Academic journal article The Qualitative Report

Clinic Exploration of Care Processes to Promote Colorectal Cancer Screening in Rural Accountable Care Organization Clinics: A Qualitative Case Study

Academic journal article The Qualitative Report

Clinic Exploration of Care Processes to Promote Colorectal Cancer Screening in Rural Accountable Care Organization Clinics: A Qualitative Case Study

Article excerpt

Despite the growing evidence of the benefit of colorectal cancer (CRC) screening to reduce incidence and mortality rate of CRC, CRC screening rate in the United States is still not optimal (American Cancer Society, 2015). According to a recent report from the Center for Disease Control and Prevention (CDC), about one-third of Americans aged 50 to 75 years have not been screened for CRC as recommended by the United States Preventive Services Task Force (Whitlock, Lin, Liles, Beil, & Fu, 2008). Rural residents encounter additional barriers in CRC screening compared with their urban counterparts due to geographic isolation or lack of education opportunities (Cole, Jackson, & Doescher, 2012; Fan, Mohile, Zhang, Fiscella, & Noyes, 2012; Hughes, Watanabe-Galloway, Schnell, & Soliman, 2015; Ojinnaka, Choi, Kum, & Bolin, 2015). The role of health care providers can be critical in increasing CRC screening as physician recommendation is found as a major predictor of CRC screening adherence among rural residents (Atassi, Nemeth, Edlund, Mueller, & Tessaro, 2012; Coughlin et al., 2006; Coughlin & Thompson, 2005; Jillcott Pitts et al., 2013).

To respond to the needs of improving CRC screening, the National Colorectal Cancer Roundtable has recently announced an initiative to increase CRC screening rates in the United States to 80% by 2018, which would result in a total of 203,000 averted CRC deaths from 2013 through 2030 (Meester et al., 2015). The CDC report highlighted that more people may be screened if their clinics or health care providers have a systematic screening protocol (or process). The protocol includes identifying people who are not up-to-date, sending out reminders to persons' homes or community settings, communicating with them of each test, and carefully monitoring adherence or follow-up of abnormal tests (CDC, 2013). American Cancer Society introduced the four essential elements for improved CRC screening rates in primary care practices: physician recommendation, a clinic policy, a clinic reminder system, and an effective communication system between providers and patients (Sarfaty, 2008). Three out of the four elements are related to a well-organized clinical protocol for CRC screening. Therefore, establishing an effective care process for recommending or referring CRC screening is critical.

Previous studies used "process mapping" approaches in healthcare to improve patients' health outcomes and care experiences, by analyzing patient care process, identifying wastes in the care processes, establishing meaningful measures of quality, and developing effective interventions (Daly et al., 2006; Trebble, Hansi, Hydes, Smith, & Baker, 2010; Yabroff, Washingotn, Leader, Neilson, & Mandelblatt, 2003; Zapka, Taplin, Solberg, & Manos, 2003). Several studies analyzed the process of care to examine factors associated with cancer screening in reducing patients' waiting time (Chand, Moskowitz, Norris, Shade, & Willis, 2009) and in the follow-up of abnormal screening tests (Zapka, Taplin, Price, Cranos, & Yabroff, 2010).

Although previous studies provided insights on the importance of understanding the care process to successfully implement CRC screenings, these studies have been primarily focused on the "follow-up process" or "waiting time." Very few studies have examined the entire processes of CRC screening recommendation and referral from the pre-visit moment of care to post-visit follow-ups. Also, the study setting was limited to mostly urban areas (Price, Zapka, Edwards, & Taplin, 2010), which leaves us with a question if these strategies apply to rural primary care settings. Furthermore, the studies that examined one part of the care process (e.g., follow-up) in cancer screening have used mainly quantitative research designs (Price et al., 2010). However, past studies conducted on colorectal cancer screening through qualitative research demonstrated the provision of rich information that informed the current body of knowledge identifying facilitators of CRC screening participation such as awareness of appropriate CRC screening and its purpose, positive attitudes towards CRC screening tests, the motivation for screening (Honein-AbouHaidar et al. …

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