Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods

Abstract

Background: Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors.

Objectives: As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program.

Design: Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program.

Main measures: We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model.

Key results: FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present.

Conclusions: Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter.

Trial registration: ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.

Keywords: Consolidated Framework for Implementation Research; FIT tests; colorectal cancer; configurational comparative methods; fecal immunochemical tests; implementation; screening.

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Dr. Coronado: From November 2014 to August 2015, Dr. Coronado served as a co-investigator on an industry-funded study to evaluate patient adherence to an experimental blood test for colorectal cancer. The study was funded by EpiGenomics. From September 2017 to June 2018, Dr. Coronado served as the Principal Investigator on an industry-funded study to compare the clinical performance of an experimental FIT to an FDA-approved FIT. This study is funded by Quidel Corporation. Dr. Coronado has served as a scientific advisor for Exact Sciences and Guardant Health. All other authors declare no conflicts of interest.

Figures

Figure 1

Implementation Outcome: % of eligible patients mailed a FIT.