Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation
Bibliographic record
Abstract
RATIONALE: Only half of newly implemented evidence-based practices are sustained. Though poor sustainment can lead to negative consequences for clinical teams, organizations and patients, the causal explanations of sustainment are largely unknown. AIMS AND OBJECTIVES: We aimed to ascertain how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome). METHODOLOGY: Informed by an integrated knowledge translation approach, we conducted a realist evaluation using a mixed method, embedded single case study design with data collection up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory - version 4 (MPAI-4), a rehabilitation outcome measure. Quantitative data (survey and patient charts) was analysed using descriptive statistics, then integrated with qualitative data (interviews with 10 key informants) and analysed using inductive and deductive retroduction. We integrated the data to develop a case description and ultimately, to refine the programme theory to better understand the sustainability of the MPAI-4. RESULTS: We linked context, mechanisms and outcomes, and also emphasized sustainability strategies in 18 explanations of how sustainability works. These explanations provide evidence for four overarching patterns: (1) implementation and sustainability phases are interconnected, (2) outcomes build on each other recursively, with patient benefits as the keystone outcome, (3) sustainment is achieved to varying levels across different sustainability outcomes [e.g., high level (e.g., rate of MPAI-4 scoring: 77.7%) to low level (e.g., rate of MPAI-4 application to clinical decision-making: 3.7%)] and (4) the work of sustaining the MPAI-4 is shared amongst different stakeholders. CONCLUSION: Implementation teams can draw from this programme theory to improve the sustainment of outcomes measures while researchers could continue to refine the theory. Continued investigation of sustainability, including diverse and continuous sustainability outcomes, is needed to understand how to maintain improvements in quality of care and patient outcomes.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.160 | 0.208 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.003 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.002 | 0.004 |
| Scholarly communication | 0.004 | 0.004 |
| Open science | 0.002 | 0.004 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.005 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".