Sustainability in chronic disease: Evaluating the factors that contribute to sustaining evidence-based health recommendations
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2021
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Melbourne Authors
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Melbourne School of Population and Global Health
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PhD thesis
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Open Access
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Description
© 2021 Linda Anne Francis
Abstract
Background
Sustaining implemented evidence-based recommendations in health care has received increasing attention over recent years; however, little is still known about the factors that contribute to sustainability. This presents a challenge for researchers, program planners and policy makers planning sustainable implementation interventions to improve health care for individuals. The factors that contribute to sustaining implemented evidence-based recommendations in the chronic disease field of stroke care forms the focus of this thesis.
Stroke management has undergone major advancements in recent years. The establishment of specialist stroke teams in hospital has reduced mortality and disability. As part of supporting improved access to best practice stroke care the Victorian Government funded the implementation of several evidence-based recommendations to improve care for patients across eight selected Victorian hospitals in regional and urban areas. The sustainability of three priority recommendations was evaluated for this research including the establishment of specialist stroke units, transient ischaemic attack clinics, and swallow screening programs.
Aim
The aim of this research was to evaluate factors that contributed to the sustainability of the three priority evidence-based stroke recommendations 2 years after financial support from the Victorian government ceased. Evaluating the factors across the eight hospitals was intended to provide an in-depth appreciation of the way the factors manifested differently in relation to particular aspects of context.
Method
This research followed a mixed methods multi-site (pre-post) cohort based design to evaluate the factors of sustainability related to evidence-based care delivery for acute stroke across the selected hospitals in Victoria. A sequential qualitative, quantitative, qualitative approach following method triangulation was employed.
Qualitative data collection involved narrative review and in-depth one on one interviews over separate time periods to explore factors that contributed to sustainability of the implemented recommendations. Adherence to delivery of the evidence-based recommendations and in-hospital patient outcomes were evaluated using Stroke Foundation audit data. Data from the various phases were triangulated to gain insight into the overall achievement of sustainability or not and the factors that contributed to this.
Results
Sustained adherence was apparent for over half of the evidence-based recommendations. Improved access to stroke unit care (OR 2.2; p < 0.05; 95% CI 1.1 – 4.2) and dysphagia screening (67%, OR 2.2; p < 0.05; 95% CI 1.5 – 3.2) was sustained two years after implementation. TIA clinics were not successfully implemented or sustained.
Patient outcomes did not improve from implementation to sustainability – morbidity (OR 0.55; P = < 0.05; 95% CI 0.38 – 0.82) and malnutrition incidence (OR 5.9; P = < 0.05; 95% CI 1.8 – 19.2) worsened and mortality (OR 2.10; P = > 0.05; 95% CI 0.92 – 4.8) and aspiration (OR 1.2; P = > 0.05; 95% CI 0.60 – 2.4) did not significantly change.
Fifteen factors were identified as important for overall sustainability. These factors manifested differently over time across contexts and the cultural climates of the selected hospitals.
Conclusion
The combination of qualitative and quantitative research undertaken as part of this doctoral research provides insight into the way the factors influenced sustainability. It also provides guidance for future program planners and researchers developing sustainable implementation initiatives in the field of chronic disease.
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Keywords
Sustainability, Program evaluation, Knowledge translation, Implementation research, Acute Stroke, Chronic disease