Champions and early adopters in an implementation-effectiveness study of shared decision making: implications for interpersonal strategies

BACKGROUND: Although recommended, shared decision making (SDM) is not widely adopted for primary prevention of cardiovascular (CV) disease. Champions may influence peer adoption if they are enthusiastic and skilled. We describe adoption of an SDM conversation aid for CV risk reduction (CV Prevention Choice) by champions and early adopters in a pragmatic implementation trial and consider their influence on uptake in clinics. METHODS: We embedded the SDM tool in the electronic health record in three U.S. health care systems. Eight of their 15 affiliated clinics deployed a champion implementation strategy. Adopters used the SDM tool in ≥ 2 routine clinical encounters. Superusers had ≥ 20 encounters. Penetration was the proportion of adopters among eligible clinicians. Adoption and penetration were assessed in the usual care (early adoption), active implementation, and maintenance implementation phases. Thematic analysis methods were used to analyze qualitative data from individual interviews and periodic reflections. RESULTS: Between May 2021 and January 2025, 37 interviews with clinicians and other staff and 65 periodic reflections were completed. Among 176 clinicians, 55% (n = 97) used CV Prevention Choice at least once and 42% (n = 76) adopted it. Champions and other opinion leaders gave presentations and demonstrated their practice, but targeted individual persuasion and group dialogue were less common, especially when champions appreciated peers' preferences. Champions used the tool more frequently (median = 93, IQR 53-150) than non-champions (median = 16, IQR 4-50), although only 4 of the top 20 users were champions. Clinics with champions had higher penetration rates (50% vs 29%) and lower rates of one-time tool use than clinics without champions (17% vs 33%). CONCLUSION: Champions, superusers, and other opinions leaders may influence peer adoption of clinical innovations by sharing their experience, but group discourse may be needed to build the case for uptake of innovations. Superusers may be impactful in clinics without formal champions. TRIAL REGISTRATION: The protocol described herein was registered with ClinicalTrials.gov on 22 June 2020 (No. NCT04450914).