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Davis, M., et al.,1 present a compelling analysis showcasing the importance of support staff in the delivery of preventive primary care services, especially in the context of colorectal cancer (CRC) screening. In their study, authors focused on 15 clinics within an urban Federally Qualified Health Center (FQHC). Their analysis unequivocally shows the value of adding staff and promoting a team-based care model to promote CRC screening among patients served by the clinics. Too often though in usual clinical practice, such a team-based, well-supported staff approach often lacks appropriate and sustainable funding further leading clinics away from the recent recommendations for promoting equity in clinical preventive services.2,3
CRC incidence and mortality rates are higher among American Indian/Alaskan Native (AI/AN) individuals compared to White individuals.4 These rates reflect a higher prevalence of risk factors such as diet,5 smoking,6 and the lower receipt of screening.4 Particularly among the AI/AN populations receiving care at the facilities operated by the Indian Health Services (IHS), that provide care to approximately 2.6 million of the 9.7 million AI/AN individuals in the US.7 The IHS provides health care for the AI/AN population either directly or through facilities operated by Tribes or Tribal Organizations via self-determination contracts and self-governance compacts. This health care delivery system is commonly referred to as the as the “I/T/U” system, in which “I” represents Indian Health Service direct health care services, “T” represents Tribally operated health care services, and “U” represents the Urban Indian health care services and resources. In 2021, only 27.9% of individuals seeking care in these settings were up-to-date on CRC screening.8 In addition to consistent funding for IHS, there is growing recognition of the importance of implementation research to inform screening delivery for these facilities.9
Unlike Davis et. al.’s study that was conducted in FQHCs, the University of New Mexico Comprehensive Cancer Center (UNMCCC) in partnership with the Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) is collaborating with four sovereign Tribal Nations and their healthcare facilities to improve CRC screening rates within the tribal communities. Funded by the Cancer Moonshot initiative (NCI: 3P30CA118100-17S3; Sanchez, PI; Mishra, PD),9 the project collaborates with the clinical staff at the healthcare facilities to develop multi-sector action teams that select, adapt, and implement contextually-relevant Community Preventive Services Task Force recommended10,11 evidence-based interventions and strategies for promoting the uptake of CRC screening. Guided by the principles of Community Based Participatory Research (CBPR),12 these multi-sector healthcare action teams have representatives, varying in configuration between healthcare facilities, from health administration, physicians, clinic nursing, public health nursing, community health workers, medical records (EHR), purchase/referred care, medical assistants, quality assurance, and patient registration, transportation, pharmacy, and behavioral health.
Facilitated by AASTEC and UNMCCC, the multi-sector healthcare action teams that are essentially made up of the clinical staff have been instrumental in addressing barriers, improving clinical workflows, and implementing evidence-based, contextually relevant interventions and strategies for the delivery of CRC screening services. By recognizing gaps in coordination and services through the initial phases of this CBPR-guided implementation research, some healthcare facilities have recently added patient navigators to ensure care coordination from the community to the healthcare facility and from screening to timely diagnostic, treatment, and follow-up services. Of importance here, are the efforts put forth by the clinic champions (from among the clinic staff), that cultivate a learning climate, engage key individuals in the clinic, and overcome institutional silos for healthcare change.
In summary, our efforts to engage and improve nonphysician staff support to improve CRC screening rates are aligned with the observations noted in the Davis et al. study.1 Through the ongoing project we hope to delineate the processes by which multi-sector healthcare teams plan and guide the implementation of contextually-relevant evidence-based strategies and other promising practices for their healthcare settings. Continued study of these collaborative approaches as a component of cancer control is especially critical within the I/T/U healthcare facilities, which are chronically under-resourced and usually funded at just 50% of need. Further elucidation of the implementation and impact of a multi-sector, team-based approach in the delivery of clinical preventive services in resource-limited primary care settings is warranted and may hold enduring promise towards achieving equity in the face of persistent cancer disparities.
References
1. Davis MM, Schneider JL, Petrik AF, Miech EJ, Younger B, Escaron AL, Rivelli JS, Thompson JH, Nyongesa D, Coronado GD. Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff. The Annals of Family Medicine. 2022 Mar 1;20(2):123–129. PMID: 35346927
2. Carey TS, Bekemeier B, Campos-Outcalt D, Koch-Weser S, Millon-Underwood S, Teutsch S. National Institutes of Health Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services. Ann Intern Med. American College of Physicians; 2020 Feb 18;172(4):272–278.
3. Bretthauer M, Kalager M. Disparities in Preventive Health Services: Targeting Minorities and Majorities. Ann Intern Med. American College of Physicians; 2020 Feb 18;172(4):287–288.
4. Kratzer TB, Jemal A, Miller KD, Nash S, Wiggins C, Redwood D, Smith R, Siegel RL. Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer. CA: A Cancer Journal for Clinicians [Internet]. [cited 2022 Dec 29];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.3322/caac.21757
5. Warne D, Wescott S. Social Determinants of American Indian Nutritional Health. Curr Dev Nutr. 2019 Aug;3(Suppl 2):12–18. PMCID: PMC6700461
6. Islami F, Goding Sauer A, Miller KD, Siegel RL, Fedewa SA, Jacobs EJ, McCullough ML, Patel AV, Ma J, Soerjomataram I, Flanders WD, Brawley OW, Gapstur SM, Jemal A. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018 Jan;68(1):31–54. PMID: 29160902
7. Leston J, Reilley B. Toward a New Era for the Indian Health System. New England Journal of Medicine. Massachusetts Medical Society; 2021 Sep 30;385(14):1249–1251. PMID: 34569731
8. GPRA Report Summary 2021 | Government Performance and Results Act (GPRA) [Internet]. Quality. 2021 [cited 2023 Feb 28]. Available from: https://www.ihs.gov/quality/government-performance-and-results-act-gpra/...
9. Accelerating Colorectal Cancer Screening and follow-up through Implementation Science (ACCSIS) [Internet]. [cited 2022 Dec 29]. Available from: https://healthcaredelivery.cancer.gov/accsis/
10. Colorectal Cancer Screening: Patient Navigation | The Community Guide [Internet]. 2023 [cited 2023 Feb 28]. Available from: https://www.thecommunityguide.org/findings/cancer-screening-patient-navi...
11. What Works Fact Sheet: Cancer Screening | The Community Guide [Internet]. 2023 [cited 2023 Feb 28]. Available from: https://www.thecommunityguide.org/resources/what-works-cancer-screening....
12. Wallerstein N, Duran B, Oetzel JG, Minkler M. Community-Based Participatory Research for Health: Advancing Social and Health Equity [Internet]. Wiley; 2017. Available from: https://books.google.com/books?id=Gkk3DwAAQBAJ
Acknowledgements: This research was supported by supplements to the UNMCCC CCSG NIH/NCI 3P30CA118100 (Sanchez, PI; Mishra, PD) and the UNMCCC Behavioral Measurement and Population Science and Biostatistics Shared Resources. The authors are extremely grateful to the study participants for their engagement and collaboration on this research project.