Sustainability of knowledge translation interventions in healthcare decision-making: a scoping review

Evidence from systematic reviews suggests that numerous knowledge translation (KT) interventions are effective [1, 2]. A KT intervention is one which facilitates the uptake of research into practice and/or policy and can also be referred to as research utilization. When KT interventions are aimed at the clinician, organization, or health system level, these can also be considered implementation science interventions. In order to increase the uptake of KT interventions, researchers within the KT field have focused on surmounting barriers to their initial implementation [3, 4]. However, less research has been done to examine the long-term sustainability of KT interventions [5‐8], which can be defined as the extent to which a KT intervention continues after adoption has been secured [9].

The sustainability of KT interventions is paramount to ensure the long-term quality of care for patients [10‐13]. It has been suggested that KT interventions that are not sustained in the long-term may result in worse patient outcomes [10, 11, 14], such as decreased quality of care and quality of life. As such, evaluating sustainability is increasingly important in the field of KT [5‐8].

Sustainability of interventions is particularly critical in the management of patients with chronic diseases. Half of all US adults (117 million people) have at least 1 chronic condition; 26 % of US adults have ≥2 chronic conditions (including diabetes, hypertension, cancer, arthritis, vascular disease, depression, chronic obstructive pulmonary disease [COPD], and dementia) [15]. More chronic conditions translate to increased risks of functional limitations and admission to acute and long-term care hospitals. In 2006, 84 % of all US healthcare spending was for the 50 % of the population who have ≥2 chronic conditions [16]. This situation is not unique to the US. Chronic diseases are increasing rapidly in prevalence and are recognized by the World Health Organization as the major challenge facing health systems worldwide [17]. Our decision-maker partners [18] have identified sustainability of KT interventions to be a particular challenge in chronic disease management, as most research initiatives and pilot project focus on short-term implementation, yet this does not reflect the needs of the healthcare system [18]. For example, in a recent systematic review of effective KT strategies for coordination of care to reduce use of healthcare services by those who are identified as “frequent users of healthcare” (i.e. those with chronic disease), the majority of the 36 included studies lasted less than 12 months; with just 1 study extending to 3 years [19]. Yet, these patients have chronic disease, implying the intervention should extend beyond 1 year to reflect the course of their disease.

Frameworks for implementing sustainability interventions as well as for measuring sustainability have been proposed [6, 7, 20, 21]. Chambers and colleagues developed a “Dynamic Sustainability Framework” for sustainability involving “continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time” [6]. Doyle and colleagues conducted a formative evaluation of the National Health Service Institute for Innovation and Improvement Sustainability Model (SM), which provides information on 10 factors that may improve sustainability for teams who are implementing new practice in their organization [7]. Schell et al. developed a sustainability framework specific to public health interventions that includes nine domains that are essential for success [20]. Simpson et al. describe their model that was developed to sustain oral health interventions including addressing barriers and considering contextual factors [21]. These frameworks are likely useful for empirical research to develop, implement, or measure sustainability of KT interventions. However, this has not been formally evaluated.

We aimed to conduct a scoping review of KT intervention research to characterize KT interventions to manage chronic disease that have been used for healthcare outcomes beyond 1 year or beyond the termination of funding. We also aimed to determine the uptake of frameworks that focus on the sustainability of KT interventions in the included studies.

It has been postulated that while nearly $300 billion is spent on research globally, much of this is wasted because of poor implementation [47‐50]. Sources of waste include lack of consideration of sustainability of effective interventions. This waste is a particular challenge when considering how to optimize care of patients with chronic diseases given the growing proportion of these patients and their impact on health systems. Our scoping review found limited studies on sustainability of KT interventions for people with chronic diseases. Similar to what was postulated in a consensus project on gaps in sustainability research [8], we found that there is a need for clarity on the terms and definitions used to describe sustainability, which would enhance our ability to find this literature.

In addition, we found few studies that tested KT interventions beyond 2 years. This could be due to various reasons, such as a lack of funding or the belief that KT sustainability is not the top priority. As well, we were unable to identify any studies that used a framework to develop, implement, or measure sustainability of KT interventions. This would allow individuals to test different models of sustainability to determine which ones are the most optimal. Our results suggest that KT sustainability is in its infancy in the literature.

To ensure longevity, it has been suggested that planning for sustainability should be done early, when KT interventions are being designed [51]. In particular, theories, process models, and frameworks should be considered when trying to develop, implement, or evaluate KT interventions and their sustainability. However, our review found no studies that reported use of a framework to consider sustainability of a KT intervention. Testing sustainability frameworks empirically is also an area of future research. Moreover, the studies focused on KT interventions focused on single chronic diseases rather than patients with multiple conditions, failing to reflect the complexities of real-world clinical practice and policy.

It is plausible to postulate that depending on the nature and target audience of the intervention, the type of sustainability effort may differ. For example, a simple KT intervention in a clinical setting targeting patients (such as patient reminders) might not require extensive sustainability endeavours. However, more complex KT interventions at the organization or health system level (i.e. implementation science), such as financial incentives, may require more extensive sustainability initiatives. This is an area for future empirical research.

Most of the included studies focused on KT interventions at the patient level, such as patient education and self-management. This finding might be explained by accessibility of the KT intervention; for example, patient-oriented interventions are often easier to employ than more resource-intensive interventions, such as team changes or case management. Across all of the chronic conditions examined by the included studies, the most common was diabetes.

Although we did not formally appraise the methodological quality of included studies, we identified some limitations worth noting. Most of the studies did not mention fidelity or adaptation of the intervention, which should be mentioned in future KT sustainability studies to increase transparency and quality of reporting; indeed, these elements have been suggested in the checklist proposed to enhance reporting of interventions (TIDieR) [52]. As well, the quality of reporting of these studies was low overall and could be improved. For example, the duration of the KT intervention period was difficult to discern across the included studies. In addition, our results found a significant gap in “sustainability” terminology, with only nine (15 %) included studies providing a definition, and the individual terms used were not consistent across studies.

There are some limitations to our scoping review process that are worth mentioning. Due to the large number of citations identified (>12,000), we were unable to search unpublished literature or include studies on mental illness because of resource restraints. Although this is a deviation from our protocol [24], only half of the published scoping reviews in the literature do an extensive search for grey literature [43]. As well, we had hoped to develop a framework for developing, implementing or evaluating sustainability of KT interventions for chronic disease management but were unable to do so due to the dearth of included studies. Since sustainability was poorly reported across studies, we were also unable to formally evaluate factors that influence sustainability of KT interventions. Our scoping review was resource- and time-intensive due to the large screening yield, as well as the unanticipated time required to independently categorize the 13 identified KT interventions, which appeared 464 times across the included papers. Although our literature search is outdated, the purpose of our scoping review was to chart the literature on sustainability initiatives and identify areas to inform the conduct of a future systematic review. We are currently in the process of updating the literature search from our scoping review, focusing on RCTs. We have identified 31 randomized trials through our scoping review and plan to statistically evaluate the impact of sustainable KT interventions on health outcomes through meta-analysis in our future systematic review.

We found few studies that focused on sustainability of KT interventions. Most of the included studies focused on patient-level outcomes and patient-level KT interventions. A future systematic review can be conducted of the RCTs to examine the impact of sustainable KT interventions on health outcomes. Our results showed several gaps in the literature worth exploring in future research. In particular, our findings suggest that more work is needed on exploring sustainability of KT interventions for patients with chronic diseases.