This insightful article, “Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation”, authored by Rebecca Ataman, Sara Ahmed, Whitney Berta, and Aliki Thomas, was published in the Journal of Evaluation in Clinical Practice in 2024. The study addresses a critical challenge in healthcare: the poor sustainment of newly implemented evidence-based practices, with only about half of such practices being maintained over time. This lack of sustainment can lead to negative consequences for clinical teams, organizations, and patients, yet the specific causal explanations behind successful or unsuccessful sustainment remain largely unknown.
The primary aim of this research was to ascertain precisely how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome). To achieve this, the authors employed a realist evaluation using a mixed-method, embedded single case study design. Data was collected for up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory – version 4 (MPAI-4), a significant rehabilitation outcome measure. The methodology involved analyzing quantitative data from surveys and patient charts using descriptive statistics, which was then integrated with qualitative data obtained from interviews with 10 key informants. The data integration utilized inductive and deductive retroduction to develop a comprehensive case description and refine the underlying program theory.
The results of this study provided 18 explanations (Context-Mechanism-Outcome Configurations, or CMOCs) that detail how sustainability works, emphasizing the interplay of context, mechanisms, and sustainability strategies. Four overarching patterns emerged from the findings:
- Implementation and sustainability phases are interconnected. Factors and achievements from the implementation phase often carry over into the sustainability phase.
- Outcomes build on each other recursively, with patient benefits identified as the keystone outcome. The perceived and demonstrated benefits for patients are crucial drivers for the continued pursuit and influence of other sustainability outcomes.
- Sustainment is achieved at varying levels across different sustainability outcomes. For instance, MPAI-4 scoring showed a high rate of sustainment (77.7% of patients scored), often driven by a provincial mandate, while its application to clinical decision-making was significantly lower (3.7%). This highlights the utility of evaluating diverse sustainability outcomes on a continuous scale.
- The work of sustaining the MPAI-4 is shared amongst different stakeholders. Sustained collaboration among diverse groups, including clinicians, managers, researchers, and IT specialists, was found to be essential for achieving sustainability outcomes.
In conclusion, this research offers a refined program theory that implementation teams can utilize to improve the sustainment of outcome measures in rehabilitation. It also provides a foundation for researchers to continue refining the theory to enhance the understanding of how outcome measures are sustained, ultimately aiming to maintain improvements in quality of care and patient outcomes.
Reference for the Article:
Ataman, R., Ahmed, S., Berta, W., & Thomas, A. (2024). Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation. Journal of Evaluation in Clinical Practice, 30(4), 559–574. https://doi.org/10.1111/jep.13972
