Built to last? The sustainability of healthcare system improvements, programmes and interventions: a systematic integrative review

Abstract

IntroductionThe sustainability of healthcare delivery systems is challenged by ageing populations, complex systems, increasing rates of chronic disease, increasing costs associated with new medical technologies and growing expectations by healthcare consumers. Healthcare programmes, innovations and interventions are increasingly implemented at the front lines of care to increase effectiveness and efficiency; however, little is known about how sustainability is conceptualised and measured in programme evaluations.ObjectivesWe aimed to describe theoretical frameworks, definitions and measures of sustainability, as applied in published evaluations of healthcare improvement programmes and interventions.DesignSystematic integrative review.MethodsWe searched six academic databases, CINAHL, Embase, Ovid MEDLINE, Emerald Management, Scopus and Web of Science, for peer-reviewed English journal articles (July 2011–March 2018). Articles were included if they assessed programme sustainability or sustained outcomes of a programme at the healthcare system level. Six reviewers conducted the abstract and full-text review. Data were extracted on study characteristics, definitions, terminology, theoretical frameworks, methods and tools. Hawker’s Quality Assessment Tool was applied to included studies.ResultsOf the 92 included studies, 75.0% were classified as high quality. Twenty-seven (29.3%) studies provided 32 different definitions of sustainability. Terms used interchangeably for sustainability included continuation, maintenance, follow-up or long term. Eighty studies (87.0%) clearly reported the timepoints at which sustainability was evaluated: 43.0% at 1–2 years and 11.3% at <12 months. Eighteen studies (19.6%) used a theoretical framework to conceptualise or assess programme sustainability, including frameworks that were not specifically designed to assess sustainability.ConclusionsThe body of literature is limited by the use of inconsistent definitions and measures of programme sustainability. Evaluations of service improvement programmes and interventions seldom used theoretical frameworks. Embedding implementation science and healthcare service researchers into the healthcare system is a promising strategy to improve the rigour of programme sustainability evaluations.

Sustainment of Proactive Physical Therapy for Individuals With Early-Stage Parkinson’s Disease: A Quality Improvement Study Over 4 Years

“…This program evaluation uniquely focuses on sustainability of a clinical program targeting an outpatient physical rehabilitation setting. In two recent reviews on program sustainability, none occurred in similar departments (20,23). However, in one quasi-experimental study, behavior change strategies were implemented in a PT clinic with good uptake during the intervention, but poor sustainment at the three, six, or twelve-month follow up (24).…”

Trialists perspectives on sustaining, spreading, and scaling-up of quality improvement interventions

“…One contributing factor to this difficulty is the inconsistent use of definitions [ 3 – 7 ]. In a systematic review of 92 studies about how sustainability is conceptualized and measured in evaluations of healthcare improvement programs and interventions, 53 studies explicitly mentioned sustainability, yet only 27 studies provided a definition, and 32 definitions were used [ 8 ]. For our study, we used the Moore et al (2017) [ 6 ] definition of sustainability: “(1) after a defined period of time, (2) the program, clinical intervention, and/or implementation strategies continue to be delivered and/or (3) individual behavior change (i.e., clinician, patient) is maintained; (4) the program and individual behavior change may evolve or adapt while (5) continuing to produce benefits for individuals/ systems” [ 6 ] (p.6); and the Shaw et al (2018) [ 9 ] definitions of spread and scale with a main difference being that spread is for “complex” problems where following a specific formula may not work and extensive adaptation may be needed.…”

“…The need for effective QI programs to be sustained, spread, and/or scaled-up is self-evident; however, there is minimal research in this area [ 2 – 4 , 8 , 14 – 16 ]. As diabetes is a chronic disease with high impact in terms of health care resource utilization, costs, societal impact, and health outcomes [ 17 – 19 ], more consideration for how to continue effective diabetes QI programs is needed.…”

The Clinical Sustainability Assessment Tool: Measuring Organizational Capacity to Promote Sustainability in Healthcare

“…Studies within implementation science often focus on initial program or intervention adoption and implementation, placing less emphasis on sustainability [8]. In two recent reviews of sustainability, the authors found relatively few studies focusing on sustainability, most of which were of limited quality and methodological rigor [9,4,10]. Research on sustainability is limited in part because data collection for grant funded studies is typically not carried out past the funding end date and is beyond the scope of many public health and health services studies [11].…”

“…Research on sustainability is limited in part because data collection for grant funded studies is typically not carried out past the funding end date and is beyond the scope of many public health and health services studies [11]. Consequently, there have been recent calls for increased attention to sustainability research, theory, and methods [4,10].…”