Presentation
Shared Cognition – A Driver to Colorectal Cancer Screening Success
DescriptionBackground:
Colorectal cancer (CRC), a highly treatable disease, remains the third most common cancer and the third leading cause of cancer deaths in the United States (US) [American Cancer Society, 2024]. When detected early, survival is likely. Therefore, screening for CRC is critical to reducing CRC mortality; however, 40% of Americans aged 45 and up do not receive guideline-concordant screenings [Siegel, 2023]. Federally qualified health centers (FQHCs), which serve as a national model for primary care delivery to underserved and uninsured patient populations, care for nearly one-third of all US adults living in poverty [Behr, 2022]. However, FQHCs frequently fall short of cancer screening benchmarks despite their goal to provide comprehensive prevention and treatment services [Zhao, 2024].
Colorectal cancer screenings (CRCS) include stool-based (e.g. Fecal immunochemical test – FIT) and direct visualization methods (e.g., colonoscopy), both of which require effective coordination between patients and providers. Successful screening depends largely on effective coordination to schedule, administer, and manage results appropriately following CRC testing, including appropriate follow-up actions (e.g., cancer treatment). Patient navigation (PN) services can improve vulnerable populations' healthcare access and CRC screening rates [Chen, 2024]. However, these programs often face challenges due to ill-defined roles, inadequate training, and difficulties integrating into clinical workflows [Chan, 2023], which can negatively impact patient safety. Our larger study aims to enhance patient navigation services for CRCS in FQHCs, first by understanding gaps in coordination needed to improve screening rates and outcomes for underserved populations.
Method
We conducted semi-structured interviews with members of frontline staff and patients who recently underwent CRCS at an academically affiliated network of FQHCs in the US Midwest region. For patients, we invited those between the ages of 45 and 75 who had done FIT tests and/or colonoscopies within the past year at selected FQHC clinics. Patients received emails, mail, and phone calls to introduce the study. Patients who expressed interest were scheduled for a 30-minute Zoom (audio-only) interview with consent sent via email. Clinicians received study information via email study and clinic presentations. Interested clinicians responded to the REDCap screening for eligibility survey and scheduled an interview time. Visa gift cards were used to reimburse participants ($65 USD for medical providers, $30 USD for clinical staff, patient navigator, or patient). All interviews were conducted by trained research staff and recorded with participant consent. Recordings were transcribed verbatim and stripped of identifying information before analysis. Transcripts were uploaded to Atlas.ti version 23.2.1 [Atlas.ti] for analysis. A mixed inductive-deductive coding approach was used, with two independent coders per transcript and complete consensus resolution (i.e., 100% consensus). Given the study’s focus on coordination, Salas’s Heuristic Critical Considerations for Teamwork (also known as the “C’s of Teamwork”) guided the deductive codes. [Salas, 2015] The qualitative team iteratively reviewed coded excerpts to identify emergent themes, including facilitators and barriers to CRCS.
The CRCS process starts with consultation and/or recommendation for testing from the provider. Once the test was placed, the patient was informed about the test (for the FIT test, the patient received instructions on how to get the sample and return to the clinic; for the colonoscopy, the patient was instructed on bowel preparation and the requirement of having someone accompanying them home after the procedure). Sharing the test result was the last activity of the screening process. This abstract focuses on our primary emerging theme: Shared cognition. This report emphasizes the importance of shared cognition between patients and the care team and within the care team in coordinating colorectal cancer screening, where team members’ knowledge helps them coordinate actions and adapt to task demands and each other (Cannon-Bowers et al. 1993) to ensure safe, high-quality care around CRC screening.
Results:
Twenty-five semi-structured interviews were conducted with 9 clinicians and 16 patients to investigate the current CRCS procedures (FIT test and colonoscopy) and the dynamics of teamwork between clinical teams and patients.
Key findings underscore the need for shared understanding between patients, care team members, and within the care team itself. For FIT tests, patient comprehension of screening importance, sample return, and follow-up steps was crucial. Colonoscopy success hinged on clear preparation instructions. For example, one patient stated: “…if it's something new to a lot of people, they don't understand the dynamics of what actually needs to be done. And I believe one of the biggest barriers for some people, is yes, how to actually take the prep.”
Care teams emphasized the need for coordinated tracking of FIT test completion and consideration of patient preferences. For example, a provider explained: “I have no idea, like, what percentage of colonoscopies that I order are actually being done. Like, I just, we don't have that metric, but I would be curious, um, to know, yeah, and then if, if it's, if it's low, like, you know, why people aren't, aren't able to get them, but I don't, it's not really something that comes up in like follow up visits.”
For both FIT and colonoscopy tests, effective intra-team communication facilitated timely status updates, while standardized instructions for FIT test or colonoscopy preparation were identified as essential for enhancing patient understanding the importance of getting tested and their experience. As stated by one provider when discussing FIT tests: “I think what helps things go successfully is when staff definitely understand how to provide [FIT test] instructions to the patient. So when, staff are comfortable with being able to provide instructions to the patient, then that's gonna make the, that's gonna improve the patient's ability to understand what they need to do, how they need to bring [the FIT test] back. And so I think that that is very helpful…”
Discussion:
Our study has key implications for healthcare practitioners, clinical informaticians, and academics. Firstly, demonstrating the value of HF principles in improving CRCS processes can enhance ROI for healthcare institutions under Medicare’s value-based care model. Our findings highlight the need for standardized workflows and communication in EHRs to improve colorectal cancer screening completion rates and patient outcomes. Lastly, this study supports the development of evidence-based team interventions to enhance teamwork, which is crucial for improving CRCS rates in FQHCs and can increase patient safety by ensuring CRCS is completed accurately. That care is coordinated so that results are reported back to the patient.
Colorectal cancer (CRC), a highly treatable disease, remains the third most common cancer and the third leading cause of cancer deaths in the United States (US) [American Cancer Society, 2024]. When detected early, survival is likely. Therefore, screening for CRC is critical to reducing CRC mortality; however, 40% of Americans aged 45 and up do not receive guideline-concordant screenings [Siegel, 2023]. Federally qualified health centers (FQHCs), which serve as a national model for primary care delivery to underserved and uninsured patient populations, care for nearly one-third of all US adults living in poverty [Behr, 2022]. However, FQHCs frequently fall short of cancer screening benchmarks despite their goal to provide comprehensive prevention and treatment services [Zhao, 2024].
Colorectal cancer screenings (CRCS) include stool-based (e.g. Fecal immunochemical test – FIT) and direct visualization methods (e.g., colonoscopy), both of which require effective coordination between patients and providers. Successful screening depends largely on effective coordination to schedule, administer, and manage results appropriately following CRC testing, including appropriate follow-up actions (e.g., cancer treatment). Patient navigation (PN) services can improve vulnerable populations' healthcare access and CRC screening rates [Chen, 2024]. However, these programs often face challenges due to ill-defined roles, inadequate training, and difficulties integrating into clinical workflows [Chan, 2023], which can negatively impact patient safety. Our larger study aims to enhance patient navigation services for CRCS in FQHCs, first by understanding gaps in coordination needed to improve screening rates and outcomes for underserved populations.
Method
We conducted semi-structured interviews with members of frontline staff and patients who recently underwent CRCS at an academically affiliated network of FQHCs in the US Midwest region. For patients, we invited those between the ages of 45 and 75 who had done FIT tests and/or colonoscopies within the past year at selected FQHC clinics. Patients received emails, mail, and phone calls to introduce the study. Patients who expressed interest were scheduled for a 30-minute Zoom (audio-only) interview with consent sent via email. Clinicians received study information via email study and clinic presentations. Interested clinicians responded to the REDCap screening for eligibility survey and scheduled an interview time. Visa gift cards were used to reimburse participants ($65 USD for medical providers, $30 USD for clinical staff, patient navigator, or patient). All interviews were conducted by trained research staff and recorded with participant consent. Recordings were transcribed verbatim and stripped of identifying information before analysis. Transcripts were uploaded to Atlas.ti version 23.2.1 [Atlas.ti] for analysis. A mixed inductive-deductive coding approach was used, with two independent coders per transcript and complete consensus resolution (i.e., 100% consensus). Given the study’s focus on coordination, Salas’s Heuristic Critical Considerations for Teamwork (also known as the “C’s of Teamwork”) guided the deductive codes. [Salas, 2015] The qualitative team iteratively reviewed coded excerpts to identify emergent themes, including facilitators and barriers to CRCS.
The CRCS process starts with consultation and/or recommendation for testing from the provider. Once the test was placed, the patient was informed about the test (for the FIT test, the patient received instructions on how to get the sample and return to the clinic; for the colonoscopy, the patient was instructed on bowel preparation and the requirement of having someone accompanying them home after the procedure). Sharing the test result was the last activity of the screening process. This abstract focuses on our primary emerging theme: Shared cognition. This report emphasizes the importance of shared cognition between patients and the care team and within the care team in coordinating colorectal cancer screening, where team members’ knowledge helps them coordinate actions and adapt to task demands and each other (Cannon-Bowers et al. 1993) to ensure safe, high-quality care around CRC screening.
Results:
Twenty-five semi-structured interviews were conducted with 9 clinicians and 16 patients to investigate the current CRCS procedures (FIT test and colonoscopy) and the dynamics of teamwork between clinical teams and patients.
Key findings underscore the need for shared understanding between patients, care team members, and within the care team itself. For FIT tests, patient comprehension of screening importance, sample return, and follow-up steps was crucial. Colonoscopy success hinged on clear preparation instructions. For example, one patient stated: “…if it's something new to a lot of people, they don't understand the dynamics of what actually needs to be done. And I believe one of the biggest barriers for some people, is yes, how to actually take the prep.”
Care teams emphasized the need for coordinated tracking of FIT test completion and consideration of patient preferences. For example, a provider explained: “I have no idea, like, what percentage of colonoscopies that I order are actually being done. Like, I just, we don't have that metric, but I would be curious, um, to know, yeah, and then if, if it's, if it's low, like, you know, why people aren't, aren't able to get them, but I don't, it's not really something that comes up in like follow up visits.”
For both FIT and colonoscopy tests, effective intra-team communication facilitated timely status updates, while standardized instructions for FIT test or colonoscopy preparation were identified as essential for enhancing patient understanding the importance of getting tested and their experience. As stated by one provider when discussing FIT tests: “I think what helps things go successfully is when staff definitely understand how to provide [FIT test] instructions to the patient. So when, staff are comfortable with being able to provide instructions to the patient, then that's gonna make the, that's gonna improve the patient's ability to understand what they need to do, how they need to bring [the FIT test] back. And so I think that that is very helpful…”
Discussion:
Our study has key implications for healthcare practitioners, clinical informaticians, and academics. Firstly, demonstrating the value of HF principles in improving CRCS processes can enhance ROI for healthcare institutions under Medicare’s value-based care model. Our findings highlight the need for standardized workflows and communication in EHRs to improve colorectal cancer screening completion rates and patient outcomes. Lastly, this study supports the development of evidence-based team interventions to enhance teamwork, which is crucial for improving CRCS rates in FQHCs and can increase patient safety by ensuring CRCS is completed accurately. That care is coordinated so that results are reported back to the patient.
Authors
Event Type
Oral Presentations
TimeWednesday, April 210:52am - 11:15am EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)