Healthcare professionals' perspectives on a multilevel cardiovascular risk management intervention (PROSPERA programme)
This study identifies barriers and facilitators among healthcare professionals regarding the implementation of the PROSPERA multilevel cardiovascular risk management programme, highlighting the need for targeted education, training, and environmental restructuring to support its adoption in primary care.
Original authors:Bongaerts, V. A. M. C., van Gestel, L. C., van Peet, P. G., Vuijk, M.-L. S., Hageman, S. H. J., Dorresteijn, J. A. N., Bonten, T. N., Numans, M. E., van Os, H. J. A., Vos, R. C.
Original authors: Bongaerts, V. A. M. C., van Gestel, L. C., van Peet, P. G., Vuijk, M.-L. S., Hageman, S. H. J., Dorresteijn, J. A. N., Bonten, T. N., Numans, M. E., van Os, H. J. A., Vos, R. C.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ⚕️ This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer
Imagine your local neighborhood doctor's office as a busy lighthouse. For years, this lighthouse has been excellent at spotting ships (patients) that are already in trouble or have known storms ahead (chronic conditions like heart disease). However, the lighthouse has struggled to see the ships that are about to run into trouble but haven't crashed yet, simply because there are too many ships in the fog, and the crew doesn't have a radar system to sort them out.
This paper is about testing a new "Super-Radar System" called PROSPERA. The researchers wanted to know: Will the lighthouse crew (doctors and nurses) actually use this new radar, or will they find it too confusing or annoying?
Here is the breakdown of their findings in plain English:
The New System: Two Parts
The PROSPERA programme tries to fix the lighthouse in two ways:
The Big Picture (Population Level): Instead of waiting for a ship to call for help, the system uses data to create a "priority list." It sorts all the patients into three groups:
Green: Doing fine, maybe just check in once a year.
Amber: Needs a closer look soon.
Red: Needs immediate, intensive help.
The Goal: The crew can stop guessing who to call and start proactively reaching out to the "Red" and "Amber" ships.
The One-on-One Tools (Individual Level): When a patient walks in, the crew has three new gadgets to help them talk to the patient:
The Homework Sheet (Lifestylecheck): A questionnaire the patient fills out before the visit to think about their habits.
The Risk Calculator (U-Prevent): A computer tool that draws colorful charts to show the patient, "If you keep doing X, here is your risk. If you change to Y, here is how much safer you become."
The Remote Box: A kit with a blood pressure cuff and scale that patients can use at home to send data back to the doctor.
What the Crew Said: The Good, The Bad, and The Ugly
The researchers asked the doctors and nurses (the crew) what they thought about using this new system. Here is what they found:
1. The "Big Picture" Hurdles (Sorting the Ships)
The "Who is Who?" Problem: The crew said, "We used to know our patients by heart. Now, we have a computer list, but the list isn't perfect." Sometimes the computer missed people or included the wrong people because the digital records in the office were messy.
The "Too Much Paperwork" Problem: Getting patients to sign up for this new system felt like running a marathon just to invite them to a party. The process was too slow and complicated.
The "Who's in Charge?" Confusion: The nurses felt a bit nervous. They are used to following strict rules. The new system asked them to make big decisions on their own (like saying, "This patient is fine, let's skip their appointment"). They felt they needed more training to trust their own gut feelings without a doctor hovering over them.
The "Relationship" Fear: Some nurses worried that if they stopped seeing patients as often (because the computer said they were "Green"), they would lose that personal connection. They felt like they were letting go of the reins.
2. The "One-on-One" Hurdles (Using the Gadgets)
The "Old Habits" Problem: It's hard to break a routine. Some nurses were so used to asking the questions themselves that they forgot to hand out the "Homework Sheet" (Lifestylecheck). They got so focused on the new Risk Calculator that they accidentally ignored the other tool.
The "Reading the Map" Problem: Some patients had trouble reading the homework sheet because the language was too hard. Also, the "Remote Box" (the home monitoring kit) was seen as too much work for patients who aren't tech-savvy or organized.
The "Visuals Work" Win: The crew loved the colorful charts from the Risk Calculator. They said, "When we show a patient a red bar turning green, they finally get it." It made the scary concept of "heart risk" easy to understand.
The "Nervous Excitement": The first time they used the new tools, everyone felt a bit jittery, like a kid trying a new video game for the first time. But once they got the hang of it, they felt it was actually helpful.
The Bottom Line
The paper concludes that this new "Super-Radar" has a lot of potential, but it's not ready to be turned on full blast yet.
To make it work, the doctors and nurses need better training (especially on how to read the risk charts and make independent decisions).
The technology needs a tune-up so the lists are more accurate and the paperwork is less annoying.
The environment needs to change to make these new tools easier to remember and use every day.
Essentially, the crew is willing to use the new radar, but they need the lighthouse owner to fix the glitches and give them a better map before they can sail confidently into this new way of working.
Technical Summary: Healthcare Professionals' Perspectives on the PROSPERA Programme
Problem Statement Cardiovascular disease (CVD) remains a leading cause of mortality globally. In the Netherlands, while two-thirds of cardiovascular risk management (CVRM) occurs in primary care, the current approach is largely reactive and uniform. Although guidelines recommend calculating individual risk scores, there is no established population-level structure for risk-based patient outreach. Consequently, resources are not distributed equitably across heterogeneous patient subgroups, and personalized treatment goals are not universally discussed. The PROSPERA programme was developed as a multilevel intervention to address this gap, combining population-level risk stratification with individual-level support tools. However, previous research indicates that a small proportion of health research translates into sustainable clinical practice, particularly for complex interventions. Therefore, understanding the barriers and facilitators influencing healthcare professionals' (HCPs) behavior change is critical before implementation.
Methodology This qualitative study assessed anticipated and experienced barriers and facilitators among primary care HCPs to inform the implementation of the PROSPERA programme.
Design: The study utilized four focus groups and six semi-structured interviews with nine primary care HCPs (general practitioners and practice nurses) affiliated with the Extramural Leiden University Medical Center Academic Network (ELAN).
Theoretical Framework: Data collection and analysis were grounded in the Theoretical Domains Framework (TDF) and the Capability, Opportunity, Motivation model of Behaviour (COM-B).
Intervention Components: The PROSPERA programme includes:
Population Level: Risk stratification of patients into three panels (normal, high, extra high) based on primary/secondary prevention needs and treatment goal achievement.
Individual Level:
Lifestylecheck: A pre-consultation questionnaire on lifestyle motivation.
U-Prevent: A clinical decision support tool for interactive risk calculation and communication.
The Box: Remote patient monitoring tools (blood pressure, weight, activity).
Data Collection Process: The study followed a sequential approach:
Focus groups on current CVRM practices (June 2023).
Focus groups on anticipated barriers/facilitators using a pilot version of PROSPERA, including a "think-aloud" method for dashboard testing (September 2023).
A pilot implementation in three general practices in The Hague.
Focus groups and individual interviews on experienced barriers/facilitators after clinical use (January–March 2024).
Analysis: Transcripts were coded inductively, classified as barriers or facilitators, and mapped to TDF domains and COM-B constructs.
Key Results Barriers and facilitators were identified across 11 of the 14 TDF domains, categorized by the two target behaviors:
1. Providing Proactive Care at the Population Level
Capability: HCPs expressed a need for data support to identify high-risk patients, noting they could not rely on memory alone due to large patient populations.
Opportunity:
Facilitators: The panel concept was viewed as valuable for prioritization, shifting reliance from intuition to data.
Barriers: Time constraints arose because lists displayed all patients rather than assigned ones. Inaccuracies in panel creation were reported due to limited real-time data extraction from Electronic Health Records (EHRs) and poor documentation. The study's informed consent procedure was also cited as a cumbersome barrier.
Motivation:
Facilitators: HCPs were motivated to identify patients needing intensive follow-up and, conversely, those who could reduce consultation frequency (self-management).
Barriers: HCPs expressed unease regarding the shift from reactive to proactive care. Practice nurses specifically lacked confidence in deviating from standard guidelines to alter follow-up frequencies independently. There was also concern that reducing in-person visits or using remote monitoring might negatively impact the professional-patient relationship and alter professional identity. Ambiguity existed regarding who holds responsibility for population risk stratification, with a preference for regional organizations to automate the process.
2. Using Support Tools at the Individual Level
Capability:
Facilitators: HCPs actively planned how to integrate the Lifestylecheck and U-Prevent into consultations.
Barriers: Habitual routines made it difficult to alter workflows; some HCPs forgot the Lifestylecheck when overwhelmed by the U-Prevent tool. There were questions regarding the interpretation of treatment modellers for patients who did not fit standard calculator profiles.
Opportunity:
Barriers: Low health literacy in the patient population hindered the completion of pre-consultation questionnaires. The "Box" (remote monitoring) was deemed feasible only for specific patients capable of self-management. Practice nurses noted a need for more preparation time and instruction to develop risk communication skills.
Motivation:
Facilitators: Pre-consultation completion of the Lifestylecheck was seen as a way to activate patient reflection. Visualizations in U-Prevent (colored bars/graphs) were considered helpful for explaining risk concepts, particularly to less educated patients.
Barriers: While visualizations were helpful, some HCPs felt they did not always translate to a deeper understanding of abstract risk percentages. There was a perceived skill gap among practice nurses in interpreting risk scores and treatment benefits, as these were not part of their vocational training.
Neutral/Emotion: Initial use of the tools generated nervousness and excitement, viewed as a natural reaction to new approaches. Most HCPs had no intention of using the "Box" for continuous monitoring, preferring temporary loans for periodic checks.
Significance and Claims The paper claims that addressing the identified barriers and facilitators at both population and individual levels is essential for the successful implementation of the PROSPERA programme.
Implementation Strategy: The authors suggest that opportunities exist in education and training for HCPs regarding risk communication and in restructuring the physical and digital environment (e.g., desktop shortcuts, visible placement of tools) to support behavior change.
Contribution to Literature: This study is presented as the first to use a proactive population health management approach to explore how HCPs perceive the shift from reactive to reactive care delivery.
Modesty: The authors explicitly state that the study assesses anticipated and experienced barriers to inform implementation strategies. They do not claim to have proven the clinical effectiveness of the programme, noting that effectiveness will be examined in a separate future cluster randomized controlled trial. The study emphasizes that demonstrating effectiveness does not guarantee uptake, and thus, early-stage research into behavioral determinants is crucial for selecting effective implementation strategies.