Applying the behavior change wheel to design de-implementation strategies to reduce low-value statin prescription in primary prevention of cardiovascular disease in primary care

Abstract

IntroductionA substantial proportion of individuals with low cardiovascular risk receive inappropriate statin prescription for primary prevention of cardiovascular disease (CVD) instead of the evidence-based recommendations to promote healthy lifestyle behaviors. This study reports on the structured process performed to design targeted de-implementation strategies to reduce inappropriate prescription of statins and to increase healthy lifestyle promotion in low cardiovascular risk patients in Primary Care (PC).MethodsA formative study was conducted based on the Theoretical Domains Framework and the Behavior Change Wheel (BCW). It comprised semi-structured interviews with PC professionals to define the problem in behavioral terms; focus groups with Family Physicians and patients to identify the determinants (barriers and facilitators) of inappropriate statin prescription and of healthy lifestyle promotion practice; mapping of behavioral change interventions operationalized as de-implementation strategies for addressing identified determinants; and consensus techniques for prioritization of strategies based on perceived effectiveness, feasibility and acceptability.ResultsIdentified key determinants of statin prescription and healthy lifestyle promotion were: the lack of time and clinical inertia, external resources, patients' preferences and characteristics, limitation of available clinical tools and guidelines, social pressures, fears about negative consequences of not treating, and lack of skills and training of professionals. Fourteen potential de-implementation strategies were mapped to the identified determinants and the following were prioritized: 1) non-reflective decision assistance strategies based on reminders and decision support tools for helping clinical decision-making; 2) decision information strategies based on the principles of knowledge dissemination (e.g., corporative diffusion of evidence-based Clinical Practice Guidelines and Pathways for CVD primary prevention); 3) reflective decision-making restructuring strategies (i.e., audit and feedback provided along with intention formation interventions).ConclusionsThis study supports the usefulness of the BCW to guide the design and development of de-implementation strategies targeting the determinants of clinicians' decision-making processes to favor the abandonment of low-value practices and the uptake of those recommended for CVD primary prevention in low-risk patients. Further research to evaluate the feasibility and effectiveness of selected strategies is warranted.Clinical trial registrationSanchez A. De-implementation of Low-value Pharmacological Prescriptions (De-imFAR). ClinicalTrials.gov, Identifier: NCT04022850. Registered July 17, 2019. In: ClinicalTrials.gov. Bethesda (MD): U.S. National Library of Medicine (NLM). Available from: https://www.clinicaltrials.gov/ct2/show/NCT04022850.

De-imFAR phase II project: a study protocol for a cluster randomised implementation trial to evaluate the effectiveness of de-implementation strategies to reduce low-value statin prescribing in the primary prevention of cardiovascular disease

“…Patients were involved in the DE-imFAR phase I project as one of the main stakeholders (health professionals, patients and researchers) in the formative process conducted to map and design de-implementation strategies to reduce PIP, which will be evaluated in the DE-imFAR phase II project. Specifically, during the phase I project, a focus group with six patients was conducted to ascertain patients’ experience with the clinical practice of statin prescription and triangulate physicians discourse 14…”

“…Second, we applied two of the most successfully used behaviour change theories in the field of Implementation Science, the Theoretical Domains Framework (TDF)3 11 12 and Behaviour Change Wheel (BCW),13 to (a) understand and define the problem (low-value practice) in behavioural terms and select and specify the target behaviours; (b) identify the factors that may influence it and (c) map targeted de-implementation and implementation strategies conducive to reducing the low-value practice in question. Briefly, after having prioritised our specific target behaviour (ie, ‘clinician decision-making on intervention/treatment to be provided based on objective clinical information and subjective schemas and heuristics’), identified the determinants (facilitators of the non-desired behaviour of PIP of statins and barriers to apply the recommended clinical practice behaviour of promoting healthy lifestyles), and mapped specific behaviour change techniques, three types of de-implementation strategies were selected based on being the most potentially effective, feasible and acceptable to influence decision-making through different mechanisms 14. Hence, the three strategies derived from the systematic theory- and evidence-based intervention design process were: (a) a non-reflective decision assistance strategy based on providing family physicians (FPs) with evidence-based information communication technology tools to help and guide decision-making; (b) a decision information strategy based on the dissemination of CVD primary prevention evidence framed in a corporate campaign encouraging FPs to abandon PIP and (c) a reflective decision structure strategy encouraging reflection on actual performance based on an audit/feedback system 14…”

“…According to the literature review performed within the phase I of the DE-imFAR project14 regarding the evaluation of effective intervention strategies for the reduction of low-value prescribing,15–24 multicomponent interventions—combining passive dissemination interventions, based on training in or dissemination of clinical practice guidelines (CPGs), with more proactive interventions incorporating decision-making aids or sending audit/feedback—achieve the most positive results. Specifically, in the context of PIP of statins, a positive impact was observed on recording of CVR and prescription adequacy using (a) multicomponent dissemination strategies including informational websites and implementation of electronic CPGs compared with routine practice and training activities and (b) interventions based on sending clinical scenarios/cases and audit/feedback to professionals as well as decision support tools 19–23.…”

“…Briefly, after having prioritised our specific target behaviour (ie, 'clinician decision-making on intervention/treatment to be provided based on objective clinical information and subjective schemas and heuristics'), identified the determinants (facilitators of the non-desired behaviour of PIP of statins and barriers to apply the recommended clinical practice behaviour of promoting healthy lifestyles), and mapped specific behaviour change techniques, three types of de-implementation strategies were selected based on being the most potentially effective, feasible and acceptable to influence decision-making through different mechanisms. 14 Hence, the three strategies derived from the systematic theory-and evidence-based intervention design process were: (a) a non-reflective decision assistance strategy based on providing family physicians (FPs) with evidencebased information communication technology tools to help and guide decision-making; (b) a decision information strategy based on the dissemination of CVD primary prevention evidence framed in a corporate campaign encouraging FPs to abandon PIP and (c) a reflective decision structure strategy encouraging reflection on actual performance based on an audit/feedback system. 14 According to the literature review performed within the phase I of the DE-imFAR project 14 regarding the evaluation of effective intervention strategies for the reduction of low-value prescribing, [15][16][17][18][19][20][21][22][23][24]…”

“…14 Hence, the three strategies derived from the systematic theory-and evidence-based intervention design process were: (a) a non-reflective decision assistance strategy based on providing family physicians (FPs) with evidencebased information communication technology tools to help and guide decision-making; (b) a decision information strategy based on the dissemination of CVD primary prevention evidence framed in a corporate campaign encouraging FPs to abandon PIP and (c) a reflective decision structure strategy encouraging reflection on actual performance based on an audit/feedback system. 14 According to the literature review performed within the phase I of the DE-imFAR project 14 regarding the evaluation of effective intervention strategies for the reduction of low-value prescribing, [15][16][17][18][19][20][21][22][23][24]…”