RecruitingNot ApplicableNCT06682650

Implementation of a ColoRectal Cancer Screening Tool in US Primary Care Practices - Usual Quality Improvement (10 Clinics) vs Normalization Process Theory-Participatory Learning in Action (10 Clinics)

PB-iCRC: Multi-site Practice-Based Implementation of a ColoRectal Cancer Screening Intervention

Sponsor

University of Kansas Medical Center

Enrollment

2,200 participants

Start Date

Apr 30, 2025

Study Type

INTERVENTIONAL

Conditions

Colorectal Carcinoma

Summary

Although implementation intentions (I2)-based tools enhance colorectal cancer (CRC) screening uptake, prior studies have not tested their implementation into routine primary care delivery. In this study, investigators will conduct a cluster-randomized trial in 20 US primary care clinics. Specific aims for the project will be: 1) to test whether a Normalization Process Theory-informed Participatory Learning in Action (NPT-PLA intervention) implementation of a proven implementation Intentions-based colorectal cancer screening tool ("I2") improves screening uptake (i.e. screening order and completion) within 6 months of patient enrollment versus usual quality improvement (control) implementation; and 2) to evaluate the facilitators and barriers of each implementation arm using the 2022 expanded Normalization Process Theory (NPT) framework. Multi-disciplinary clinic 'implementation teams' that include clinic staff and patients whose preferred language is Spanish will meet monthly during the first 6 months of clinic participation and aim to integrate into routine primary care the "I2" CRC screening tool, using the NPT-PLA intervention or control approach. The I2 tool addresses the "when," "where" and "how" details of stool sample or colonoscopy screening. The I2 tool will be delivered via an on-line survey or (if patients prefer) by paper form customized for use in English or Spanish. At least 100 patients in each clinic will be enrolled in the first 6 months of clinic participation (2000 in total). All patients eligible for CRC screening will be offered the I2 tool. Their choices will be communicated automatically to clinics for order entry. Primary (Aim 1) outcomes will be CRC screening orders placed (by clinic staff); completion of the I2 tool and CRC screening completion (by patients) over 6 months of patient follow-up. For Aim 2, surveys based on the NPT domains (the "NOMAD") will be used to assess staff comprehension of their role in implementing the I2-based CRC screening tool, its salience, their buy-in, feasibility of altering workflows, and the potential impact of using the tool in their setting. Investigators will conduct summative qualitative focus group discussions in all participating clinics after 6 months of clinic participation. The study will provide important information on barriers and facilitators of embedding NPT-PLA interventions in "real-world" primary care clinical settings.

Eligibility

Min Age: 45 YearsMax Age: 75 Years

Inclusion Criteria4

Clinics participating in the DARTNet Institute /AAFP-affiliated NRN clinic serving communities in which at least 25% of the population prefers Spanish-language.
Clinic implementation teams Patients participating in implementation teams for whom Spanish is their preferred language, who are bilingual in English and Spanish, Clinics Staff will be included who have any contact regarding CRC screening with patients eligible for screening.
Patients whose CRC screening outcomes will be monitored:
adults 45 to 75 years of age who are due for CRC screening, i.e. who have not received a high-sensitivity fecal occult blood test or a fecal immunochemical test within the past year, fecal DNA testing within 3 years, sigmoidoscopy or barium enema within 5 years, or colonoscopy within 10 years; and who receive primary care at least annually from the site.

Exclusion Criteria2

patients ineligible for routine screening based on a personal or close family history of colorectal cancer or who have increased genetic risk of colon cancer.
cognitive or decisional incapacity will be excluded from the implementation teams, after completion of a brief, validate screening tool, the Mini-Cog Exam.

Interventions

BEHAVIORALNPT-PLA

NPT-PLA was developed and initially tested in 5 European countries in the EU-funded RESTORE study. PLA "Participatory Learning in Action" is a set of participatory research techniques in which participants use democratic processes to identify key actions needed to achieve a specific goal e.g. implementation of a tested decision making tool such as I2; and prioritize which of these need to be acted upon first and subsequently (in which order). Normalization Process Theory (NPT) is combined with PLA to help implementation teams using PLA to assess organization capacity and readiness to enact the selected action steps vis-a-vis NPT constructs, iteratively. These are coherence "does everyone understand what needs to be done?"; Cognitive participation "Does everyone who needs to act 'buy in' to take action"; collective action "Is everyone who needs to act taking steps to make the change?'; and reflexive monitoring "After the step has been taken, has it had the desired impact on the goal?"

BEHAVIORALUsual Quality Improvement

Usual quality improvement includes principles of continuous quality improvement, such as Plan-Do-Study-Act cycles, to implement a specific goal. In this study, 'usual QI' methods already in use in 'active comparator' arm will be documented during the baseline assessment of clinical workflows in clinics assigned to that arm; and will be provided with a 'preset protocol' to implement the study shared decision-making tool (I2). Processes that implementation teams in these clinics use to achieve implementation will be documented.