Identifying barriers to lipoprotein(a) testing in secondary cardiovascular prevention and co-designing implementation strategies: an Italian behavior change wheel-informed study.

Background: Lipoprotein(a) [Lp(a)] is a causal risk factor for atherosclerotic cardiovascular disease, which remains unaddressed by current lipid-lowering therapies. Given its established role as a genetic independent cardiovascular risk factor, national and international guidelines recommend screening for Lp(a) levels, as elevated concentrations indicate a higher risk of cardiovascular events. Despite these implications and the availability of a simple standardized assay reimbursed by the Italian National Health Service, Lp(a) testing remains largely underused in the Italian clinical practice. The aim of this project was to identify barriers to Lp(a) testing in clinical practice and to develop targeted strategies to promote its incorporation into secondary cardiovascular prevention strategies in Italy, using an implementation science framework. Methods: This project adopted a multi-method approach, using the Behavior Change Wheel (BCW) framework to identify barriers to Lp(a) testing. Barriers identified in the literature were mapped using the Capability, Opportunity, Motivation- Behavior (COM-B) model, and further characterized through the Theoretical Domains Framework. Each identified barrier was subsequently discussed and rated for perceived impact during a multidisciplinary working group involving 12 stakeholders (cardiologists, internists, lipidologists and laboratory professionals). Building on these findings, several intervention strategies were developed in line with BCW guidance and prioritized by stakeholders during a second multidisciplinary working group to ensure overall feasibility Results: Capability-related barriers, including limited knowledge of Lp(a) as a cardiovascular risk factor, and uncertainty about its role on patient management, were among the most influential. Opportunity barriers included the absence of approved Lp(a)-lowering treatments, and a lack of test standardization. Motivational barriers included a lack of evidence of clinical benefit of Lp(a) reduction and limited awareness of its role in patient management. To address the identified barriers, training initiatives, creation of working groups, sharing of practical tools, alignment between clinicians and laboratories, and patient support emerged as high-priority interventions. Conclusion: To promote Lp(a) testing in secondary cardiovascular prevention Italian clinical practice, this project identified behavioral barriers across all COM-B domains and designed actionable key strategies using a theory-driven approach. Future research should pilot these activities to overcome identified barriers and improve patient management.