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BMC Health Serv Res. 2018 Oct 30;18(1):824. doi: 10.1186/s12913-018-3636-2.

Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts.

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Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA.
University of South Florida, 3720 Spectrum Blvd, Suite 304, Tampa, FL, 33612, USA.
Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97202, USA.
Department of Medicine and the Meyers Primary Care Institute, University of Massachusetts Medical School, 365 Plantation St. Biotech 1, Suite 100, Worcester, MA, 01605, USA.
Colorado Center for Personalized Medicine, University of Colorado, Aurora, CO, 80045, USA.
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.
HealthPartners Institute, Bloomington, MN, USA.
Division of Gastroenterology, Department of Medicine, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA.
Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA.
Kaiser Permanente Colorado, Institute for Health Research, 2550 S. Parker Rd., Ste 200, Aurora, CO, 80014, USA.
Intermountain Healthcare, Precision Genomics, IMC campus, Bldg. 2, Suite 610, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.
Geisinger Department of Epidemiology and Health Services Research 100 N, Academy Ave Danville, Mahoning Township, PA, 17822, USA.
Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA.



Systematic screening of all colorectal tumors for Lynch Syndrome (LS) has been recommended since 2009. Currently, implementation of LS screening in healthcare systems remains variable, likely because LS screening involves the complex coordination of multiple departments and individuals across the healthcare system. Our specific aims are to (1) describe variation in LS screening implementation across multiple healthcare systems; (2) identify conditions associated with both practice variation and optimal implementation; (3) determine the relative effectiveness, efficiency, and costs of different LS screening protocols by healthcare system; and (4) develop and test in a real-world setting an organizational toolkit for LS screening program implementation and improvement. This toolkit will promote effective implementation of LS screening in various complex health systems.


This study includes eight healthcare systems with 22 clinical sites at varied stages of implementing LS screening programs. Guided by the Consolidated Framework for Implementation Research (CFIR), we will conduct in-depth semi-structured interviews with patients and organizational stakeholders and perform economic evaluation of site-specific implementation costs. These processes will result in a comprehensive cross-case analysis of different organizational contexts. We will utilize qualitative data analysis and configurational comparative methodology to identify facilitators and barriers at the organizational level that are minimally sufficient and necessary for optimal LS screening implementation.


The overarching goal of this project is to combine our data with theories and tools from implementation science to create an organizational toolkit to facilitate implementation of LS screening in various real-world settings. Our organizational toolkit will account for issues of complex coordination of care involving multiple stakeholders to enhance implementation, sustainability, and ongoing improvement of evidence-based LS screening programs. Successful implementation of such programs will ultimately reduce suffering of patients and their family members from preventable cancers, decrease waste in healthcare system costs, and inform strategies to facilitate the promise of precision medicine.




Colorectal Cancer; Configurational comparative method; Consolidated framework for implementation research (CFIR); Decision analytic modeling; Economic evaluation; Implementation; Lynch syndrome; Precision medicine; Qualitative comparative analysis (QCA); Universal screening

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