Introduction: Academic detailing, patient-panel management, and mailed, stool-based testing have each been utilized to increase colorectal cancer (CRC) screening in rural clinics. The effectiveness of combining these interventions to increase CRC screening during COVID-19 restrictions was unclear. Methods: We explored the effects of a multi-component intervention including academic detailing, active patient panel management, and mailed MT-sDNA testing on colorectal cancer screening in our rural family medicine clinic. Baseline interventions included EMR-based provider alerts and mailed patient reminders. Our intervention (March-May 2020) and follow-up periods (June-August 2020) coincided with the initial COVID-19 surge, giving us the opportunity to observe the effects of our inter-vention during COVID-19 restrictions. Results: A total of 407 patients were eligible and overdue for colorectal cancer screening. Our clinic's CRC screening rate increased significantly after intervention (69.7%) as compared with before (64.3%) (P = <0.01; 95%CI = 5.39-5.4). Our clinic's CRC screening rates increased significantly during the initial 3 months of the COVID-19 surge (67.8%) compared with the same period the prior year. (62.3%) (P = .003; 95%CI = 3.4-7.6). Our CRC screening rates increased after intervention (69.7%) compared with our re-gional health system (67%) (P = <0.01; 95%CI = 2.6-2.77). Our weekly stool-based CRC screening increased (94% increase) compared with other health systems nationally (61 to 83% decrease). Discussion: A multi-component intervention, including academic detailing, panel management, and mailed MT-sDNA testing, can lead to significant increases in CRC screening in a rural family medicine clinic, empowering providers to maintain an effective CRC screening outreach during COVID-19 related restrictions. ( J Am Board Fam Med 2023;36:933-941.)

Background: Barriers to screening are significantly higher among rural women in the US, where the population has little choice in the characteristics of their physician. We aim to determine the attributes of the screening exam techniques, physician characteristics, and known social barriers among under-screened rural women in Michigan, United States.Methods: Our mixed methods study evaluated a vaginal self-screening technique. We used Health Information National Trends Survey (HINTS) modules to develop the quantitative survey questions using Likert scales and the Theoretical Domains Framework (TDF) to develop the qualitative interview guide. We used descriptive statistics, t-tests, and Mann-Whitney-U tests for the quantitative data and thematic analyses of women's interview responses. We jointly compared the quantitative and qualitative findings to describe robust perceptions of screening.Findings: A majority white sample of forty-one women indicated that the pelvic exam technique had significantly worse negative rankings across all fourteen attributes than the self-sampling technique. Having social barriers to screening did not change the importance of the technique for screening. The woman's descriptors did not influence screening technique preference. The physician's race/ethnicity and religion/culture did not influence technique preference. Fearing abnormal screening results, regardless of technique, remained a barrier to cervical cancer screening. Analysis of interviews resulted in four themes that supported and elaborated on survey results: 1) preference for the self-sampling technique; 2) physical and emotional discomfort with the pelvic exam technique; 3) convenience of the self-screening technique; and 4) empowerment through self-sampling.Interpretation: The self-sampling cervical cancer screening technique can reduce all but the fear of abnormal results associated with cervical cancer screening.Funding: NIH supported this work through the Michigan Institute for Clinical and Health Research UM1TR004404 and NCI through The University of Michigan Rogel Cancer Center P30CA046592 grants.Declaration of Interest: We mailed all interested and eligible women a written informed consent document and contact information for the study team. Research protocols received approval from the university and collaborative health system institutional review boards. We mailed all interested and eligible women a written informed consent document and contact information for the study team. Research protocols received approval from the university and collaborative health system institutional review boards.

ContextHuman Papillomavirus (HPV) is the most common sexually transmitted infection and the leading cause of cervical and oropharyngeal cancers. Vaccination can prevent over 90% of HPV-attributed cancers among those aged 9-26. Rural populations are less likely to receive the complete HPV protocol than urban.ObjectiveThe aim of this mixed methods study is to evaluate multilevel (youths, parents, primary care physician(PCP)/team, clinic, community, and policy)influences on HPV vaccine hesitancy.Study Design and AnalysisA mixed methods analysis was conducted to integrate quantitative(cross-sectional PCP survey, multiple linear regression analysis) and qualitative data(youth, parent focus groups, inductive descriptive analysis)in a joint display table.SettingMidwestern state rural communities.Population StudiedRural youths, parents, PCPs. Instrument.PCP online survey, focus group protocols. Outcome Measures.HPV vaccine uptake, HPV vaccine continuous stages of change.ResultsThrough the joint display, the qualitative and quantitative data reveal two different perspectives on the role of the PCP in educating about vaccination, and on involvement of youth in decision-making about the vaccine; although the primary barriers to vaccination were consonant. Youths and parents reported limited unbiased HPV vaccine information; yet, 40% of physicians reported educating their patients about the HPV vaccine. Inductive descriptive analyses revealed that youth wanted a greater role in decision-making about the HPV vaccine, while parents were the PCPs primary focus. Integrative analyses of both the qualitative and quantitative data identified parental out-of-pocket cost as a significant predictor of lower HPV vaccine uptake (t=-3.35, p=0.0048), and a primary qualitative theme. Similarly, structural supports in the clinics (up-to-date HPV vaccination rates for patients; t=-2.17, p=0.0475), and established office workflows to identify the unvaccinated (t=2.31; p=0.0366) were significantly associated with higher HPV vaccine uptake.ConclusionsAdapting dissemination approaches to rural primary care physicians, through Academic Detailing or practice facilitation, could decrease HPV vaccine hesitancy by sharing evidence-based counseling approaches and clinic structural modifications. Youths could be engaged as champions of the HPV vaccine, further disseminating unbiased information to peers. Linking primary care practices and public health dissemination strategies are key.

Background: The opioid crisis presents many challenges for family practice providers in rural communities who treat patients with chronic non-cancer pain (CNCP). Unfortunately, evidence for effective opioid reduction strategies is sparse. We evaluated the effects of implementing a comprehensive opioid reduction protocol on overall opioid prescribing among patients with chronic non-cancer pain in our rural family medicine clinics. Methods: We compared mean daily milligrams morphine equivalent (MME) prescribed to patients with CNCP in our rural family medicine clinic (n = 93) with another matched clinic (n =93) after implementation of our comprehensive protocol. We also compared mean daily MME prescribed to our patients with CNCP before and after implementation of the protocol. In a subsequent cross over phase, we examined the effects of the protocol when applied to the original control group patients. Results: Mean daily MME in the intervention clinic (29.77) was significantly lower than the control clinic (93.2) after the intervention (t = 6.03; P < .00). Mean daily MME in the intervention group was significantly lower after implementation of the protocol (29.77) than before the protocol (MME 80.34) (t = 5.889; P < .00). After crossover, the mean daily MME was significantly lower (14.34) in the original control group than prior to the cross over intervention (85.68); (t = 8.19; P = .00). Discussion: Our comprehensive opioid reduction protocol led to significant reductions in opioid prescribing in our rural family medicine clinics. Future studies should include important qualitative outcome measures such as patient function.