Parkland-UT Southwestern PROSPR Center: Colon cancer screening in a safety net: Organizational & patient factors influencing guideline-based CRC screening
Completion of the colorectal cancer (CRC) screening process, particularly follow-up of abnormal tests, results in detection of CRC at earlier stages. The process, which involves several steps and interfaces between patients, physicians, and clinic staff, is sub-optimal in the US, especially among under- and un-insured populations. These populations depend on safety-net clinical provider networks for their medical home, so safety-nets hold tremendous potential to reach out and deliver the CRC screening process to those needing it most. Safety-net patients and amp;apos; degree of social disadvantage (e.g., income, housing situation, social network and amp; support) makes the screening process particularly challenging to complete. Little is known about how safety-nets address inadequate insurance and patient social disadvantage to overcome these challenges. Organizational factors such as culture, structure, and protocols may be key factors to improving CRC screening in safety-nets.
This project uses qualitative methods (document analysis, participant observation, semi-structured interviews) and quantitative methods (EMR abstraction, hierarchical modeling) to elucidate organizational and patient factors associated with the CRC screening process in Parkland Health and Hospital System (Parkland), the integrated safety-net network for disadvantaged populations in Dallas County. The project has three specific aims: 1) Characterize the organizational factors at the network- and clinic-levels that influence guideline-based CRC screening process among patients in the safety-net network; 2) Characterize patient interactions with the safety-net network during the CRC screening process including those patients enrolled in Projects 1 and 2 of our PROSPR center; 3) Examine the effect of patients and amp;apos; degree of social disadvantage on completion of guideline-based CRC screening and follow-up and organizational factors (characterized in Aim 1) that may modify these relationships. This innovative mixed-methods approach will characterize best practices in CRC screening within a safety-net network. These findings will help address needs of disadvantaged populations and aid development of evidence-based interventions in the complex health care environment of disadvantaged populations.
Human subjects in this project will consist of both selected primary care patients who speak English and/or Spanish, ages 50-64, seeking care at Parkland community-oriented primary care clinics; and selected physicians and staff of those clinics and the GI specialty clinic.
• Inclusion criteria for patient participants include: As stated in the Screening Process Documentation Unit (SPDU) (Parkland-UT Southwestern PROSPR Center IRB #082011-040) we will include Dallas county resident age 50 to 64 years old with at least one visit to a Parkland adult primary care clinic between January 2010–September 2011 or become eligible during the study period (October 2011–September 2016). This method of continued rolling recruitment will maximize identification of screen-eligible patients. We will continue to follow patients in the study cohort database and collect EMR data until the conclusion of the study. Additional criteria to patient participants in interviews include: adults age 50-64, able to read, speak and comprehend English and/or Spanish, the capacity to comprehend study information, and ability to communicate with voice (to participate in interviews). Based on electronic medical record data, patients will be sampled at various points in the screening test follow-up process for semi-structured interviews. Both English and Spanish speakers will be eligible for participation.
• Inclusion criteria for physicians and staff include: current employment with a Parkland primary care or GI specialty care clinic, involved in CRC screening or diagnosis. Both women and men will be eligible to participate but participation is dependent on the current sex (gender) profile of personnel employed in the Parkland network. All physicians and staff that meet the criteria outlined above will be eligible for participation. We anticipate an age range of 18-89 for physicians and staff participants. No racial or ethnic group will be excluded from participation.