. 2021 Apr 1;2:35. doi: 10.1186/s43058-021-00137-6

Table 3.

Select case examples to demonstrate trajectories within sustainability, spread, and scale of projects and careers

Case	Implementation intervention	Trajectory
The challenges of scaling too quickly	Diabetes self-management support delivered by community pharmacists.	The initial pilot of this self-management program showed benefit and led to a larger randomized control trial that demonstrated significant improvements in glycemic control, blood pressure control, and adherence in a number of outcomes. Based on this success, a plan was made to disseminate the program across the country in 2 stages. Stage 1 included a process evaluation of key barriers and facilitators to implementation and sustainability. Stage 2 was due to scale the program across the country, using the findings from stage 1. However, stage 2 was rolled out too soon, and the barriers identified in stage 1 could not be addressed or the facilitators applied before scaling began. As a result, the uptake in stage 2 was very low due to limitations in organizational capacity within the pharmacy as well as difficulties in identifying eligible people living with uncontrolled type 2 diabetes which was dependent on general practitioner confirmation. In the end, the government decided to fund a modified program that had limited evidence of effectiveness yet was more acceptable to the system.
Pursuing the business case	A computerized behavior and psychosocial assessment approach to support patients with type 2 diabetes	The initial research used motivational interviewing and a computerized behavior and psychological assessment tool to support patients living with type 2 diabetes. The research found that the motivational interviewing aspect was not effective, but the assessment tool was, as it used a patient-centered approach and helped clinicians support self-managed behaviors. A second Randomized Control Trial conducted with community health centers that served a diverse diabetes patient population demonstrated the patient-centered assessment was clinically effective (reduced HbA1c) in a team model. However, “there wasn’t a bridge of sustainability from the clinical research to real world scaling up and adoption.” The success of this project, but lack of sustainability, spread or scaling, is what led this researcher to leave his academic career in order to bring effective interventions into the real world. The tool developed in the research studies has now been converted into a sophisticated commercial product used by clinicians. By selling the product and relevant coaching, the revenue is used to do more research and grow the product. To achieve the population level impact that was needed, this researcher left academia in order to follow a strong business case to have the capacity to achieve impact and sustainability.
Naïvely hoping for sustainability	Development of shared medical appointments for diabetes and hypertension	The hospital was interested in how to deliver group interventions for chronic illness, and this researcher wanted to know if group interventions were cost-effective. The resulting Randomized Control Trial demonstrated that the group intervention was more effective than the control and was worth pursuing. This success led to the development of a manual for developing shared medical appointments, and a meta-analysis, that took 3 years, further demonstrated the success. With these positive outcomes, three new hospitals were asked to implement this intervention; however, the uptake was very low. The new hospitals found that the intervention was “too disruptive” and thus not implemented. Although the group intervention was evidence-based with proven effectiveness, due to challenges in implementation, a modified version was later implemented that was never fully evaluated. The researcher was not consulted about the modified version. On reflection, the researcher noted that they were naïve about the concepts, expecting that if the intervention worked and the team championed the effort, that others would “come along for the ride”—but they did not. The evidence-based version is no longer used, while the modified, less disruptive, intervention with a limited evidence-base is used.

Case

Implementation intervention

Trajectory

The challenges of scaling too quickly

Diabetes self-management support delivered by community pharmacists.

The initial pilot of this self-management program showed benefit and led to a larger randomized control trial that demonstrated significant improvements in glycemic control, blood pressure control, and adherence in a number of outcomes.

Based on this success, a plan was made to disseminate the program across the country in 2 stages. Stage 1 included a process evaluation of key barriers and facilitators to implementation and sustainability. Stage 2 was due to scale the program across the country, using the findings from stage 1. However, stage 2 was rolled out too soon, and the barriers identified in stage 1 could not be addressed or the facilitators applied before scaling began. As a result, the uptake in stage 2 was very low due to limitations in organizational capacity within the pharmacy as well as difficulties in identifying eligible people living with uncontrolled type 2 diabetes which was dependent on general practitioner confirmation. In the end, the government decided to fund a modified program that had limited evidence of effectiveness yet was more acceptable to the system.

Pursuing the business case

A computerized behavior and psychosocial assessment approach to support patients with type 2 diabetes

The initial research used motivational interviewing and a computerized behavior and psychological assessment tool to support patients living with type 2 diabetes. The research found that the motivational interviewing aspect was not effective, but the assessment tool was, as it used a patient-centered approach and helped clinicians support self-managed behaviors. A second Randomized Control Trial conducted with community health centers that served a diverse diabetes patient population demonstrated the patient-centered assessment was clinically effective (reduced HbA1c) in a team model. However, “there wasn’t a bridge of sustainability from the clinical research to real world scaling up and adoption.”

The success of this project, but lack of sustainability, spread or scaling, is what led this researcher to leave his academic career in order to bring effective interventions into the real world. The tool developed in the research studies has now been converted into a sophisticated commercial product used by clinicians. By selling the product and relevant coaching, the revenue is used to do more research and grow the product. To achieve the population level impact that was needed, this researcher left academia in order to follow a strong business case to have the capacity to achieve impact and sustainability.

Naïvely hoping for sustainability

Development of shared medical appointments for diabetes and hypertension

The hospital was interested in how to deliver group interventions for chronic illness, and this researcher wanted to know if group interventions were cost-effective. The resulting Randomized Control Trial demonstrated that the group intervention was more effective than the control and was worth pursuing. This success led to the development of a manual for developing shared medical appointments, and a meta-analysis, that took 3 years, further demonstrated the success. With these positive outcomes, three new hospitals were asked to implement this intervention; however, the uptake was very low. The new hospitals found that the intervention was “too disruptive” and thus not implemented.

Although the group intervention was evidence-based with proven effectiveness, due to challenges in implementation, a modified version was later implemented that was never fully evaluated. The researcher was not consulted about the modified version. On reflection, the researcher noted that they were naïve about the concepts, expecting that if the intervention worked and the team championed the effort, that others would “come along for the ride”—but they did not. The evidence-based version is no longer used, while the modified, less disruptive, intervention with a limited evidence-base is used.