PROJECT TITLE: The factors and strategies that improve the adherence to colorectal cancer screening guidelines in rural/remote residents: a systematic review and meta-analysis protocol

Scientific Abstract

BACKGROUND: Colorectal cancer (CRC) poses a serious health problem worldwide. While screening is effective in reducing CRC mortality, adherence to CRC screening guidelines is generally suboptimal in rural/remote areas. Factors and strategies to improve adherence to CRC screening guidelines have been reported in rural populations; however, critical appraisals, comprehensive analyses and syntheses of existing evidence through well-designed systematic reviews do not exist, hindering rural clinicians and researchers in disseminating and implementing evidence-based interventions that promote adherence. PURPOSE: The goal of this review is to critically appraise, analyze, and synthesize factors that influence rural individuals’ adherence to CRC screening guidelines, the effectiveness of rural population-oriented interventions, and the underpinning program implementation framework. DATA SOURCES: Nine electronic databases (from inception to December 2015), such as MEDLINE, EMBASE, CINAHL, Cochrane library, ERIC, PsycINFO, Health Business Elite, Springer Protocols and Social Science Abstracts (SSA), will be searched for quantitative studies. Additional data sources include grey literature, reference lists of included articles, conference abstracts, and book chapters. DESIGN: A systematic review and meta-analysis of quantitative studies addressing mechanisms of CRC screening behavior in rural and remote areas. REVIEW METHODS: Two reviewers will independently search and determine the eligibility of studies based on inclusion/exclusion criteria, as well as data extraction. The retrieved data will be analyzed using random-effects meta-analyses to determine factors and the effect of interventions associated with CRC screening behavior. The multivariate meta-regression will be used to evaluate heterogeneity between studies. Publication bias, overall strength and quality of evidence will be evaluated. DISCUSSION: Our systematic review will provide important information regarding factors influencing CRC screening behavior in rural/remote areas. Next steps include disseminating strategies through publications, presentations at national and state level conferences, local community, and rural healthcare facilities. In addition, we plan to apply for extramural funding to support implementation studies.

Lay Abstract Colorectal cancer (CRC) is the second leading cause of death in the United States. Routine screening can reduce CRC incidence and improve survival. Despite the health benefits of screening, rural residents are less likely to adhere to CRC screening guidelines than urban residents, leading to a higher occurrence and death rate. The optimal approach to increase rural individuals’ adherence to CRC screening guidelines remains uncertain, although various studies have reported reasons and effective strategies to improve the adherence rate in rural communities. The objective of this study is to identify the high quality evidence related to the promotion of guideline adherence in rural residents through a systematic review of the existing body of literature. The results will be of relevance to policy makers, rural clinicians, researchers, public health practitioners, and individuals living in rural and remote communities. The findings will help disseminate and implement evidence based strategies to improve the adherence rate to CRC screening guidelines in rural and remote areas.

DESCRIPTION OF RESEARCH PROPOSED: A. Specific Aims

Our overarching goal is to implement evidence-based, multi-level interventions to increase the colorectal cancer (CRC) screening rate in Nebraska rural/remote areas.

Colorectal cancer (CRC) is the second leading cause of death in the United States.1 CRC survival primarily depends on early detection.2 Screening detects CRC in its early stages when the person is still asymptomatic. 3 Therefore, multiple professional societies have developed guidelines to recommend routine CRC screening starting at age 50. 4,5 In spite of the significant health benefits of routine CRC screening, CDC data indicates screening rates have plateaued at only 65.1 % since 2008. 6 The non-adherence to guidelines is more pronounced in rural and remote areas. 7 Studies have been conducted to identify factors and effective strategies promoting adherence to CRC screening guidelines in rural communities; however, these findings have not been critically appraised through systematic review, limiting our understanding of the barriers of the adherence to CRC screening guidelines. To fill the gap of knowledge, we propose to conduct an intensive, systematic review of the existing literature related to rural individuals’ CRC screening behavior. The outcome of this well-designed systematic review is to improve our understanding of the factors and effective strategies that will impact rural residents’ adherence to CRC screening guidelines and, in turn, help disseminate and implement multi-level, rural population-oriented programs to improve guideline adherence. The following specific aims will help achieve the purpose of the study.

SPECIFIC AIM

1: Identify the system-, practice-, and individual-level factors influencing the adherence to CRC screening guidelines in rural/remote areas.

SPECIFIC AIM

2: Identify the existing interventions/strategies designed to improve adherence to CRC screening guidelines in rural/remote areas.

1) What interventions are designed to improve adherence to CRC screening guidelines in rural/remote areas?

2) What are the methodological strengths and weaknesses of these interventions? 3) Are the interventions designed to target those factors identified in Aim 1?

SPECIFIC AIM

3: Specify the effect of interventions on CRC screening rates among rural and remote residents.

4) What is the overall effect of interventions on CRC screening rates? SPECIFIC AIM

4: Identify the factors that influence the effect of interventions designed to increase CRC screening adherence.

5) What variations do study design characteristics cause in the efficacy of interventions?

6) What variations do subject attributes cause in the efficacy of interventions? 7) What variations do intervention characteristics cause in the efficacy of the

interventions? 8) What are other factors (e.g, study siting, and payment policy change)?

SPECIFIC AIM

5: Determine the appropriateness of the evaluation framework of intervention or program.

These aims will be accomplished by conducting an extensive literature search, coding primary studies for attributes that address the research questions, and synthesizing findings regarding effect sizes of both intervention and moderators through standard meta-analytic procedures. This project is complementary to the PI’s and her team’s other project funded by The Fred & Pamela Buffett Cancer Center, entitled “An Examination of Factors Influencing Colorectal Cancer Screening of Rural Nebraskans Using Data from Clinics Participating in An Accountable Care Organization.” 8 Both projects will add to our knowledge about mechanisms of adherence to CRC screening guidelines

through existing evidence and real world mechanisms, which is urgently needed to move both practice and research forward. Furthermore, the inter-professional teamwork between researchers from the College of Nursing and College of Public Health will: 1) strengthen the sustained, productive collaboration in future research; 2) help build preliminary data for extramural grants we have contracted to pursue in June 2016; and 3) support junior researchers launching their program research in oncology science. Without this funding support, these important outcomes will not be accomplished and the unappraised, synthesized evidence will not be readily translated to best practices that could help vast numbers of rural residents adhere to CRC screening guidelines. B. Background and Significance B.1. Significance of the problems

Cancer is the second most common cause of death in the US.9 The colorectal cancer (CRC) incidence rate for Nebraska is higher than for the US as a whole (50 for men, 37.8 for woman per 100,000 in US vs. 54.9 for men, 42.9 for women per 100,000 in Nebraska).1,9 The CRC mortality rate for Nebraska is also higher than for the US in both men (20.4 vs. 19.1 per 100,000) and women (15 vs. 13.5 per 100,000).1,9 Without a full understanding of the causal links of CRC onset, primary prevention of CRC remains an elusive goal. On the other hand, secondary prevention through routine CRC screening plays a vital role in reducing the incidence and mortality rates of CRC.10 It is estimated that approximately 60% of colorectal cancer deaths could be prevented if all men and women aged 50 years or older were screened routinely. 11 As a result, the American Cancer Society and the US Preventive Services Task Force recommend that adults aged between 50 and 75 have a CRC screening, including fecal occult blood testing (FOBT) annually, sigmoidoscopy every 5 years, or colonoscopy every 10 years.4,5,12

Despite the significant clinical benefit of routine CRC screening,9 disparities in CRC screenings

persist in rural and remote communities.13 Compared to urban residents, rural residents had lower CRC screening rates.2,7,14-22 Remote rural residents had the lowest screening rates overall (45%).19 Compared to urban dwellers, rural residents have the higher incidence rate of colorectal cancer17,23 and the CRC-related mortality rate. 24In addition, rural survivors reported poorer self-rated health, greater physical distress, activity limitation, as well as less cancer follow-up care.25,26

Nebraska, which consists of a larger rural population compared to the national average, ranks

36th nationally for CRC screening.2,7 To date, rural disparity in CRC screening participation has been well demonstrated in the literature, and a wide range of studies have attempted to examine the mechanisms of adherence to CRC screening guidelines based on the data collected from rural population. Without the systematic triangulation of the raw data, comprehensive evaluation of data quality and better understanding theoretical underpinnings of the data, the existing evidence is less likely to be translated into practice. Therefore, a well-designed systematic review of existing evidence is needed to facilitate the dissemination and implementation of best evidence to rural practice. No systematic review has been done to appraise, analyze and synthesize the existing literature associated with CRC screening practice in rural and remote communities. The proposed study will fill the gap of knowledge. B. 2. Conceptual framework

Considering the heterogeneity in the research design, sample characteristics, research methods and the interventions between studies, we will use a conceptual framework to search available evidence and interpret findings. The quality in the continuum of cancer care model framework 27,28 will be used to guide the systematic review that examines multilevel factors and strategies (figure 1). The model illustrates the complexity of CRC screening behavior and demonstrates CRC screening behavioral change as the result of the interaction of multilevel factors. Moreover, one of the aims is to determine whether this model would be an appropriate program evaluation model for the implementation phase. To be a useful model for guiding the translation of best evidence to practice,

the model should cover majority factors related to the CRC screening behavior addressed in the literature.

C. Preliminary Studies (if any).

Currently, our team is conducting a project funded by the College of Public Health and The Fred & Pamela Buffett Cancer Center. The purpose of the project is to examine multi-level factors related to CRC screening, and providers’ perception of barriers and facilitators of CRC screening in rural patients cared for by accountable care organization (ACO) clinics. 8 The preliminary findings generated from both quantitative (survey) and qualitative data (interviews) confirm the existing evidence associated with factors that impact CRC screening behavior in rural areas. Participating in CRC screening is a complex process affected by multi-level factors (i.e., system-, practice-, and individual- [providers and patients] level). 27,28 Based on our preliminary findings, the patient-level factors related to CRC screenings include discomfort, embarrassment, fear, financial concern, lack of awareness, low literacy/educational level and lack of provider recommendations, which is concurred by other studies13,29-31 The lack of provider recommendation was not perceived as a barrier from our survey and interview data, however, it is the most cited barrier in literature. 13,29-37. Again, access was not perceived as the barrier based on both survey and interview data, which is contrary to other studies’ results.33,38,39 On the other hand, having a regular care provider was reported as the facilitator of CRC screening by our preliminary findings and previous studies. 19,34,40,41

One of the most common strategies in both survey and interviews is that care coordination and shared care system for preventive services (including CRC screening) play vital roles in promoting guideline adherence to CRC screening in rural/remote areas. The previous interventional studies designed to improve rural CRC screening rates have been primarily focused on overcoming individual (i.e., patient- and provider-) level barriers, without much consideration of system and

Figure 1: The quality in the continuum of cancer care model framework27,28

practice levels of factors.35,42-45 Our preliminary findings may provide additional mechanisms to promote guideline adherence and shine a light on the strategies at system and practice levels.

Furthermore, the skill, knowledge and experience we have gained from this project raises our confidence as a team to conduct the proposed systematic review. We feel having both observational study and systematic review is the most cost-effective way to develop an efficient team with research longevity, generate high quality evidence and fast forward best evidence to practice. D. Progress Report (for Renewal Applications only) Not applicable E. Research Design and Methods E.1. Design and scope

We will conduct a systematic review and meta-analysis guided by the reporting standards as outlined in PRISMA criteria (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). 46 A 27-item PRISMA checklist and the flow diagram will be used to organize study flow.47 The protocol will be registered in the PROSPERO database. The statement of ethics is not required for systematic review. E.2. Outcomes

Table 1 lists the outcomes selected based on the proposed aims, research questions and the conceptual framework (Figure 1). Table 1. Outcomes

RESEARCH AIMS AND QUESTIONS OUTCOME VARIABLES

SPECIFIC AIM 1: Determine factors influencing the adherence to CRC screening guidelines in rural/remote areas (Figure 1)

System level: types of insurance, community resources

Practice level: organization structure, type of practice

Individual level: provider performance, patient sociodemographic, clinical characteristics

SPECIFIC AIM 2: Identify interventions promoting adherence to CRC screening guideline in rural/remote areas

Study design, strengths and weaknesses of research methods,

Intervention characteristics (e.g, mechanisms of action, frequency, duration, mode, format, etc.), study attrition rates, recruitment strategies, intervention fidelity measures,

SPECIFIC AIM 3: Specify the effect of interventions on CRC screening rate among rural and remote residents

Difference between intervention and control groups in the age of first time screening, interval of screening, types of screening modalities.

SPECIFIC AIM 4: Identify the factors that influence the effect of interventions designed to increase CRC screening adherence

See above

SPECIFIC AIM 5: Determine the appropriateness of the program evaluation framework

See above

E.3. Search strategy

We will conduct a systematic search in the following electronic databases (from inception to December 2015): MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane library, Education Resources Information Center (ERIC), PsycINFO, Health Business Elite, Springer Protocols and Social Science Abstracts (SSA). Other sources include: 1) the grey literature; 2) the reference lists of articles; 3) articles identified by experts and team members; 4) conference abstracts; 5) book chapters and their reference lists. Additionally, we will conduct

computerized searches using the names of all authors and co-authors of all retrieved eligible articles. There will be no language restrictions.

The databases will be searched using MeSH headings and keywords within nine key themes: rural and remote population, adult (aged 50 and greater), cancer preventive services, early detection of colorectal cancer methods, patient participation, socioeconomic factors, clinical/practice factors, environmental/contextual quantitative study. Keywords are combined using ‘OR’ and ‘AND’. We will closely work with reference librarian during the process. All studies identified through literature search strategies will be entered in bibliographic software (RefWorks).48 Studies meeting the eligibility criteria will be fully coded in data extraction codebook. The inclusion/exclusion criteria (Table 2) are developed from our research questions using the following PICOS. Table 2. Inclusion/exclusion criteria

PICOS INCLUSION CRITERIA

Population Adults who are 50 years or over and reside in rural/remote communities.

Exclusion Criteria

Individual with history of CRC or active CRC undergoing aggressive treatments.

Individual with a history of inflammatory bowel disease (e.g., ulcerative colitis and Crohn’s disease);

Intervention Studies examining interventions to promote CRC screening behavior in rural/remote communities

Context Studies examining factors influencing CRC screening behavior or practice in rural/remote communities.

Outcomes See E.2.

Study design Quantitative studies including RCTs quasi-experimental, before and after, prospective and retrospective cohort, case control, and analytical cross-sectional and mixed-methods studies.

Exclusion Criteria

Qualitative studies,

Non-empirical studies (e.g., opinion, comments, editorials, letters, commentaries and narrative reviews, etc.)

E.4. Screening process

The search procedure will proceed according to the three stages as described below in Table 3. Table 3. Screening process

STAGES DESCRIPTIONS

Stage 1: Broad overview

Two reviewers will independently scan all titles of articles for eligibility.

Stage 2: Pilot testing of the data collection form for study selection.

A data collection checklist will be developed and pilot tested by two reviewers. Two reviewers independently review a random sample of 50 abstracts. A Cohen’s kappa statistic will be used to assess inter-rater reliability, ensure consistency of use of the tool and evaluate the clarity of the data collection instrument. The full abstract screening of articles will begin when greater than 90% agreement is reached.

Stage 3: Assessment of remaining studies for inclusion.

Articles will be moved forward for full-text review if both reviewers agree on eligibility based on the inclusion/exclusion criteria. Two reviewers will be review the articles independently using the data collection checklist developed in stage 2. Reviewers then meet as a group and compared full-text article reviews to resolve any potential discrepancies and finalize decisions on article inclusion.

E.5. Data extraction

The same investigators involved in study search and selection process will independently extract data from eligible studies using a data extraction form (i.e. data extraction codebook) based on our research questions and outcomes of interest. In Stage 1, the data extraction codebook will be developed and pilot tested with a sample of ten articles to ensure clarity and consistency. In Stage 2, the reviewers will independently enter the extracted data in codebook. Discrepancies will be reviewed and resolved by discussion among the weekly team. E.6. Study quality

The two reviewers involved in the aforementioned procedures will independently evaluate the quality of eligible studies using the Newcastle-Ottawa scale (NOS).49 Discrepancies will be reviewed and resolved by consensus during weekly meetings. NOS assesses the quality of study based on: 1) study design; 2) selection of the study groups; 3) comparability of the study design or analysis; and 4) assessment of outcomes of interest. 49,50 It measures nine criteria and the maximal score is nine.51 We will define the study as high quality if it scores seven or more out of nine. In addition, the quality of the study will be evaluated based on study participation, attrition, and outcome measures. E.7. Statistical analysis

For Aim 1 and 3, we will conduct a random-effects meta-analysis to determine: 1) factors associated with CRC screening behavior and 2) the effect of interventions.52. For Aim 2, we will use I2 and Ƭ2 statistics. 53 To identify contributing factors of heterogeneity and their potential moderator roles, we will conduct a multivariate meta-regression.52 We also will use meta-regression to assess study quality using the study quality variable (e.g., studies that met >4 quality indicators), and its impact on the relationship between intervention (or factor identified) and CRC screening. If at least ten studies are available, we will test for reporting and other bias using funnel plots with Egger’s test.54,55 But, we will be very cautious when interpreting asymmetrical funnel plot that may not be caused by reporting bias, rather, other possible reasons, such as poor methodological quality, variation in degree of control of confounding factors between small and large studies, or true heterogeneity between studies. All statistical analyses will be conducted using Comprehensive Meta-Analysis 56 and SPSS version 22 57 E.8. Strategies to manage potential limitations & problems (Table 4)

Table 4. Potential problems and strategies

POTENTIAL LIMITATIONS & PROBLEMS STRATEGIES

Conducting meta-analysis of the existing evidence can turn into an enormous project, overwhelming, labor intensive and time consuming.

Weekly team meeting

Goal re-orientation among team members

Remind team members the scope of project

Combining studies with divergent conceptualizations and measurement of variables, as known as the “apples and oranges” problem

Define all outcomes and concepts of interest before starting search

Keep records of all definitions

Team meeting to review and resolve the confusing cases

Small sample size that could impede our ability to examine effect sizes

We have conducted preliminary search and feel confident about our sample size.

We will utilize reference librarians to maximize study volumes

Unable to assess quality of intervention Address limitation in future manuscripts

E.9. Time table for completion of the study: Table 5 outlines the proposed time line. Table 5. Project timeline

Activities / Month 1 2 3 4 5 6 7 8 9 10 11 12

Hire and train study staff X X X

Literature search and data collection X X X X X X

Data extraction, entry and analysis X X X X X X X

Manuscripts and extramural Grant Preparation X X X X X X X X

F. Statement of Cancer Relevance

Colorectal cancer could kill and destroy a person’s life, while routine screening saves lives, reduces family and societal burden, improves quality of life, and decreases healthcare and societal cost. 58 The current adherence to CRC screening guidelines is low. Promoting CRC screening adherence is a complex process, requiring an evidence-based, community specific, and population-oriented intervention program orchestrated by publicly funded healthcare systems.59 The success of such an intervention program rests on comprehensive, high quality synthesized evidence through systematic review and meta-analysis.59 To our knowledge, our study is the first systematic review to appraise, analyze and synthesize evidence associated with CRC screening practice and behavior in rural and remote communities after the Patient Protection and Affordable Care Act went into effect in 2010, which mandates coverage of preventive screening services. 60 This policy change may impact CRC screening behavior pattern. Our systematic review could capture the potential moderating effect of this change on the effect of interventions on CRC screening in rural/remote areas.

Another project our team is conducting aims to examine the impact of the accountable care organization (ACO)-structured rural behavior on CRC screening rate in rural population. The full results are expected in March 2016. If this project is funded, the findings from both projects will play important roles in: 1) implementing evidence-based interventions and 2) moving the CRC screening program from opportunistic, practice-based to an organized, system level, which is the recommended priority areas for CRC sreening.27,61

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2010;27(1):1-31.

BIOGRAPHICAL SKETCH

Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2. Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME POSITION TITLE

Young, Lufei Assistant Professor

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.)

INSTITUTION AND LOCATION

DEGREE MM/YY FIELD OF STUDY

(if applicable)

Xi’an Medical University, China, Xi'an, Shaanxi

MD 06/1993 Medicine

University of Nebraska Medical Center , Lincoln, Nebraska

BSN 05/2004 Nursing

University of Nebraska Medical Center , Omaha, Nebraska

PhD 12/2010 Nursing

A. Personal Statement

The purpose of the proposed research is to conduct a systematic review and meta-analysis to critically appraise, analyze and synthesize factors that influence rural individuals’ adherence to CRC screening guidelines, the effectiveness of rural population-oriented interventions, as well as the underpinning implementation framework. I have the expertise, training, knowledge, and motivation necessary to successfully carry out the proposed project. Prior to coming to the U.S., I had six years of practice experience as a family physician in rural China. A large portion of my clinical responsibility (>65%) was to provide secondary prevention services (e.g., screening, vaccinations, monitoring chronic disease self-care markers and self-care education) to rural populations. Initially I was surprised and perplexed with the amount of resource allocation and effort put on tertiary care (e.g., chemo and radiation treatments for cancer) and with the little focus on primary and secondary cancer preventions in US healthcare system.

My program research is focused on rural healthcare services targeting residents living with multiple, chronic conditions (e.g., heart failure, chronic obstructive pulmonary disease, and cancer survivors). I have two funded projects: (1) NIH-funded randomized control trial to enhance rural heart failure patients’ engagement to self-care and (2) the observational study funded by Fred & Pamela Buffett Cancer Center to examine CRC screening behavior and practice in accountable care organization managed rural clinics. I have also been involved in several NIH-funded grants since I was a doctoral student. In addition, I am the practice clinician working at a rural community hospital. My “real world” experience as a rural clinician and “data world” experience as a researcher have prepared me well as a productive leading investigator who provides positive NPV for long-term investment from the funding agencies (e.g., Fred & Pamela Buffett Cancer Center, NIH).

The proposed project will play an important role in shifting the focus of colorectal cancer care from tertiary to secondary prevention (i.e., colorectal cancer screening). The findings of the proposed project will also help my inter-professional collaborative team (investigators from College of Public Health and College of Nursing) move forward to extramural grant applications that support our research trajectory in promoting guideline adherence to colorectal cancer screening. My success as a

PI in multiple funded grants and my productive track record in scholarly work demonstrates my ability, motivation, and commitment to successfully lead the proposed work. B. Positions and Honors Positions

1993 - 1999 Physician, Beijing 503 Hospital, Rural clinic, Beijing

2004 - Registered Nurse , Beatrice Community Hospital and Health Center, Beatrice, NE

2011 - Assistant Professor, University of Nebraska Medical Center, College of Nursing, Lincoln, NE

2013 - APRN, Southeast Nebraska Center for Lifestyle Medicine, Beatrice , NE

2013 - APRN, Beatrice Community Hospital and Health Center, Beatrice, NE

Other Experience and Professional Memberships

2004 - Member, Sigma Theta Tau International Honor Society of Nursing International

2005 - Member, Chinese American Medical Society

2007 - Member, Midwest Nursing Research Society

2007 - Member, Asian American Pacific Islander Nurses Association (AAPINA).

2009 - Member, American Heart Association

2011 - Member, Nebraska Nurse Practitioner

2013 - Certified lifestyle medicine and plant-based nutrition coach, Southeast Nebraska Center for Lifestyle Medicine

2013 - Meta-Analyst, Meta-Analysis from University of Missouri

2014 - Member, Emergency Nurses Association

2014 - Member, Kinesio Taping Association

2014 - 2014 Center grant reviewer , NIH/NINR

2014 - 2016 Grant and publication reviewer, Midwest Nursing Research Society

Honors

2004 Nursing Honorary, Sigma Theta Tau International Honor Society of Nursing International

2008 Nellie House Craven Scholarship for an Academic Nursing Career, University of Nebraska Medical Center, College of Nursing

2009 Kate Field Grant-In Aid , University of Nebraska

2009 Nellie House Craven Scholarship for an Academic Nursing Career, University of Nebraska Medical Center, College of Nursing

2010 Kate Field Grant-In Aid , University of Nebraska

2012 Nominated for March of Dimes Excellence in Nursing, Nebraska, March of Dimes, Nebraska

2012 Kathryn Sandahl Philp Award for Creativity and Innovation , University of Nebraska Medical Center College of Nursing

2014 New Investigator Award , University of Nebraska Medical Center

C. Contributions to Science 1. Symptom management and community based complex disease management in rural individuals

living with multiple chronic consuming conditions (e.g., heart failure, chronic obstructive pulmonary disease, and cancer survivors). a. Young L, Healey K, Charlton M et al. A Home-Based Comprehensive Care Model In Patients

With Multiple Sclerosis: A Study Pre-Protocol [version 1; referees: awaiting peer review] F1000Research 2015, 4:872 (doi:10.12688/f1000research.7040.1)

b. Zimmerman L, Barnason S, Young L, Tu C, Schulz P, et al. Symptom profiles of coronary artery bypass surgery patients at risk for poor functioning outcomes. J Cardiovasc Nurs. 2010 Jul-Aug; 25(4):292-300. PubMed PMID: 20498614.

c. Zimmerman L, Barnason S, Hertzog M, Young L, Nieveen J, et al. Gender differences in recovery outcomes after an early recovery symptom management intervention. Heart Lung. 2011 Sep-Oct; 40(5):429-39. PubMed PMID: 21501872; PubMed Central PMCID: PMC3166972.

d. Barnason S, Zimmerman L, Nieveen J, Schulz P, Young L. Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review. J Cardiovasc Nurs. 2012 Mar-Apr; 27(2):175-91. PubMed PMID: 22210146.

2. Healthcare utilization and cost analysis in patients undergoing cardiac surgery. BACKGROUND: the older women had worsen symptom following cardiac surgeries FINDINGS: The proposed intervention was cost effective to relieve symptoms in older women following cardiac procedures IMPLICATION TO SCIENCE: help build comparative effectiveness research in cardiac population MY ROLE: This was my dissertation project. As the investigator, I independently carried out the research, completed and submitted the publication. a. Young L, Zimmerman L, Pozehl B, Barnason S, Wang H. Cost-effectiveness of a symptom

management intervention: improving physical activity in older women following coronary artery bypass surgery. Nurs Econ. 2012 Mar-Apr; 30(2):94-103. PubMed PMID: 22558727.

3. Primary and secondary prevention with lifestyle modification and routine screening in rural residents living with chronic conditions. a. Young L, Kim J, Wang H and Chen LW. Examining Factors Influencing Colorectal Cancer

Screening of Rural Nebraskans Using Data from Clinics Participating in an Accountable Care Organization: A Study Protocol http://f1000r.es/5me] F1000Research 2015, 4:298 (doi: 10.12688/f1000research.6782.1)

b. Young L, Barnason S. Older Patients’ Perception and Experience with Lifestyle Changes Following Cardiac Revascularization. American Journal of Clinical Medicine. 2014 January; 10(1):30-38.

c. Young, L. and Barnason, S. (2015). Uptake of Dietary Sodium Restriction by Overweight and Obese Patients After Cardiac Revascularization. Rehabilitation Nursing. doi: 10.1002/rnj.205

4. Self-management intervention in rural heart failure patient. BACKGROUND: Rural heart failure patients have low engagement to self-care FINDINGS: pending. IMPLICATION TO SCIENCE: help identify feasible and sustainable program to promote self-management in rural heart failure patients. MY ROLE: PI, lead, administrate and conduct this 2-year ongoing project funded by NIH a. Young, L., Barnason, S., & Kupzyk, K. (2015). Mechanism of Engaging Self-Management

Behavior in Rural Heart Failure Patients. Applied Nursing Research. b. Young, L., Montgomery, M., Barnason, S., Schmidt, C., & Do, V. (2015). A Conceptual

Framework for Barriers to the Recruitment and Retention of Rural CVD Participants in Behavior Intervention Trials. GSTF Journal of Nursing and Health Care (JNHC), 2(2).

c. Do V, Young L, Barnason S and Tran H. (2015). Relationships Between Activation Level, Knowledge, Self-Efficacy, And Self-Management Behavior In Heart Failure Patients Discharged From Rural Hospitals. F1000Research http://f1000r.es/5fl, 4:150 (doi:10.12688/f1000research.6557.1)

d. Barnason S, Zimmerman L, Young L. An integrative review of interventions promoting self-care of patients with heart failure. J Clin Nurs. 2012 Feb; 21(3-4):448-75. PubMed PMID: 22098479.

e. Young L, Barnason S, Do V. Promoting self-management through adherence among heart failure patients discharged from rural hospitals: a study protocol. F1000Research. 2015 January

f. Young, L., Barnason, S., Hays, K., & Do, D. (2015). Nurse Practitioner led Medication Reconciliation in Critical Access Hospitals. The Journal for Nurse Practitioners. PII: S1555-4155(15)00266-4 DOI: 10.1016/j.nurpra.2015.03.005

D. Research Support

Active

1R15NR 13769-01A1, Lufei Young $300,000.00 2013/08/01-2016/03/31

NIH/NINR

Promoting self-management through adherence among heart failure patients The major goals of the project are to examine the feasibility of a 12-week patient activation intervention (Patient Activated Care at Home [PATCH]) to improve self-management adherence and its health outcome (i.e., hospital readmissions) in the heart failure patients discharged from rural hospitals. Your Role: PI

NA Jungyoon Kim and Hong Mei Wang

$99,930.00 2015/05/01-2016/05/1

UNMC College of Public Health and Fred & Pamela Buffett Cancer Center An examination of factors influencing colorectal cancer screening of rural Nebraskans using data from clinics participating in an accountable care organization The major goals of the project are to examine multi-level factors related to CRC screening, and providers’ perception of barriers and facilitators of CRC screening in rural patients cared for by accountable care organization (ACO) clinics. Your Role: Co-I

Pending None Overlap There is no potential overlap between the active projects and this application in terms of the science, budget, or an individual’s committed effort.

L_Young 21

BUDGET

CATEGORY COST Personnel

Data analyzer : 15 hours per week for 780 hours at unit rate of $35.00/hour

Graduate assistant

$27,300.00 $5,000.00

Materials and Supplies

SPSS License

Cost for Comprehensive Meta-Analysis (CMA) statistical software (used to do meta-analysis), 2 year memberships

Printing services

$150.00 $795.00 $200.00

Equipment

Travel

Travel between Omaha and Lincoln (PI’s work place): 100 miles per trip for 18 times per year at unite rate of $ 0.575/mileage

$1,380.00

Other Direct Costs

Attend scientific meetings and conferences for presentations

Editing services and publication cost

$3,000.00 $2,175.00

Total Cost

40,000.00

L_Young 22

BUDGET JUSTIFICATION:

PERSONNEL A graduate research assistant will commit 50% FTE for the project. She/he will participate on the research team by conducting literature searches, develop data collection checklists, data extraction forms, data analyses, syntheses and interpretation. She/he will also assist in developing manuscripts, posters and podium presentations. The total amount of student fees for a GA is 5,000 per year. CONSULTANTS: The data analyst will commit 15 hours per week for this project at a rate of $35 per hour. The data analyst clinical coordinator will be responsible for assisting in: 1) literature searches; 2) data extraction; 3) data analysis and synthesis; 4) data interpretation; and 5) development of publications and presentations. A salary of $27,300 is requested for the overall project period. MATERIALS AND SUPPLIES To conduct systematic review and meta-analysis, we need an SPSS license and Cost for Comprehensive Meta-Analysis (CMA) statistical software, as well as printing services. A total of $1,145 was requested. TRAVEL: Funds are requested to cover costs for the investigators, clinical analyst and graduate assistant to attend biweekly then monthly project team meetings. A total of $1,380 was requested for these trips. OTHER DIRECT COSTS Editing service will be used to prepare manuscripts, presentations and larger extramural grants. We also request expense coverage for attending scientific meeting, conferences and workshops to disseminate our findings and learn from others. A total of $5,175 was requested.