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Discussion #7

Discuss your individual critical analysis of the posted article with in-text referencing to support your thoughts and ideas and with a reference list. 

Critique the posted QI article and respond to the following items:

1.      Analyze and discuss why a QI project was needed.

2.      What initial steps were assessed by the QI team? Discuss their findings, including the data.

3.      Why was the focus of the QI project on a specific population?

4.      Analyze the QI model used for this project. Name and discuss an alternative QI model that could have been used in this project.

5.      Evaluate the findings of the QI project. Were the findings relevant? How did the RNs utilize and integrate the findings into their nursing    practice? 

6.      What is your cosmic question?

QI colorectal screening article.pdf

1Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

Open access

Offering patients a choice for colorectal
cancer screening: a quality improvement
pilot study in a quality circle of primary
care physicians

Yonas Martin,1,2 Leo Alexander Braun,1 Marc-Andrea Janggen,1 Kali Tal,1
Nikola Biller-Andorno,3 Cyril Ducros,4 Kevin Selby,5 Reto Auer,1,5
Adrian Rohrbasser 6

To cite: Martin Y, Braun LA,
Janggen M-A, et al. Offering
patients a choice for colorectal
cancer screening: a quality
improvement pilot study in a
quality circle of primary care
physicians. BMJ Open Quality
2019;8:e000670. doi:10.1136/

► Additional material is
published online only. To view
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bmjoq- 2019- 000670).

Received 24 February 2019
Revised 15 September 2019
Accepted 21 September 2019

1Institute of Primary Health Care
(BIHAM), University of Bern,
Bern, Switzerland
2Department of General Internal
Medicine, Inselspital, Bern
University Hospital, University of
Bern, Bern, Switzerland
3Institute for Biomedical Ethics
and History of Medicine (IBME),
University of Zurich, Zurich,
4Foundation for Cancer
Screening of the Canton of Vaud
(FVDC), Lausanne, Switzerland
5Center for Primary Care
and Public Health (Unisanté),
University of Lausanne,
Lausanne, Switzerland
6Medbase, Wil, Switzerland

Correspondence to
Dr Yonas Martin;
yonas. [email protected] biham. unibe. ch

Quality improvement report

© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY.
Published by BMJ.

Background Guidelines recommend primary care
physicians (PCPs) offer patients a choice between
colonoscopy and faecal immunochemical test (FIT) for
colorectal cancer (CRC) screening. Patients choose almost
evenly between both tests but in Switzerland, most
are tested with colonoscopy while screening rates are
low. A quality circle (QC) of PCPs is an ideal site to train
physicians in shared decision-making (SDM) that will help
more patients decide if they want to be tested and choose
the test they prefer.
Objective Systematically assess CRC screening status of
eligible 50–75 y.o. patients and through SDM increase the
proportion of patients who have the opportunity to choose
CRC screening and the test (FIT or colonoscopy).
Methods Working through four Plan-Do-Study-Act
(PDSA) cycles in their QC, PCPs adapted tools for SDM and
surmounted organisational barriers by involving practice
assistants. Each PCP included 20, then 40 consecutive
50–75 y.o. patients, repeatedly reported CRC status as
well as the proportion of eligible patients with whom CRC
screening could be discussed and patients’ decisions.
Results 9 PCPs initially included 176, then 320 patients.
CRC screening status was routinely noted in the electronic
medical record and CRC screening was implemented
in daily routine, increasing eligible patients’ chance
to be offered screening. Over a year, screening rates
trended upwards, from 37% to 40% (p=0.46) and FIT use
increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no
patient ever tested with FIT; after the intervention, only 2/8
recorded no FIT tests.
Conclusions Through data-driven PDSA cycles and
significant organisational changes, PCPs of a QC
systematically collected data on CRC screening status
and implemented SDM tools in their daily routine. This
increased patients’ chance to discuss CRC screening. The
more balanced use of FIT and colonoscopy suggests that
patients’ values and preferences were better respected.

Primary care physicians (PCPs) do not
usually offer their patients to make an
informed choice on colorectal cancer (CRC)
screening1 and patients might not have the
opportunity to decide whether they want to

be tested or how they would like to do so.
Guidelines emphasise the importance of
offering patients a choice between a struc-
tural examination like colonoscopy and a
high-sensitivity stool-based test like faecal
immunochemical test (FIT).2 3 When offered
both options, patients divide almost evenly in
their preferences.4 The large preponderance
of colonoscopy in Switzerland5 6 suggests
that PCPs in this country strongly prefer
colonoscopy over FIT regardless of patient
preferences.7 Consistent failure to offer FIT
may contribute to low CRC screening rates in
Switzerland.5 8

We designed this quality improvement
(QI) project to encourage practice teams
to implement systematic collection of CRC
screening status and communication tools
promoting shared decision-making (SDM)
in CRC screening decisions. We conducted
and tested the feasibility of data-driven
PDSA cycles in a practice team and aimed to
increase the proportion of patients eligible
for CRC screening who could express their
preference for or against testing and for FIT
versus colonoscopy.

In Switzerland, screening colonoscopies and
faecal occult blood tests (FOBTs) such as FIT
are nationally reimbursed by the basic health
insurance, for people aged 50–69 years. Access
to colonoscopy varies by personal insurance
plan. If patients are insured under a Health
Maintenance Organisation plan, they need
to be referred by their PCP. If insured with
a flexible plan, patients have direct access
to any specialists such as gastroenterologists
but are typically referred by their PCP or by
other involved specialists. Any specialist can
prescribe FOBT, but because PCPs are the

2 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

Open access

coordinating healthcare professionals in Switzerland,
they issue almost all the FOBT prescriptions.

CRC kills 1600 people each year and is the third most
common cause of death from cancer in Switzerland. If
screening with either colonoscopy or FIT begins at age
50, the absolute risk of dying from CRC at age 80 can
be halved.9 Colonoscopy is accurate but invasive, requires
unpleasant preparations that begin the day before, and
carries a small risk of serious adverse effects. FIT is conve-
nient, and the patient can take the sample at home. It
can detect CRC as well as colonoscopy but may not iden-
tify as many polyps.10 Since these screening options have
various benefits and harms with similar expected efficacy,
this makes the choice of CRC screening methods a ‘pref-
erence sensitive’ situation in which physicians should
accept their patient’s judgement about which test is better
for them.11

SDM is an approach where clinicians and patients share
the best available evidence when faced with the task of
making decisions, and where patients are supported to
consider options, to achieve informed preferences.11–13 If
SDM was adopted by most Swiss PCPs to discuss CRC with
their patients, it could increase the rate of patients getting
the choice to be screened and reduce the discrepancy
between patient’s preferences and prescribed methods
for CRC screening. SDM is based on the assumption that
the PCP is the person most trusted by the patients to
help them consider and decide on a treatment path that
accords with their values and needs.12 14 15

Changing PCPs’ routine so that most will offer patients
the opportunity to be tested for CRC and the choice
between screening tests poses a serious challenge, and
the best place to address it may be in a quality circle
(QC). QCs are groups of 6–12 healthcare professionals
who meet regularly to reflect on their practice and realise
multifaceted, step-based interventions for QI.16 17 80%
of PCPs in Switzerland regularly attend QCs18 . QCs
can use data-driven Plan-Do-Study-Act (PDSA) cycles to
implement changes in their practices, especially if PCPs
actively collect reliable data that inform their efforts.19 20
QC participants create new concepts by combining practi-
tioner-based and evidence-based medical knowledge and
test these new concepts to implement them into everyday
practice.21 22

Practice assistants (PAs) can be deployed to help
PCPs overcome organisational barriers to implementing
systematic SDM for CRC screening. PAs are health profes-
sionals who carry out clinical and administrative tasks in
PCP practices; they are common in Germany, the Nether-
lands, the USA and Switzerland.23 24 PAs might be able to
take over some work of SDM, lowering the burden that it
imposes on PCPs.25 26

To assist comprehension, please see online supplemen-
tary appendix 1. In collaboration with the PCPs of the
QC, we developed and adjusted our data collection

form, which allows PCPs to systematically and consecu-
tively collect data on 50–75 y.o. patients seen for more
than 5 min in a non-urgent face-to-face consultation.5 6 To
check consecutive enrolment, PCPs reported the number
of weeks it took them to collect all the data. PCPs reported
the patient’s age (birth year only), sex and previous CRC
testing. We categorised previous CRC testing status as no
previous testing, colonoscopy within the last 10 years,
colonoscopy more than 10 years ago, FOBT within the
past 2 years, FOBT more than 2 years ago, other tests
and unknown. We collected data on any prior FOBT
because FIT was introduced only 4 years ago in Switzer-
land; it was likely some patients were screened with other
types of FOBT like the guaiac-based test. If patients had
been tested within recommended intervals, PCPs did not
need to collect more data. If patients had not been tested
before or within recommended intervals, PCPs reported
if patients had contraindications to CRC screening (life
expectancy <5 years, current severe condition or other);
if the patient had a contraindication, the PCP could
stop collecting data. For eligible patients, PCPs reported
whether they had discussed CRC. If they did not discuss it,
they reported the reason: it was not appropriate to discuss
screening during this visit; they had already discussed
screening with the patient; or the patient had been seen
during data collection or for another medical reason. If
they discussed screening, PCPs reported the presence of
potential symptoms of CRC (bloody stools, abdominal
pain, weight loss, change in the bowel habits, others) and
risk factors for CRC (personal history of CRC or polyps,
family history of CRC or polyps, personal history of
Crohn disease or ulcerative colitis or other). If the patient
refused screening, the PCP noted the reason: no reason
for refusal; patient does not feel concerned; patient fears
side effects or complications; financial barriers; or other.
Then, the PCP recorded the patient’s choice and the
test they planned to take (no screening, colonoscopy,
FOBT or other). In the second data collection, we added
‘decision postponed’ to the choices to give patients the
chance to think about it before making a decision. PCPs
took their first measurement in March 2017 and included
20 consecutive patients. They took their second measure-
ment in May 2018 and included 40 consecutive patients.

The long-lasting QC in Wil has been created 21 years ago
and currently includes nine PCPs working in the same
primary care office. One psychiatrist and one derma-
tologist working in the same office do not participate
to the QC. The group consists of five senior and four
younger physicians, five men and four women. They are
employed by a large network providing primary health-
care. The patient population is mixed, rural and urban,
as the practices serve a small city, surrounding villages
and rural areas. Between January 2017 and May 2017,
two clinician-researchers from the research team of the
Institute of Primary Healthcare of Bern met with the QC’s

3Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

Open access

Figure 1 Study timeline.

participants in four QC meetings. PAs from the primary
care office participated in the second part of the QI
project lasting until September 2018. We describe these
meetings in detail in the Strategy section and a timeline
(see figure 1) offers an overview of the QI project. One
PCP who moved to a different region did not participate
to the second data collection.

The research team helped the QC conduct overlapping
PDSA cycles.

Pdsa cycle 1 (January 2017–march 2017)
This first PDSA cycle focused on updating existing inter-
vention material consisting in communication tools
promoting SDM15 to suit QC’s specifications and values. In
Switzerland, all citizens have healthcare coverage by law,
but flexible deductibles are applied and can be as high as
2500 Swiss franc (≈US$2500). The material presented at
the first meeting had been developed for Canton Vaud’s
organised CRC screening programme, which waives the
deductible of the screening tests and the medical consul-
tation when a test is performed within the programme.
Our study was conducted in Canton St Gallen, which has
no organised screening programme and where costs of
both tests are reimbursed, but deductible is not waived.
The QC examined the communication tools which
consisted in (1) a two-page structured evidence summary
on CRC screening and information about colonoscopy
and FIT, (2) a patient decision aid (20-page booklet) on
CRC and (3) a four-page abridged version of the booklet
to help PCPs discuss CRC screening with patients (‘Deci-
sion Board’).27 28 The QC also looked at a data collection
form developed for this study by the research team.5 6 The

PCPs studied and discussed the documents and suggested
adaptations to better meet their specific needs. The
research team updated the materials and data collection
process accordingly.

Pdsa cycle 2 (January 2017–June 2017)
This second cycle was the core of the QI project. At the first
QC meeting, the research team worked with QC partic-
ipants to identify and analyse current problems in CRC
screening. The group acknowledged current literature on
CRC and screening methods. PCPs accepted that screening
rates were generally low and that PCPs’ preferences for
screening method is likely to have a disproportionate
influence on the ratio of colonoscopy to FOBT. Partici-
pants then set out to change behaviour and use SDM to
give their patients an opportunity to discuss CRC screening
options. The group used the adapted material in role plays
to improve their communication skills. The QC addressed
organisational barriers by adjusting their electronic medical
record (EMR) and coding patients’ CRC status as well as the
performed test. In the next QC meeting, the group agreed
that a data collection was necessary to quantitatively assess
the current situation using the developed data collection
form. The group decided that each PCP should collect data
from 20 patients within a 4-week period, and they did this
in March 2017. Then, the research group analysed the data
and presented them to the PCPs at a fourth QC meeting.
The PCPs said they had changed their behaviour and that
it took less time to discuss screening with their patient than
they had expected. They decided to further implement
SDM and suggested they include PAs in the process because
these showed interest during the first data collection and
their involvement could increase the chance for patients to
be screened for CRC.

4 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

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Pdsa cycle 3 (march 2017–may 2018)
In the third PDSA cycle, PCPs decided to involve PAs and
delegate them CRC screening discussions with patients
at average risk. PCPs decided to integrate CRC screening
into the basic preventive care services the practice regu-
larly provide for patients aged over 50 y.o. In this practice,
PAs regularly collect patients’ smoking status and system-
atically measure their body mass index (BMI), heart
rate and blood pressure (BP). The PCPs conducted an
internal pilot trial and involved two PAs in SDM about
CRC screening options. During a session, the QC facili-
tator taught the PAs how to use the adapted SDM tools
(the booklet intended to patients and the decision board
to support discussions on screening). The PAs then prac-
tised by role playing. The PCPs implemented a rigorous
process that identified high-risk patients; each morning
before the consultations, PAs and PCPs briefly discussed
the scheduled patients to assess to determine which of the
50–75 y.o. ones were at increased risk for CRC (personal
history, familial history or symptoms suggestive for CRC)
and if those conditions precluded screening (eg, pres-
ence of malignancies or psychiatric diseases). The PCPs
discussed screening options with high-risk patients, and
the PAs discussed screening with all other eligible patients,
if time allowed. If the PA identified CRC risk factors or
symptoms during the discussion, the PCPs took over. If a
patient opted for FIT, the PA supplied the necessary mate-
rial and information. If a patient opted for colonoscopy,
the PCP performed a few medical tests and organised the
referral to the gastroenterologist. After their discussion
with eligible patients, PAs coded patient decisions: not
willing/contraindication to screening; FIT; colonoscopy;
or postponed decision. The new process was tested with
two PAs for 2 weeks and then PCPs’ and PAs’ suggestions
were integrated; for instance, they simplified the refer-
rals to gastroenterologists. The two PAs found this new
process feasible and acceptable. They shared their expe-
riences with the whole PA team during a meeting led by
the QC facilitator. Finally, all PCPs met with the two PAs
to finalise details before the strategy was routinely imple-

Pdsa cycle 4 (June 2017–september 2018)
The fourth PDSA cycle evaluated PAs participation in the
SDM process. All PCPs and all PAs were invited to a new
QC meeting where the majority agreed that the whole
team should implement the new process developed in
PDSA cycle 3. The PCPs shared evidence and knowledge
about CRC and screening with the PAs. They taught them
the use of the information booklets and decision boards
for SDM through role play. The QC facilitator along with
the two PAs involved in the previous cycle presented the
morning triage process, where eligible patients were
identified. They also introduced electronic reporting
of patients’ CRC status as follows: contraindications;
chosen screening method; refusal or (in the second data
collection round) postponed decision. The QC facili-
tator and the two PAs established routines to provide

patients who chose FIT with information and sampling
kits. Patients who chose colonoscopy had blood drawn to
exclude a higher bleeding risk and were referred to the
closest hospital. The PAs implemented the new process
in their routine between January 2018 and April 2018.
They discussed CRC screening with patients who were
not at high risk whenever possible and used the EMR
to report on patients’ CRC status, BMI, heart rate, BP
and smoking status. Once this process was embedded
in the PAs’ routine (April 2018), PAs and PCPs decided
to conduct the second data collection. For this second
data collection, the collection form was filled by PAs for
non-high-risk patients, and by PCPs for the other ones.
The research team met with all PAs at a supplementary
meeting and explained how to use the data collection

Pdsa cycle 1
PCPs suggested adapting the intervention documents,
notably concerning information on reimbursement
of screening tests in their canton, since St Gallen does
not have an organised screening programme. They also
changed the order of items on the data collection form
so it better matched the order in which topics were raised
by PCPs when they discussed CRC screening with their

Pdsa cycle 2
PCPs implemented SDM in discussions about CRC
screening options and continued to improve their
communication techniques. They developed and imple-
mented an electronic coding algorithm ([0;1;2]: refusal/
contraindication; colonoscopy <10 years; FIT<2 years)
that allowed them to reliably report CRC status. During
the first data collection, the nine QC participants reported
data on 20 consecutive patients (176 patients; one PCP
only collected data on 16 patients). At baseline, screening
rate was 37% (65/176) and almost all patients who were
already up-to-date (colonoscopy ≤10 years or FOBT ≤2
years) had been screened with colonoscopy (colonoscopy
58/65; FOBT 3/65; other 4/65; see figure 2—Panel A).
Of the nine PCPs, seven had no patients ever tested with
FOBT (results not shown). PCPs could discuss screening
options with most of the previously untested patients
(55%–100%) who had not been excluded for contrain-
dications (figure 2—Panel B). After discussion, a quarter
of patients refused screening. 63% opted for FIT and
12% opted for colonoscopy (figure 2—Panel C). PCPs
found they were able to discuss CRC screening with most
eligible patients and it was much less time-consuming to
diagnose patients’ preferences than they had expected.
But because of some very high discussion rates (100%),
the group agreed at a further QC meeting that PCPs
could not be expected to discuss CRC screening with all
eligible patient they saw.

5Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

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Figure 2 Panel A: CRC status at baseline in 2017 (n=176),
Panel B: discussion rates for each PCP in 2017 (n=106),
Panel C: decisions after discussion in 2017 (n=85). CRC,
colorectal cancer; FOBT, faecal occult blood test; PCP,
primary care physician.

Figure 3 Panel A: CRC status at baseline in 2018 (n=320),
Panel B: discussion rates conducted by PAs and PCPs
for each PCP in 2018 (n=171), Panel C: decisions after
discussion in 2018 (n=111). CRC, colorectal cancer; FOBT,
faecal occult blood test; PAs, practice assistants, PCP,
primary care physician.

Pdsa cycle 3
Two PAs learnt to prepare the consultation agenda with
PCPs so they could identify patients who were not at high
risk, and then used the intervention material to facilitate
SDM with these patients. They adapted them to suit their
preferences and added the item ‘postponed decision’ to
the data collection to capture this common choice. PAs
learnt how to use the EMR to report a patient’s CRC
status [(0;1;2;3): refusal/contraindication; colonoscopy
<10 years; FIT <2 years; decision postponed). Finally,
they learnt how to systematically assess CRC screening

status and then discuss CRC screening with non-high-risk
patients using SDM material.

Pdsa cycle 4
The team (24 PAs and 8 PCPs) participated in data collec-
tion and reported data on 40 consecutive patients for each
PCP (320 patients). We show our main results in figure 3
(panels A, B and C). Baseline screening rate increased
from 37% to 40% but the increase was not statistically
significant (p=0.46). The proportion of patients screened
with FIT increased more than threefold (from 2% to

6 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

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7%, p=0.008). The number of PCPs who had no patients
tested with FOBT at baseline dropped to 2 of 8 (it was
7/9 in 2017, results not shown). All but one PCP were
able to discuss CRC screening with most of their eligible
patients (42%–84%). Of patients with whom screening
was discussed, 20% decided to postpone their decision
and 80% made one (30% refused screening, 38% opted
for FIT and 12% for colonoscopy).

Further results
► PAs added CRC status to routine collection of BMI,

BP, and smoking status in EMR.
► PCPs developed routines for colonoscopy referrals

that included sampling the patient’s blood, supplying
detailed information about the test and giving the
patient the necessary instructions for using laxative
and dietary instructions.

lessons and limitations
When PCPs get the chance to choose what they want to
address and can adapt the study material to do so, they
actively get involved in the conception of a QI project.
They are even able to overcome structural and organisa-
tional barriers such as patients’ triage for discussions on
CRC screening, time restrains, delivery of quality infor-
mation and patient referrals.

Baseline screening rates tended to be higher over time
(37% vs 40%) and the proportion of patients screened
with FOBT increased more than threefold (from 2% to
7%, p=0.008). The number of PCPs who had no patients
tested with FOBT dropped from 7/9 in 2017 to 2 of 8 in
2018. These results suggest that PCPs massively changed
their prescription patterns for CRC screening while
patients could better choose the option which best fitted
their preferences.

When PCPs could discuss CRC screening, the vast
majority of their patients took an active decision for CRC
screening (for or against screening, and with which test).
These results suggest the importance and relevance of
offering patients a choice. When offered a choice, the
proportion of patients who choose either colonoscopy or
FOBT does not seem to match the proportion of colo-
noscopy screenings (89%) found in a recent Swiss study,5
which suggests that PCP preferences overdetermine the
choice of test.

We found that during first data collection (PDSA cycle
2), some of the PCPs discussed screening with 100% of
their eligible patients. They figured out, after discussing
this point at a further QC meeting, that it was not prac-
tically feasible to do so in a real-life practice. This rate
markedly decreased in the second data collection corre-
sponding to what seems to be routinely feasible and

Consistent with the literature,29–31 participating PCPs
found out that they needed to make substantial organ-
isational changes and involve PAs to implement SDM
and facilitate discussions on CRC screening. PAs could
significantly reduce PCP workloads25 26 by identifying and

discussing CRC screening with non-high-risk patients, as
well as reporting CRC status in the EMR.

The higher screening rates and substantial increase in
the number of patients, who had been tested with FOBT
after the second data collection, suggest that imple-
menting SDM increased the number of patients who were
able to choose which test best suited their preferences
and values. We are following up this pilot study with two
randomised controlled trials in primary care practices32 33
aimed at generating more evidence that training PCPs
in SDM can decrease the variation in CRC test choice
between PCPs and increase the variation in screening
methods,15 and that this will ultimately raise screening
rates. Our study has some limitations. Since we did not
perform a chart-based validation of the data collected, we
could not determine the accuracy of PCP self-reports and
cannot rule out the possibility of selection bias in choice of
participants by PCPs who might not always have followed
the rule to include patients consecutively. During the first
data collection some PCPs thought the goal was to discuss
CRC screening with all eligible patients, which might have
influenced and increased prescription rates (after discus-
sion) of the first results. In the second data collection,
discussion rates decreased showing how PCPs and PAs
integrated the notion that it was not feasible to discuss
screening with all patients. Furthermore, our ability to
compare the results of the first and second data collec-
tion is limited because PCPs alone collected the data in
the first round, and PCPs and PAs both collected the data
in the second round. Another point needs to be voiced as
a limitation; although PCPs changed their practices after
the intervention, screening rates at baseline need years
to actually represent current prescription practices. The
short observation time could explain the only moderate
increase in screening rates at baseline between data
collections. Finally, although the overall baseline testing
rates and test proportions we found seem consistent with
the literature,5 8 34 generalisation to practices in Switzer-
land is difficult due to the local context and the limited
number of patients assessed in this pilot study.

Our study was strengthened by the use of a data collec-
tion form created by PCPs, who made sure it was clear
and easy to integrate into their daily routine. Developing
the implementation in a QI group allowed us to closely
collaborate with PCPs, and allowed the PCPs to work
together to make necessary modifications to the interven-
tion materials and the data collection form. This certainly
enhanced an important sense of ownership among the
participants regarding the study and its material. Further-
more, the study design offered PCPs to set convenient
times for meetings, to improve data collection efficiency
and PAs involvement as well as to implement changes to
the EMR. Piloting the intervention as …

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