JMIR Publications

ABSTRACT

Background:

Despite robust evidence supporting the efficacy of anti-obesity medications (AOMs), their use remains limited and inequitable across populations. Patient, provider, and system-level barriers constrain equitable AOM use in eligible persons, bounding the cumulative health benefits realized in eligible patients.

Objective:

Guided by the Tailored Implementation for Chronic Disease (TICD) framework and Implementation Mapping (IM), the DOMINO study aims to identify determinants of AOM use, obtain stakeholder input, and develop an implementation roadmap to guide payers, health systems and prescribers to support equitable and appropriate clinical use of AOMs.

Methods:

The DOMINO study begins with data-driven needs assessment, followed by qualitative interviews to assess contextual factors, then stakeholder-guided selection of strategies to address barriers and contextual factors that result in an IM approach. Aim 1 evaluates AOM prescribing patterns and determinants of use using electronic health record data from three southeastern U.S. health systems. Demographic, clinical, and provider characteristics of AOM users and non-users will be compared. Cox regression will estimate time from first eligible BMI to AOM initiation, incorporating time-varying covariates and calendar-year fixed effects; secondary analyses will assess repeated use, duration, and medication switching. Aim 2 uses the TICD framework to guide ~90 semi-structured interviews with patients, providers, health system leaders, and payers to identify multilevel barriers and facilitators to AOM adoption. Our analytic approaches will allow for both deductive and inductive insights to identify salient determinants. Aim 3 will use Aim 1 and 2 findings to develop an AOM Implementation Roadmap. Determinants will be prioritized by importance and feasibility, mapped to implementation strategies, and refined through advisory panels using acceptability, feasibility, effectiveness, cost-effectiveness, side effects or unintended consequences, safety, and equity criteria to enable future hybrid trial testing.

Results:

Preliminary data obtained prior to submitting the grant application indicated that there was significant variability in the number of AOM users, the number with a GLP-1 prescription, and race/ethnicity demographics. As of August 2026, we have extracted patient-level EHR data from the three health systems and begun to clean the data. Fourteen provider, 40 patient and 5 payer interviews have been completed. Aim 3 is anticipated to begin in late 2026.

Conclusions:

This study will generate an empirically derived, partner-driven roadmap for implementing AOM use. By addressing operational barriers, workflow integration, and patient affordability, DOMINO will produce scalable tools and processes for health systems to optimize obesity care and advance equity in obesity management. Clinical Trial: NA