Systems Intervention to Promote Colorectal Cancer (CRC) Screening

Colorectal cancer (CRC) is one of the cancers that our community partners have identified as
a priority. It is the second leading cause of cancer death in the United States, and one with
significant disparities in screening, stage of diagnosis, and survival. Underinsured and
uninsured adults are less likely to be screened, more likely to have their cancer diagnosed
at a late stage, and less likely to survive CRC. In this project we will work with
"safety-net" health centers serving Medicaid and uninsured patients in St. Louis City and St.
Louis County in Missouri, and in East St. Louis/St. Clair County in Illinois. Working with
our Colorectal Cancer Community Partnership we planned a cluster-randomized delayed start
trial to test the effectiveness of offering community health centers a "Menu" of
evidence-based systems interventions for increasing rates of CRC screening. The strategies
included in the Menu will be drawn from evidence-based interventions. The control condition
will be usual care, but in concordance with our partners' wishes, we will offer all
participating health centers access to state-of-the-art evidence-based patient education
materials. The primary outcome will be CRC screening adherence as measured by self-report
surveys of a random sample of health center patients. Our evaluation will also be informed by
a chart audit to assess screening referral and completion, surveys of physicians and staff at
intervention sites to assess implementation outcomes, and exit interviews with administration
of intervention health centers to assess maintenance of the intervention strategies. We
developed and will conduct our study adhering to the principles of community-based
participatory research (CBPR). The specific aims are: (1) Working with community partners, we
will select and refine the evidence-based intervention strategies for the trial; (2) Using a
CBPR approach, we will collaborate with our partners to implement and evaluate the
systems-level intervention for its effectiveness in increasing CRC screening rates. (3) Using
the RE-AIM framework, we will work with our partners to evaluate implementation and
maintenance of systems changes by intervention health centers and adoption of the changes by
control centers. Compared to traditional clinics and healthcare providers, safety-net health
centers face additional challenges in implementing evidence-based strategies for increase
screening uptake; yet rigorously testing such strategies in this context is novel. Allowing
health centers to select from a menu of strategies will provide a practical test of
effectiveness, and will increase buy-in and representativeness of participating health
centers. As a practical clinical trial with good external validity, this project has the
potential for significant impact on CRC screening rates with promise for substantial impact
on disparities in CRC burden. This study is responsive to community concerns about CRC and
about no-intervention control groups, and is responsive to the RFA by proposing a CBPR
randomized controlled trial to increase access to and utilization of CRC screening
procedures.

Inclusion Criteria:

- Community health center in the Saint Louis Metropolitan Area, including Southern
Illinois

- Participant in Partnership Planning Process

- Affiliated with the Washington University Program for the Elimination of Cancer
Disparities

Exclusion Criteria:

- Primary patient population has private health insurance.

- Not in an medically underserved area.