Improving Access to Gastrointestinal Endoscopy in the Covid-19 Recovery Phase and Beyond

Background: Ensuring access to resource-limited specialty care is an ongoing challenge for VHA, and a top priority of VHA, VISN and facility leadership. The COVID-19 pandemic has only exacerbated this challenge, particularly for procedural services. Backlogs are now growing for high-volume gastrointestinal (GI) endoscopic procedures such as colonoscopy, a central component of VHA's highly successful colorectal cancer (CRC) prevention program. As a result, there are concerns about adverse impacts on downstream outcomes, such as timely diagnosis and treatment of CRC. Thus, there is an urgent need for systematic strategies to ensure ongoing access to colonoscopy in the wake of the pandemic. Replacing average-risk screening colonoscopy with stool-based screening (i.e., fecal immunochemical testing, FIT) is the evidence-based practice (EBP) with the greatest potential to improve endoscopy access without compromising quality. Such tests are guideline- recommended and highly effective, yet underutilized. Despite a March 2020 VACO directive mandating preferential use of FIT over colonoscopy for average-risk CRC screening during the pandemic, many VHA facilities have failed to effectively implement and/or sustain this EBP. We hypothesize that creation, deployment, and facilitated use of an implementation "playbook"-a compendium of multi-level implementation strategies-will optimize and sustain facility-level uptake of FIT-based CRC screening and improve overall colonoscopy access. In this startup proposal, we will partner with VISN 10 to develop and deploy this "playbook," identify barriers and facilitators to implementation, and refine the measurement and evaluation framework and associated tools necessary to monitor EBP use and track ongoing performance. This work will lay a solid foundation for the full PII proposal focused on multi-site dissemination and evaluation of this EBP as a mechanism to improve overall endoscopy access. Significance/Impact: Optimizing and sustaining uptake of FIT-based screening will not only help VHA address procedural backlogs during the post-COVID recovery period, but more importantly will help VHA to tackle chronic access challenges by decreasing colonoscopy demand and improving overall endoscopy access. Specific Aims: Aim 1: Co-design an implementation "playbook" -- a compendium of strategies to promote optimization and sustainability of FIT-based CRC screening. Aim 2: Pilot the implementation "playbook" at 2 VISN 10 endoscopy facilities, and refine evaluation, data collection, analysis, and reporting plans. Methodology: In Aim 1, we will collaborate with 2 VISN 10 facilities to co-design and refine an implementation "playbook" - an interactive online repository of tools to promote optimization and sustainability of FIT-based screening. The project team will facilitate and encourage the process through periodic meetings, resulting in a compendium of tools targeting the patient-, provider-, and system-levels informed by recognized implementation strategies. In Aim 2, we will pilot the implementation "playbook" at two VISN 10 sites to further refine and adapt the intervention and to identify potential barriers and facilitators to implementation. Each startup facility will implement one or more tools at each level as part of this pilot. Additionally, we will refine our measurement and evaluation framework, including development of evaluation and reporting tools (e.g., interview guides, facility-specific feedback reports) in preparation for the planned full QUERI VISN PII proposal. Implementation/Next Steps: The activities proposed in this startup proposal will lay the foundation for a full QUERI PII proposal focused on multi-site dissemination and evaluation of this EBP as a mechanism to improve overall endoscopy access. Products of this grant will include: (1) An implementation "playbook" that VA facilities can use to enhance uptake of FIT-based screening and decrease colonoscopy demand; (2) evaluation and reporting tools to monitor EBP uptake and sustainability; and (3) a measurement and evaluation framework to support dissemination and evaluation of the intervention to enhance overall endoscopy access.