Sustainment of proactive physical therapy for individuals with early-stage Parkinson's disease: a quality improvement study over 4 years

Abstract

Background: Implementation science frameworks aided the development of a new, evidence-based clinical physical therapy program. The purpose of this report is to describe the process of sustaining a clinical program in practice for over 4 years. We present a framework for integrating tools for sustainability with the Knowledge-to-Action model in the context of a proactive physical therapy (PAPT) program for individuals with early-stage Parkinson's disease.

Methods: Sustainability of implementation strategies was addressed using the Dynamic Sustainability Framework and sustainability assessment tools. Repeated retrospective medical record reviews and phone interviews were used to evaluate the reach and adoption of the PAPT over 4 years. Characteristics of those who engaged with PAPT, implementation fidelity, and clinical effectiveness were assessed for year 1 and year 3. Sustainability was measured using RE-AIM, NHS Sustainability Model, and Clinical Sustainability Assessment Tool.

Results: Reach increased from 28 to 110 total patients per year and spread occurred from one to three sites. PAPT user age, sex, Hoehn and Yahr rating, time since diagnosis, and type of insurance were similar in year 1 and year 3 (p > 0.05). The program sustained its effect to help participants increase or maintain self-reported exercise (Y1, 95%; Y3, 100%). However, upon evaluation PAPT users in year 3 had longer time since symptom onset and worse UPDRS motor scores compared to the PAPT users in year 1 (p < 0.05). All sites sustained the core intervention components, with sustainability scores of 71/100 (± 9.9) on the NHS Sustainability Model and 6.1/7 (± 0.9) on the Clinical Sustainability Assessment Tool.

Conclusions: Integrating multiple sustainability models and assessments supported continued effectiveness, spread, and sustainment of PAPT for 4 years. Effective planning, anticipating common healthcare changes, and addressing sustainability determinants early in program implementation were essential aspects of long-term success.

Keywords: Implementation science; Parkinson’s disease; Physical therapy; Quality improvement; Spread; Sustainment.

Fig. 1

Applying sustainability frameworks during the implementation process. Sustainability frameworks and concepts are superimposed on the Knowledge-to-Action Cycle implementation process model (Reprinted with permission of John Wiley & Sons from: Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving From Evidence to Practice. 2nd ed. Chichester, United Kingdom: John Wiley & Sons Ltd; 2013.). The cogs have colored outlines to represent whether they were used in both (gray) or just the second sustainability cycle (black). Use of dynamic strategies assists with tailoring implementation strategies for sustainability. Using and then repeating implementation evaluation frameworks (e.g., RE-AIM), provides insight into sustainability outcomes. Sustainability assessment tools offer information about factors that affect sustainment and can guide further program adaptations

Fig. 2

PAPT Program growth and retention across 4 years

Fig. 3

PAPT Program Effectiveness in year 1 and year 3. Report of amount of exercise in the year after accessing PAPT