School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
University of Kansas Cancer Center, University of Kansas Medical Center, Kansas City, Kansas, USA.
Fam Med Community Health. 2021 Dec;9(4). doi: 10.1136/fmch-2021-001326.
To describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).
This study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.
The study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5-9, in one ACO in the Midwestern United States.
Providers, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.
With integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.
Joining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.
描述在美国中西部加入一个问责制医疗组织（ACO）后，8 家农村初级保健诊所实施癌症筛查的常见策略、特定实践障碍、适应措施和决定因素。
本研究采用多案例研究设计。采用目的性抽样方法在 ACO 内确定了一组多样化的诊所。通过焦点小组访谈和工作流程映射收集数据。使用整合实施研究框架（CFIR）指导数据收集和分析。通过诊所和 CFIR 领域交叉分析，确定癌症筛查实施的共同主题和特定实践的决定因素。
该研究包括美国中西部一个 ACO 内的 8 家农村初级保健诊所，定义为农村-城市连续体代码 5-9。
在初级保健诊所工作的提供者、工作人员和管理人员参加了焦点小组。共有 28 人参加，包括 10 名医生；1 名骨科医生；3 名高级实践注册护士；8 名注册护士、质量保证和执业护士；1 名医疗助理；1 名护理协调经理；和 4 名管理人员。
随着与 ACO 的整合，诊所采用了四项新策略来支持癌症筛查：差距清单、小组讨论表、通过年度健康访问进行筛查和信息传播。跨案例分析显示，所有诊所都使用了基于就诊和基于人群的癌症筛查策略，尽管工作流程在各诊所有很大差异。四项策略都根据实践的当地情况进行了调整。参与者表示，加入 ACO 为提高癌症筛查率提供了强有力的外部激励。在诊所层面上，癌症筛查成功的两个主要决定因素是使用电子健康记录（EHR）和让护士充分参与筛查过程。
加入 ACO 可以成为促进农村初级保健诊所癌症筛查实践的积极驱动力。诊所的特点会影响与 ACO 相关的癌症筛查工作的成功；让护士最大限度地发挥其教育和培训的作用，并将癌症筛查纳入 EHR，可以优化癌症筛查工作流程。
