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Background Clinical practice guidelines recommend antiplatelet and statin therapies as well as blood pressure control and tobacco cessation for secondary prevention in patients with established atherosclerotic cardiovascular diseases (ASCVDs). However, these strategies for risk modification are underused, especially in rural communities. Moreover, resources to support the delivery of preventive care to rural patients are fewer than those for their urban counterparts. Transformative interventions for the delivery of tailored preventive cardiovascular care to rural patients are needed. Objective A multidisciplinary team developed a rural-specific, team-based model of care intervention assisted by clinical decision support (CDS) technology using participatory design in a sociotechnical conceptual framework. The model of care intervention included redesigned workflows and a novel CDS technology for the coordination and delivery of guideline recommendations by primary care teams in a rural clinic. Methods The design of the model of care intervention comprised 3 phases: problem identification, experimentation, and testing. Input from team members (n=35) required 150 hours, including observations of clinical encounters, provider workshops, and interviews with patients and health care professionals. The intervention was prototyped, iteratively refined, and tested with user feedback. In a 3-month pilot trial, 369 patients with ASCVDs were randomized into the control or intervention arm. Results New workflows and a novel CDS tool were created to identify patients with ASCVDs who had gaps in preventive care and assign the right care team member for delivery of tailored recommendations. During the pilot, the intervention prototype was iteratively refined and tested. The pilot demonstrated feasibility for successful implementation of the sociotechnical intervention as the proportion of patients who had encounters with advanced practice providers (nurse practitioners and physician assistants), pharmacists, or tobacco cessation coaches for the delivery of guideline recommendations in the intervention arm was greater than that in the control arm. Conclusions Participatory design and a sociotechnical conceptual framework enabled the development of a rural-specific, team-based model of care intervention assisted by CDS technology for the transformation of preventive health care delivery for ASCVDs.

BACKGROUND Clinical practice guidelines recommend antiplatelet and statin therapies, blood pressure control and cessation of tobacco products for atherosclerotic cardiovascular disease (ASCVD) patients. However, these strategies for risk modification are underused by patients with ASCVD, especially in rural communities. The needs of and resources available to rural patients with cardiovascular disease are different than their urban/suburban counterparts, requiring a distinct approach to their care. Interventions developed without considering the unique needs of rural populations often fail. Approaches tailored to this population are needed. OBJECTIVE Using a Participatory Design (PD) approach, a multidisciplinary team sought to develop a sociotechnical intervention to enable rural primary care teams to systematically improve the cardiovascular health of patients with ASCVD. The intervention included adapting an existing technology for delivery of expert guideline recommendations into clinical practice in rural communities. METHODS Development took place in four stages: I) Initial Understanding, II) Ideation and Experimentation, III) Prototyping the Intervention, and IV) Designing the Sociotechnical System. Our team observed clinical encounters, interviewed patients, and conducted workshops with rural care team members to develop viable intervention concepts. We then iteratively prototyped in a routine clinical practice and refined a pilotable version of the intervention with extensive stakeholder feedback. RESULTS The sociotechnical intervention was created with input from clinical team members (n=35) in Austin and Adams, Minnesota. This collaboration resulted in contextually-grounded workflows and a clinical decision support tool that [1] identifies patients with ASCVD who would benefit from additional care touchpoints, [2] aggregates crucial medical information for clinical decision-making, and [3] assigns the appropriate care team role to determine care plans. The resulting intervention enables care teams to systematically, collaboratively, and proactively deliver care for patients with ASCVD. CONCLUSIONS The PD process was invaluable in developing a cardiovascular intervention that establishes a sociotechnical system comprised of novel responsibilities, workflows, and technology while acknowledging capacities and limitations of rural health care clinics. Next steps involve the evaluation of the intervention impact on standard metrics of quality cardiovascular care and the dissemination of the intervention to other clinic locations while maintaining core values of human-centered design.

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