Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH). Evidence-based statin therapy is highly effective at reducing cardiovascular risk but is under- prescribed for PLWH due to provider- and patient-level barriers. Potential provider-level barriers include misconceptions about potential side effects, inadequate knowledge of guideline recommendations, and concerns about patient adherence. Patient-level barriers to new prescription uptake often relate to concerns about side effects and uncertainty about benefits. Implementation science research suggests that barriers to implementation of evidence-based practices can occur at all levels of an organization, including at the leadership, provider, and patient levels, and that barriers at each level must be addressed for successful implementation to occur. We, therefore, propose a multi-level intervention to increase evidence-based statin prescribing by addressing barriers at these levels using the Consolidated Framework for Implementation Research. Following a qualitative phase to inform and tailor the intervention's educational component, we will implement (1) tailored education at the leadership, provider, and patient levels, and (2) provider peer comparisons. To educate leadership, specifically medical directors, we will provide a brief, in-person ?peer champion?-led educational module about CVD risk in PLWH and evidence-based statin use. Patients will receive pamphlets about CVD and communication strategies with providers. A behavioral economics peer comparison strategy, to be implemented six months after the first intervention component, will be email- based and compare each physician's rate of provision of statin therapy relative to top-performing physicians caring for PLWH. In partnership with the Los Angeles County Ambulatory Care Network and community clinics (N=11 clinics), we will use a stepped-wedge cluster randomized trial design to pursue these aims:
Aim 1 : Assess knowledge about and barriers to statin prescribing among clinic leadership, providers, and PLWH and adapt the intervention's education intervention to address barriers at each level.
Aims 2 a and 2b: Determine effectiveness of the (2a) education intervention and (2b) peer comparison intervention on adoption (outcome is providers' prescribing rates) of evidence-based statin therapy.
Aims 3 a, 3b, and 3c: Assess implementation outcomes, including (3a) changes in provider acceptability of statin prescribing for PLWH; (3b) provider acceptability of the education and peer comparison interventions; and (3c) cost of implementing the education and peer comparison.

Public Health Relevance

Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH), but evidence-based statin therapy?highly effective at reducing cardiovascular risk?is under- prescribed for PLWH due to provider- and patient-level barriers. Recent studies have demonstrated that patients with HIV experience approximately a 50-100% increased risk of myocardial infarction and stroke compared to HIV-uninfected persons, and face higher risks of stroke, sudden death, and heart failure. In this study, we propose an innovative implementation strategy for reducing the risk of CVD among PLWH based on principles from the Consolidated Framework for Implementation Research (CFIR) and behavioral economics.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project--Cooperative Agreements (U01)
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Special Emphasis Panel (ZHL1)
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Roper, Rebecca
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University of California Los Angeles
Internal Medicine/Medicine
Schools of Medicine
Los Angeles
United States
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