Assessing long-term sustainment of clinic participation in NIATx200: Results and a new methodological approach

Abstract

Background: Sustainability frameworks differentiate between sustainability capacity and sustainment of organizational change. Multiple studies have examined sustainability capacity. Methodological approaches to assess long-term sustainment have not been explored. This study addresses this gap by describing the development of a long-term sustainment methodology and evaluating its application utilizing data from substance abuse clinics participating in a quality improvement collaborative.

Methods: The study involved clinics (n = 121) in three states (MI, NY and WA) participating in the 2007-2009 NIATx200 quality improvement (QI) intervention. It extended the primary analysis to focus on clinics' long-term sustainment of wait time, retention and admission improvements. Long-term sustainment was defined as two years post end of the active implementation period (Calendar Years 2010 and 2011). The analysis defined case exclusion criteria and spline "knot" time intervals; allowed for C_p statistic use to address clinic data volatility; established the structure of sustainment plots and explored differences between NIATx implementation strategies.

Results: Example spline and sustain plots highlight the application of the long-term sustainment methodology for NIATx200 clinics. In clinics with available longitudinal outcome data, 40.8% (n = 31 of 76 clinics) sustained improvements in wait time, 26.7% (n = 20 of 75 clinics) in retention, and 28.1% (n = 32 of 114 clinics) for admissions. Clinic assignment to a NIATx200 implementation strategy did not significantly influence a clinics' long-term sustainment except for lower wait time changes in the interest circle interventions. Thirty clinics (24.8%) sustained improvements for two outcomes and six clinics (5.0%) did so for all three outcomes. The clinics that sustained multiple outcome improvements were assigned to the interest circle (n = 12), learning session (n = 10), combination (n = 8), and coaching (n = 6) implementation strategies. Guidance for applying the long-term sustainment methodology in other quality improvement settings is described.

Conclusions: Research about sustainability capacity and sustainment of change has become increasingly important in dissemination and implementation research. Assessment of long-term sustainment in a multi-organizational quality improvement collaborative (QIC) is needed to identify when program drift and intervention decay occurs. If "cut-points" indicate when effects diminish, specific sustainability modules could be developed and introduced within the structure of a QIC to improve organizational long-term sustainment. Coaches and change teams could be trained to focus on organizational change sustainment and strengthen the likelihood of institutionalization. ClinicalTrials.gov Identifier: NCT00934141 Registered July 6, 2009. Retrospectively registered.

Keywords: Admissions; Long-term sustainment; NIATx200; Quality improvement collaborative; Retention; Sustain plots; Wait time.