Miller David P, Snavely Anna C, Dharod Ajay, Wright Elena, Randazzo Aliza, Bundy Richa, Dignan Mark, Foley Kristie L
Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
JAMA Intern Med. 2025 May 5. doi: 10.1001/jamainternmed.2025.0779.
Patient, clinician, and system-level barriers contribute to low colorectal cancer (CRC) screening rates.
To determine whether a more intensive implementation strategy results in greater use of a mobile app targeting multilevel barriers to CRC screening.
DESIGN, SETTING, AND PARTICIPANTS: This hybrid type 3 effectiveness-implementation pragmatic trial of a tablet app for CRC screening was conducted from March 2021 to March 2023. Eighteen community-based primary care practices were randomized to either a low-touch (n = 8) or a high-touch implementation strategy (n = 10). Analysis was completed in October 2024.
All clinics received on-site training and technical support. High-touch clinics received at-elbow support during launch, identification of a clinic champion, audit and feedback, and performance coaching.
The primary outcome included reach-the percentage of eligible patients who completed the CRC app in the month 6 after implementation-and effectiveness-the percentage of screening-eligible individuals after implementation who completed a CRC test within 16 weeks of their index visit, compared with a preimplementation cohort.
Overall, 50 176 patients 18 years and older were seen (33 435 at high-touch and 16 741 at low-touch practices) in the first 6 months after implementation. The mean (SD) age of patients was 55.6 (17.7) years; most patients were female (59%) and had commercial insurance (51%). Overall, 2.0% of participants were American Indian or Alaska Native, 11.2% were Black or African American, 0.1% were Native Hawaiian, 81.1% were White, 4.5% were other race, and 0.3% were unknown. CRC app use started at 5.8% in the high-touch group and 5.3% in the low-touch group in the first month (P = .55), and decreased to 0.9% and 1.0%, respectively, in the sixth month (P = .93). Compared with low-touch clinics, high-touch clinics had similar use of the CheckIn app (odds ratio [OR], 2.8 [95% CI, 0.9-9.0]) and CRC app (OR, 1.7 [95% CI, 1.0-3.0]). After adjusting for month, there was no observed difference in CRC screening after the CRC app was implemented compared with 8 months before implementation (OR, 0.9 [95% CI, 0.7-1.2]).
This study found that use of a patient-facing health app for CRC was low, regardless of implementation intensity. CRC screening completion rates remained unchanged. Challenges of staff turnover, postpandemic fatigue, multiple handoffs in the workflow, and competing time demands may be difficult to overcome with implementation strategies.
ClinicalTrials.gov Identifier: NCT03843957.
患者、临床医生和系统层面的障碍导致结直肠癌（CRC）筛查率较低。
确定更强化的实施策略是否会使针对CRC筛查多层次障碍的移动应用得到更多使用。
设计、设置和参与者：这项针对CRC筛查的平板电脑应用的混合型3期有效性-实施务实试验于2021年3月至2023年3月进行。18个社区基层医疗诊所被随机分为低接触组（n = 8）或高接触实施策略组（n = 10）。分析于2024年10月完成。
所有诊所都接受了现场培训和技术支持。高接触诊所在启动期间获得贴身支持、确定诊所倡导者、审核与反馈以及绩效辅导。
主要结局包括覆盖面——实施后第6个月完成CRC应用的符合条件患者的百分比——以及有效性——与实施前队列相比，实施后筛查符合条件的个体在其首次就诊后16周内完成CRC检测的百分比。
总体而言，在实施后的前6个月内，共诊治了50176名18岁及以上的患者（高接触诊所33435名，低接触诊所16741名）。患者的平均（标准差）年龄为55.6（17.7）岁；大多数患者为女性（59%）且拥有商业保险（51%）。总体而言，2.0%的参与者为美洲印第安人或阿拉斯加原住民，11.2%为黑人或非裔美国人，0.1%为夏威夷原住民，81.1%为白人，4.5%为其他种族，0.3%种族不明。高接触组第一个月CRC应用的使用率为5.8%，低接触组为5.3%（P = 0.55），到第六个月分别降至0.9%和1.0%（P = 0.93）。与低接触诊所相比，高接触诊所对CheckIn应用的使用率相似（优势比[OR]，2.8[95%置信区间，0.9 - 9.0]），对CRC应用的使用率也相似（OR，1.7[95%置信区间，1.0 - 3.0]）。在对月份进行调整后，与实施CRC应用前8个月相比，实施后CRC筛查未观察到差异（OR，0.9[95%置信区间，0.7 - 1.2]）。
本研究发现，无论实施强度如何，面向患者的CRC健康应用的使用率都很低。CRC筛查完成率保持不变。员工流动、疫情后疲劳、工作流程中的多次交接以及相互竞争的时间需求等挑战可能难以通过实施策略克服。
ClinicalTrials.gov标识符：NCT03843957。
