Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP)

Jennifer L Ridgeway, Megan E Branda, Derek Gravholt, Juan P Brito, Ian G Hargraves, Sandra A Hartasanchez, Aaron L Leppin, Yvonne L Gomez, Devin M Mann, Vivek Nautiyal, Randal J Thomas, Emma M Behnken, Victor D Torres Roldan, Nilay D Shah, Charanjit S Khurana, Victor M Montori, Jennifer L Ridgeway, Megan E Branda, Derek Gravholt, Juan P Brito, Ian G Hargraves, Sandra A Hartasanchez, Aaron L Leppin, Yvonne L Gomez, Devin M Mann, Vivek Nautiyal, Randal J Thomas, Emma M Behnken, Victor D Torres Roldan, Nilay D Shah, Charanjit S Khurana, Victor M Montori

Abstract

Background: The primary prevention of cardiovascular (CV) events is often less intense in persons at higher CV risk and vice versa. Clinical practice guidelines recommend that clinicians and patients use shared decision making (SDM) to arrive at an effective and feasible prevention plan that is congruent with each person's CV risk and informed preferences. However, SDM does not routinely happen in practice. This study aims to integrate into routine care an SDM decision tool (CV PREVENTION CHOICE) at three diverse healthcare systems in the USA and study strategies that foster its adoption and routine use.

Methods: This is a mixed method, hybrid type III stepped wedge cluster randomized study to estimate (a) the effectiveness of implementation strategies on SDM uptake and utilization and (b) the extent to which SDM results in prevention plans that are risk-congruent. Formative evaluation methods, including clinician and stakeholder interviews and surveys, will identify factors likely to impact feasibility, acceptability, and adoption of CV PREVENTION CHOICE as well as normalization of CV PREVENTION CHOICE in routine care. Implementation facilitation will be used to tailor implementation strategies to local needs, and implementation strategies will be systematically adjusted and tracked for assessment and refinement. Electronic health record data will be used to assess implementation and effectiveness outcomes, including CV PREVENTION CHOICE reach, adoption, implementation, maintenance, and effectiveness (measured as risk-concordant care plans). A sample of video-recorded clinical encounters and patient surveys will be used to assess fidelity. The study employs three theoretical approaches: a determinant framework that calls attention to categories of factors that may foster or inhibit implementation outcomes (the Consolidated Framework for Implementation Research), an implementation theory that guides explanation or understanding of causal influences on implementation outcomes (Normalization Process Theory), and an evaluation framework (RE-AIM).

Discussion: By the project's end, we expect to have (a) identified the most effective implementation strategies to embed SDM in routine practice and (b) estimated the effectiveness of SDM to achieve feasible and risk-concordant CV prevention in primary care.

Trial registration: ClinicalTrials.gov, NCT04450914 . Posted June 30, 2020 TRIAL STATUS: This study received ethics approval on April 17, 2020. The current trial protocol is version 2 (approved February 17, 2021). The first subject had not yet been enrolled at the time of submission.

Keywords: Cardiovascular treatment; Implementation facilitation; Implementation science; Mixed methods; Risk-treatment paradox; Shared decision making.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
CV Prevention Choice
Fig. 2
Fig. 2
Study design
Fig. 3
Fig. 3
Study schema by quarter

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