The Choice! The challenges of trying to improve medical students' satisfaction with their specialty choices.

The authors describe the residency match as a two-step process. The first step, the Choice, is where students use a combination of intuitive and analytic information processing to select the specialty that they believe will provide fulfilment and work-life balance over their entire career. The second step, the Match, uses a "deferred-acceptance" algorithm to optimize pairing of students and their specialty choices. Despite being the rate-limiting step, in the minds of students and other stakeholders, the outcomes of the Choice have typically been eclipsed by the outcomes of the Match. A recently published study found that during their second year of residency training, one in 14 physicians reported specialty choice regret, which associates with symptoms of burnout in residents. While the obvious solution is to design interventions that improve the specialty choices of students, this approach faces significant challenges, including the fact that: 1) satisfaction with specialty choice is a difficult-to-define construct; 2) specialty choice regret may be misattributed to a poor choice; and 3) choosing is a more complicated process than matching. The authors end by suggesting that if we hope to improve satisfaction with specialty choice then we should begin by defining this, deciding when to assess it, and then creating assessment tools for which there is validity evidence and that can identify the underlying causes of specialty choice regret.

Les auteurs décrivent le jumelage des résidents comme un processus en deux étapes. La première étape, le Choix, est celle où les étudiants utilisent une combinaison de traitement intuitif et analytique de l'information pour sélectionner la spécialité qui, selon eux, leur apportera l'épanouissement et l'équilibre entre leur vie professionnelle et leur vie privée tout au long de leur carrière. La deuxième étape, le Match, utilise un algorithme « d'acceptation différée ¼ pour optimiser le jumelage des étudiants et de leurs choix de spécialité. Bien qu'ils soient l'étape limitante du processus, selon les étudiants et d'autres parties prenantes, les résultats du Choix sont généralement éclipsés par ceux du jumelage. Une étude récemment publiée a révélé que, durant leur deuxième année de résidence, un médecin sur quatorze regrette d'avoir choisi une spécialité, ce qui est associé à des symptômes d'épuisement professionnel chez les résidents. Bien que la solution évidente soit de développer des interventions qui améliorent les choix de spécialité des étudiants, cette approche pose des défis importants, notamment le fait que : 1) la satisfaction à l'égard du choix de la spécialité est un concept difficile à définir ; 2) le regret du choix de la spécialité peut être attribué à tort à un mauvais choix ; et 3) le choix est un processus plus complexe que le jumelage. Les auteurs concluent en suggérant que si nous espérons améliorer la satisfaction à l'égard du choix de la spécialité, nous devrions commencer par définir ce concept, décider quand l'évaluer, puis créer des outils d'évaluation pour lesquels il existe des preuves de validité et qui peuvent identifier les causes sous-jacentes des regrets à l'égard du choix de la spécialité.

System dynamics modeling for cancer prevention and control: A systematic review.

Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.

Cardiovascular Fellowship Training in Cardio-Obstetrics: JACC Review Topic of the Week.

The United States has the highest maternal mortality in the developed world with cardiovascular disease as the leading cause of pregnancy-related deaths. In response to this, the emerging subspecialty of cardio-obstetrics has been growing over the past decade. Cardiologists with training and expertise in caring for patients with cardiovascular disease in pregnancy are essential to provide effective, comprehensive, multidisciplinary, and high-quality care for this vulnerable population. This document provides a blueprint on incorporation of cardio-obstetrics training into cardiovascular disease fellowship programs to improve knowledge, skill, and expertise among cardiologists caring for these patients, with the goal of improving maternal and fetal outcomes.

Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial.

BACKGROUND: Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost. METHODS: PROMPT was a pragmatic, stepped-wedge, cluster-randomized effectiveness trial of mailed FIT outreach. Participants in the standard condition were mailed a FIT and received live telephone reminders to return it. Participants in the enhanced condition also received a tailored advance notification (text message or live phone call) and two automated phone call reminders. The primary outcome was 6-month FIT completion; secondary outcomes were any colorectal cancer screening completion at 6 months, implementation, and program costs. RESULTS: The study included 27,585 participants (80% ages 50-64, 82% Hispanic/Latino; 68% preferred Spanish). A higher proportion of enhanced participants completed FIT at 6 months than standard participants, both in intention-to-treat [+2.8%, 95% confidence interval (CI; 0.4-5.2)] and per-protocol [limited to individuals who were reached; +16.9%, 95% CI (12.3-20.3)] analyses. Text messages and automated calls were successfully delivered to 91% to 100% of participants. The per-patient cost for standard mailed FIT was $10.84. The enhanced program's text message plus automated call reminder cost an additional $0.66; live phone calls plus an automated call reminder cost an additional $10.82 per patient. CONCLUSIONS: Adding advance notifications and automated calls to a standard mailed FIT program boosted 6-month FIT completion rates at a small additional per-patient cost. IMPACT: Enhancements to mailed FIT outreach can improve colorectal cancer screening participation. Future research might test the addition of educational video messaging for screening-naïve adults.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making.

INTRODUCTION: Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making. METHODS: We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach. RESULTS: Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate. CONCLUSIONS: Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans.

BACKGROUND: The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes. OBJECTIVE: To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery. DESIGN: Phenomenological qualitative study. PARTICIPANTS: Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest. APPROACH: Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis. KEY RESULTS: We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services. CONCLUSIONS: Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.

Engaging stakeholders in the use of an interactive simulation tool to support decision-making about the implementation of colorectal cancer screening interventions.

PURPOSE: We aimed to understand how an interactive, web-based simulation tool can be optimized to support decision-making about the implementation of evidence-based interventions (EBIs) for improving colorectal cancer (CRC) screening. METHODS: Interviews were conducted with decision-makers, including health administrators, advocates, and researchers, with a strong foundation in CRC prevention. Following a demonstration of the microsimulation modeling tool, participants reflected on the tool's potential impact for informing the selection and implementation of strategies for improving CRC screening and outcomes. The interviews assessed participants' preferences regarding the tool's design and content, comprehension of the model results, and recommendations for improving the tool. RESULTS: Seventeen decision-makers completed interviews. Themes regarding the tool's utility included building a case for EBI implementation, selecting EBIs to adopt, setting implementation goals, and understanding the evidence base. Reported barriers to guiding EBI implementation included the tool being too research-focused, contextual differences between the simulated and local contexts, and lack of specificity regarding the design of simulated EBIs. Recommendations to address these challenges included making the data more actionable, allowing users to enter their own model inputs, and providing a how-to guide for implementing the simulated EBIs. CONCLUSION: Diverse decision-makers found the simulation tool to be most useful for supporting early implementation phases, especially deciding which EBI(s) to implement. To increase the tool's utility, providing detailed guidance on how to implement the selected EBIs, and the extent to which users can expect similar CRC screening gains in their contexts, should be prioritized.

Peripartum Cardiomyopathy: Risks Diagnosis and Management.

Peripartum cardiomyopathy is a rare cause of heart failure that occurs during late pregnancy or in the early postpartum period. Delays in diagnosis may occur as symptoms of heart failure mimic those of normal pregnancy. The diagnosis should be considered in any pregnant or postpartum woman with symptoms concerning for heart failure. If there are clinical concerns, labs including N-terminal pro-BNP should be checked, and an echocardiogram should be ordered to assess for systolic dysfunction. Prompt medical treatment tailored for pregnancy and lactation is essential to prevent adverse events. Outcomes are variable, including complete recovery, persistent myocardial dysfunction with heart failure symptoms, arrhythmias, thromboembolic events, and/or rapid deterioration requiring mechanical circulatory support and cardiac transplantation. It is essential that care is provided as part of a multidisciplinary cardio-obstetrics team including obstetrics, cardiology, maternal fetal medicine, anesthesiology, and nursing. All women with peripartum cardiomyopathy should have close follow-up with a cardiologist, although optimal duration of medical therapy following complete recovery is unknown. Women considering a subsequent pregnancy require preconception counseling and close collaboration between obstetrics and cardiology throughout pregnancy.