Table 3.

Measurement and evaluation challenges related to integrated implementation

	Examples	Specific issues related to integration and measurement challenges
Interventions and supporting activities	One-on-one education; patient reminders; provider reminders; electronic medical record system enhancements	Level of integration may vary across multicomponent interventions, with combined implementation at some levels and not others
Process measures	Proportion of patients receiving education; number of phone calls to remind patients or providers	Time spent during education sessions or phone calls on specific cancers may be difficult to accurately determine
Screening outcomes—short or medium term	Number of individuals screened; proportion completing recommended follow-up procedures	The denominator will differ for each type of screening based on individuals due for a screen during the time period of the intervention. Good tracking processes are required. Comparing outcomes across clinics may be challenging as individuals not up to date with screening may vary in the mix of screenings required during the intervention period. Diagnostic follow-up procedures are unique to each type of cancer screening and therefore the completion rates may also differ.
Screening outcomes—long term	Cancer mortality averted and life years saved due to screening	Long-term outcome estimates will require different microsimulation models for colorectal, breast, and cervical cancers. Joint impacts may be difficult to assign separately to each type of cancer screening
Implementation outcomes	Acceptability, appropriateness, feasibility, fidelity, sustainability	Joint implementation of interventions and supporting activities may mask implementation challenges related to each type of cancer screening
Cost measures and economic assessments	Activity-based cost of interventions; cost per successful screen	Stakeholders may not be able to separate out resource use and cost related to specific cancer screenings