The outcomes from this QI project suggest that relatively brief practice facilitation combined with academic detailing may be a useful tool to assist primary care practices in the implementation and augmentation of organizational procedures that lead to increased breast cancer, cervical cancer, and/or CRC screening. However, barriers to increased screening remain at the patient, staff, and organizational levels.
Several factors may have contributed to the low screening rates reported by the participating practices. The practices targeted for participation in this project are considered safety-net practices and provide health care services to underserved populations; the low screening rates reported by our practices may be a reflection of the difficulties experienced by their patients in receiving appropriate preventive care. In addition, all the participating practices felt that EHR-based reports likely underreported the true number of patients receiving appropriate screening because of data storage and retrieval issues.
Participation in this project was beneficial to practices to the extent that it initiated the implementation of evidence-based strategies to increase engagement with patients and interventions resulting in sustainable change, including team-based adaptations to office workflows and policies. Rapid-cycle improvements, guided by the project PFs, helped practices make changes to improve screening rates that were tailored to their specific priorities and constraints. Our results further indicate that engagement of the practice site coordinator and provision of educational opportunities for practice staff are particularly important to QI intervention success.
Participation in this project encouraged the initiation of data-mapping activities and efforts to address EHR data recording issues. While participants recognized the potential of EHR-based patient registries to help track and increase patient cancer screening, their current systems and staffing constraints reduced the utility of this tool. The initiation of data entry protocols and data correction procedures laid a foundation for the long-term goals of using reliable and valid clinical data to guide patient care and increasing cancer screening at these practices.
Many of the activities initiated during the practice facilitation period will take a substantial amount of time and additional resources to complete, and their impact could not be fully evaluated during the 6-month project period. In addition, the evaluation period may have been too short to capture increased screening for breast cancer and CRC, which often experience a lag between referral and test completion in certain service areas where there are long waiting lists or scheduling delays for specialist providers.
The measurement of practice-level screening rates may have been artificially inflated or underestimated based on how practices defined their active patient lists as well as the guidelines used to define screening populations (USPSTF vs American Cancer Society). However, we believe the information provided by the practices is the most accurate picture available of the screening rates they use to guide practice initiatives and patient care, and thus are the most applicable to the aims of the project. The project did not have access to patient-level or provider-level data within the enrolled practices and thus was only able to assess changes in patient screening status for practices as a whole.
The TRANSLATE rubric completed by PFs is a subjective evaluation tool. PFs were provided with training at the initiation of the project to enhance the standardization of the evaluations, but variations between PF perceptions of practice systems may have introduced bias to our findings.
J Am Board Fam Med. 2016;29(5):533-542. © 2016 American Board of Family Medicine