Physician Education and Peer Comparisons to Reduce Cardiovascular Risk Among People Living with HIV: A Stepped-Wedge Cluster Randomized Trial.

Cardiovascular disease is a major cause of death among people living with HIV (PLWH). We developed a multilevel implementation strategy to increase evidence-based statin use, which is under-prescribed in PLWH. Through a stepped-wedge cluster randomized trial in seven HIV clinics in Los Angeles, we implemented a physician champion-led education intervention and behavioral economics-informed peer comparisons. Each clinician's statin prescribing rate relative to top-performing physicians was reported back monthly, with language leveraging social norms and self-image. We also conducted post-intervention, semi-structured interviews with providers. We enrolled 37 participants, of which 29 were clinicians seeing PLWH as a primary HIV provider. We were unable to obtain complete electronic health records from two clinics. At baseline, the five clinics saw a total of 1304 PLWH during 4565 office visits, and the proportion of statin-eligible clinic visits during which a statin was prescribed was 53.65%. This increased to 58.1% after the education intervention and was 57.48% after the peer comparison intervention. The effects of the education intervention (- 1.2% points; 95% CI, - 3.68 to 1.10) and peer comparison intervention (0.052% points; 95% CI, - 3.89 to 3.77) were not significant. Providers thought feedback emails were acceptable and could be effective but most found the language and information in the emails to be lacking detail, and most found the peer comparison language to be off-putting. An implementation strategy that included a champion-led education intervention and a physician peer comparison intervention informed by principles of behavioral economics did not significantly increase evidence-based statin prescribing for PLWH.Trial registration: This trial is registered with the National Institutes of Health at ClinicalTrials.gov under identifier NCT03687060.