Implementation of a cardiovascular toolkit in primary care increased women Veterans' engagement in behavior change programs: results from a non-randomized stepped wedge trial.

Background: Cardiovascular (CV) disease is the leading cause of death among U.S. women, yet women have a limited understanding of their CV-related morbidity and mortality risks. Provider-, system-, and patient-level barriers point to a need for multi-level evidence-based strategies to facilitate CV risk reduction. Guided by the Replicating Effective Programs framework and complexity theory, we implemented a CV Toolkit in primary care clinics for women Veterans. The objective was to evaluate the effect of implementation of CV toolkit on participation in behavior change programs that target CV risk reduction. Methods: In partnership with the Veterans Health Administration (VA) Office of Women's Health and National Center for Health Promotion and Disease Prevention, we developed and implemented a CV Toolkit at five geographically diverse VA sites between March 2017-March 2020. Using a non-randomized stepped wedge design, we evaluated the effect of the implementation of toolkit on participation in the VA MOVE! weight management program, and on participation in health promotion and disease prevention (HPDP) programs (coaching, facilitated groups, etc.) and/or complementary integrative health (CIH) programs (yoga, meditation, etc.). We utilized a three-level (patient, site, time) non-linear fixed effect model with stratification by age (65 and older versus younger). Patient participation, utilization, and demographics were extracted from VA administrative data for all women with at least one primary care visit at a participating site from December 2016-March 2020 (n = 6009). Results: Women were on average 45 years old; 38% were white, 31% Black, 17% Hispanic; and over a third had CV risk factors and/or mental health diagnoses. For women 65 years and older (n = 540), active toolkit implementation resulted in increased odds of MOVE! participation (OR = 1.09; 95% CI:1.030-1.152) compared to when the toolkit was not active either within or between sites. Women younger than 65 (n = 5469) had increased odds of using HPDP/CIH programs during active toolkit implementation (OR = 1.01; 95% CI:1.002-1.022). Conclusions: Active implementation of the CV Toolkit intervention was significantly associated with increasing participation in behavior change programs. Variation in program participation by age suggests that the diversity of behavior change programs available to women Veterans may facilitate participation across the lifespan. Trial registration: Clinical Trials.gov, NCT02991534. Registered 12-09-2016, https://clinicaltrials.gov/study/NCT02991534?cond=NCT02991534&rank=1.