Amputation is a devastating complication of diabetes (DM) and peripheral artery disease (PAD) and a marker for health inequity. Yet, few amputation interventions are tailored for marginalized communities, use implementation science (IS), or community- engaged research (CEnR). Amputation interventions described in the literature include standardized diabetic foot exams (DFEs), multidisciplinary limb preservation teams, and "hot-foot" hotlines. We used IS and CEnR to adapt and implement these evidence-based interventions in a rural high-risk community and assessed 1-year feasibility and acceptability outcomes. The interventions were implemented in two rural clinics. IS models and frameworks (COM-B and CFIR) were used. CEnR methods included the creation of a Community Advisory Board (CAB) with stakeholders and a Project Advisory Board (PAB) with local health care providers. The CAB/PAB collaborated on needs assessments, mobilizing resources, intervention adaptation, and reviewing findings. A mixed methods design was used for data collection and analysis (Fig 1). DFE training was conducted in clinics focusing on needs identified pre-implementation. Prospective chart reviews were performed with virtual clinic check-ins every 6 weeks. Focus groups were held pre- implementation and at 6 months post-implementation. Concurrently, the multidisciplinary limb preservation team model was adapted into a monthly case-based learning teleconference, and a "hot-foot" phone line with standardized triage connected primary providers directly to vascular nurses. At baseline, 107 of 220 (48.6%) patients received an annual DFE, 33.6% had all four exam components, 37.4% had identified foot abnormalities, and 6.5% were referred to a specialist. At 12 months, 290 of 392 (74%) of patients received a DFE, 85.5% had all four components, 73.8% had identified abnormalities, and 26.6% were referred (Table I). All increases were statistically significant and exceeded benchmarks. Qualitative analysis identified clinic-level process changes as important facilitators, and rurality/lack of specialists and patient refusals as barriers. Mixed methods data integration found divergence between the quantitative finding of a 306% increase in referrals to specialists and the qualitative finding that providers did not believe that patients had access to specialty care. The virtual teleconference completed six sessions with 118 total attendees. The "hot-foot" hotline was used once with clinicians reporting they did not need it. We demonstrate successful, sustained implementation of an amputation prevention intervention in a high-risk rural community using IS and CEnR. This approach was crucial for overcoming barriers to intervention implementation in a resource-poor environment. Additional research to assess patient-level experience, better understand key components of the intervention, and study scalability and clinical effectiveness is planned.TableJoint display of amputation prevention intervention implementation metricsImplementation metricsBaseline (n = 220)12 months (n = 392)% Increase(P < .000)Qualitative themesInterview quotesMeta-inferencesIncrease foot exams (anticipated increase 20%)48.6%74%52%aClinic-level process changes'lust the flow is really easy, we'vemade it easy...the team effort is reallygood...1514)"It's in the water now."(56)ConvergentEncountering andaddressing patient refusals"I don't think (the patients are (as shynow.' (58)"They don't fight back as muchwhenever we started laying out wipes...for people to wipe their feet off.-(511)Increase identification of foot abnormalities (anticipated increase 50%)37.4%73.8%97.4%.Clinic-level processchanges"Prior I hadn't really... framed any of mythinking around...the ADA scale....) likehaving that structure and that littlereference card—I think we all keep itaround." (56)ConvergentIncrease referrals to specialists (anticipated increase 50%)6.5%26.6%306%Rurality/isolation/lack of specialists"We have a real problem with travel and people havin' money and cars...(to) get to specialty appointments' (Si)DivergentEncountering and addressing patient refusals"I've been a little bit surprised by...the nervousness of people literally to justcross the mountain" (56)This table shows both quantitative and qualitative data and integrates the methodologies to display meta-inferences. Open table in a new tab

Amputation is a devastating complication of diabetes and peripheral artery disease and a marker for health inequity. Implementation Science (IS) and Community Engaged-Research (CenR) allow for real-world adaptation of evidence-based interventions and provide critical frameworks for reproducibility and sustainability. However, few amputation interventions use these approaches. We describe the feasibility and acceptability of an IS and CEnR driven amputation intervention in a high-risk rural community. A Pre-Post mixed methods design was used (Fig 1). Intervention components were mapped to the Social-Ecological Model (Fig 2) and guided by the CFIR. Community and Project Advisory Boards collaborated on needs assessment, mobilizing resources, intervention adaptation, data review and dissemination. A 3-component intervention was implemented in 2 clinics to improve local foot care. Components included diabetic foot exams (DFEs), a multidisciplinary limb preservation team, and a “hot-foot” hotline. Pre-implementation, a retrospective chart review was performed along with focus groups. DFE training was then conducted at each site. After training, a prospective chart review was performed with clinic check-ins for 12 months. Focus groups were held 6- and 12-months post-implementation. Concurrently, monthly multidisciplinary teleconferences were held, and a “hot-foot” phoneline connected providers to specialty nurses. At baseline, 155/224 (69.2%) patients received an annual DFE, 17% had all four exam components, 15.6% had foot abnormalities identified and 3.6% were referred to specialists. At 12-months 212/268 (79.1%) patients received a DFE, 84.7% had all components, 54.9% had abnormalities and 20.1% were referred. All findings were statistically significant. Clinically there was a significant decrease in patients with foot wounds, infection, and foot-related hospitalization/ED visits. There were no changes in amputations. (Table 1) The virtual teleconference completed 12 sessions. The hotline was used once with clinicians reporting they did not need it. We demonstrate successful, sustained implementation of an amputation prevention intervention in a high-risk rural community using IS and CEnR. This approach was crucial for overcoming barriers to intervention implementation in a resource poor environment. Additional research to assess patient experience, understand key components of the intervention and study scalability and clinical effectiveness is planned.

Introduction:Colorectal cancer is the second leading cause of cancer deaths among men and women in West Virginia. In addition, 51% of all colorectal cancers diagnosed in West Virginia from 2012 to 2016 were detected at either regional (31%) or distant (20%) stages indicating a need for improved early detection.Methods:West Virginia University Cheat Lake Physicians participated in the West Virginia Program to Increase Colorectal Cancer Screening, a program of Cancer Prevention and Control at the WVU Cancer Institute. As a result, Cheat Lake Physicians assembled a team of health care professionals to implement evidence-based interventions and system changes including provider assessment and feedback, patient reminders, accurate data capture, and tracking of CRC screening tests.Results:These efforts resulted in a 15.8% increase in colorectal cancer screening rates within one year of implementation. Additionally, the clinic achieved a 66% return rate for Fecal Immunochemical Test kits, an inexpensive, stool-based colorectal cancer screening test.Implications:The utilization of a team-based approach to patient care yields positive results that can be carried over to other cancer and disease prevention efforts in primary care clinics.

Introduction:Colorectal cancer is the third most common type of cancer in the United States for men and women combined. While the current threat of disease nationally is significant, the majority of colorectal cancer cases and deaths could be prevented through established screening tests and guidelines. Within the Appalachian region and West Virginia in particular, colorectal cancer is a significant public health problem. A more systematic, comprehensive approach to preventing and controlling cancer is essential.Methods:Through the West Virginia Program to Increase Colorectal Cancer Screening, primary care systems across the state received data-informed practice facilitation designed to increase screening rates.Results:Year-1 cohort health systems had an overall baseline screening rate of 28.4% during calendar year 2014. This rate increased and remained steady during the three follow-up measurement time periods, with a rate of 49.5% during calendar year 2018. This increase is notably greater than comparable health systems not part of the initiative.Implications:Lessons learned in increasing colorectal cancer screening rates are applicable to other priority health needs as well.