Developing Robust Antiobesity Medication Implementation Approaches to Maximize Population Health: Protocol for the DOMINO Study

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

Guided by the tailored implementation for chronic diseases (TICD) framework and implementation mapping (IM), the DOMINO (Developing Robust Antiobesity Medication Implementation Approaches to Maximize Population Health) study aims to identify determinants of AOM use, obtain stakeholder input, and develop an implementation road map to guide payers, health systems, and prescribers in supporting equitable and appropriate clinical use of AOMs.

The DOMINO study begins with a data-driven needs assessment, followed by qualitative interviews to assess contextual factors, and then stakeholder-guided selection of strategies to address barriers and contextual factors, resulting in an IM approach. Aim 1 evaluates AOM prescribing patterns and determinants of use using electronic health record data from 3 southeastern US health systems. Demographic, clinical, and provider characteristics of AOM users and nonusers 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 approximately 90 semistructured 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 findings from aims 1 and 2 to develop an AOM implementation road map. 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.

The DOMINO study was funded in April 2024. Preliminary data obtained prior to submitting the grant application indicated significant variability in the number of AOM users, the number with a glucagon-like peptide-1 (GLP-1) prescription, and race/ethnicity demographics. Electronic health record (EHR) data extraction from the 3 health systems was completed in April 2026; data cleaning and preparation of analytic datasets are underway. As of August 2026, aim 2 included 40 patient interviews, 5 payer interviews, and 14 provider interviews. Aim 3, including advisory board panels, is anticipated to begin in late 2026. Publication of results is expected by June 2028.

This study will generate an empirically derived, partner-driven road map 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.

DERR1-10.2196/108690.