Project Summary/Abstract Colorectal cancer (CRC) remains the third most common cause of cancer mortality in the US with 53,200 deaths expected in 2021, even though this number could be greatly reduced through appropriate screening.1 Compared to their urban counterparts, individuals living in rural areas experience a 50% higher incidence of CRC (OR 1.50, CI:1.43-1.57) and 35% higher mortality (OR 1.35,CI: 1.26-1.45), with rural segments of the US falling far below the National Colorectal Cancer Roundtable CRC screening goal of 80%.2-4-5 Equally poor results are found for the resolution of a positive fecal immunological test (FIT) result, which occurs in 8% of all patients initially tested with FIT. Only 50 to 55% of individuals with positive FIT results follow through with a diagnostic colonoscopy.7-11 One of the most effective approaches to increasing CRC screening is an evidence-based intervention (EBI) combining a mailed (FIT) and patient navigation (PN).12 Unfortunately, implementation of this EBI in rural settings is limited. Thus, in response to the call to identify strategies for overcoming barriers to the adoption of evidence-based interventions (PAR-19-274), we will evaluate the effectiveness of bundled facilitation implementation strategies to increase uptake of EBI’s for CRC screening. Our aims support the modeling necessary to guide future implementation of the EBI for CRC screening in rural clinics. In Aim 1, we will evaluate the ability of an implementation of an EBI to improve CRC screening and diagnostic colonoscopy rates, defined as completed screening episode (effectiveness) through implementation of an EBI for CRC screening in rural Indiana. We hypothesize that a complete screening episode of CRC screening (FIT or screening colonoscopy), including diagnostic colonoscopy uptake following positive FIT, will be higher following implementation of an EBI and throughout maintenance compared to baseline (usual care). Resolution with diagnostic colonoscopy and repeat screening with FIT will be handled as exploratory outcomes. In Aim 2 we will evaluate the variation in contextual factors (innovation, recipient, inner and outer context), implementation strategies and implementation outcomes (reach and implementation) using mixed data (qualitative interviews and quantitative measures) to build implementation profiles of nine rural clinics. In Aim 3, we estimate the cost and budget impact of the deployment of implementation strategies and processes for rural clinics and evaluate the cost-effectiveness of implementing and sustaining the CRC screening intervention.

Project Narrative Colorectal cancer (CRC) disproportionately affects rural areas, where CRC screening falls far below national guidelines. Although evidence-based CRC interventions exist, many rural primary care practices have not implemented these interventions. Therefore, in partnership with the Indiana Rural Health Association, we propose a study to test implementation of an evidence-based CRC intervention into primary care practices to increase CRC screening and support future implementation.