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February 2024

De-“sludging” Care: Advancing Colorectal Cancer Screening for a Healthier Tomorrow

In the quest to enhance the delivery of colorectal cancer (CRC) screening services, the Family & Community Medicine Research Group at Carilion Clinic has embarked on an innovative initiative funded by iTHRIV through the Pilot Translational and Clinical Studies Program. The project, "Exploring Patient-Reported Sludge in the Delivery of Colorectal Cancer Screening Services," led by Michelle Rockwell, PhD, RD and John Epling, MD, MSEd, aims to study patients’ perspectives on health system factors that may impede access to and the efficient delivery of cancer screening services.














Addressing a Critical Gap

Screening plays a critical role in the prevention and detection of CRC, and is recommended for individuals ages 45-75 years. Despite recommendations from major health organizations, up to one-third of Americans do not receive timely colorectal cancer (CRC) screenings. Southwest Virginia has the lowest CRC screening rate in the Commonwealth of Virginia, with individuals living in rural areas and with low-income being screened at a particularly low rate.

Traditional efforts to boost CRC screening have focused on increasing patient demand and clinician referrals, overlooking systemic health system barriers. These barriers, which may be described using the behavioral economics term "sludge", encompass administrative burdens such as paperwork and long wait times, affecting both clinicians and patients. Drs. Rockwell and Epling hypothesize that the process of identifying and reducing sludge will improve access to and completion of CRC screening and influence patients’ interaction with the health system. This work responds to national calls to reduce the administrative burden associated with delivering and receiving healthcare from the Department of Health and Human Services, Cancer Moonshot Initiative, American Medical Association, and others.
















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John Epling MD, MSEd and Michelle Rockwell PhD, RD- project Co-PI’s

Brianna Chang, MS, Virginia Tech Carilion School of Medicine student research assistant and the CRC awareness month (March) colon

John Epling MD, MSEd and Brianna Chang, MS, Virginia Tech Carilion School of Medicine student research assistant at Carilion Clinic Research Day 2023

Applying a Methodical Approach

Dr. Rockwell and Epling’s team previously piloted a method that identified and quantified sludge within a large health care system CRC screening delivery process through a sludge audit. The audit uncovered sludge in the following categories:  paperwork, technology, communication, administrative tasks, and time.  This initial pilot study did not directly incorporate patients, a limitation being addressed through funding from the iTHRIV Pilot Translational and Clinical Studies program.

A Comprehensive Mixed Methods Study

Through their mixed methods, patient-centered study, the research team used Community Engagement Studios, interviews, and a survey to learn more about patients’ perceptions of sludge in the CRC screening process and the impact of this sludge to them.

John Epling MD, MSEd presenting about this study, which was named the “Research Paper of the Year” by the Society of Teachers of Family Medicine

Participants were patients ages 45 to 75 years who were referred for CRC screening or who completed CRC screening in the previous 12 months in one of several different health systems or settings. Approximately 70% of participants reported experiencing sludge in the CRC screening process, with the most common types being wait times and communication. The research team noted that sludge was experienced in both screenings conducted via colonoscopy and stool-based tests.  



The Impact of Sludge in the CRC Screening Process

One-third of participants reported that their CRC screening was delayed or skipped altogether due to sludge. There was also a significant positive relationship between the amount of sludge and ratings of poor experience and health system distrust. Drs. Rockwell and Epling and their interdisciplinary team are working on presentations and reports to summarize their integrated mixed methods results, share their survey resources, and engage in several follow-on studies focused on reducing the sludge that patients experience in CRC screening as a novel method for enhancing screening rates.

Securing Additional Support and Collaboration

Dr. Epling has teamed with Drs George Davis and Carlin Rafie (Virginia Tech) to secure pilot award funding in partnership with Virginia Cooperative Extension through the Virginia Tech College of Agriculture and Life Sciences. This collaboration underscores the broader impacts and collaborative nature of their initiatives.

Jamie Turner, MPH, doctoral student research fellow, Brianna Chang, MS, Virginia Tech Carilion School of Medicine student research assistant, and John Epling MD, MSEd analyzing data.

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