Sustainability of Complex Interventions: Recommendations From a Pragmatic Clinical Trial to Manage Cancer Symptoms

Sustained implementation of evidence-based practices and interventions in clinical settings is essential to ensure patients receive the best evidence-informed care. Information to guide sustainment of complex, multicomponent interventions in routine clinical practice after grant funding ends has had limited attention in the literature.

The purpose of this article is to describe the efforts of our multidisciplinary trial team to foster sustainment of key components of a complex electronic health record (EHR)-facilitated symptom surveillance and management intervention for people receiving cancer care at a Midwestern quaternary medical center or community practice settings.

The parent Enhanced EHR-Facilitated Cancer Symptom Control (E2C2) hybrid Type II effectiveness-implementation pragmatic trial assessed the effectiveness of a multicomponent EHR-facilitated, collaborative care model-based intervention for management of SPPADE symptoms (sleep interference, pain, impaired physical function, anxiety, depression, and energy deficit/fatigue) and its implementation in medical oncology and community practice settings. The dynamic sustainability framework (DSF) posits the need for on-going efforts to continuously optimize the fit of an intervention within dynamic and evolving delivery contexts. This brief report uses the DSF to describe our team's efforts to optimize the fit of the core E2C2 intervention components to the practice setting and broader ecological system during the conduct of the trial. These activities were designed to achieve sustained implementation of the intervention in routine care delivery as the funded research activities concluded.

Core intervention components to be sustained were symptom surveillance using electronic patient-reported outcome measures, clinician alerts for severe symptoms, access to a registered nurse symptom care manager (RN SCM) for severe symptoms, patient education materials to support symptom self-management, access to a website of cancer-related materials, and the training and supervision of the RN SCMs.

Sustainability is dynamic and multidimensional, and emphasizes the importance of optimizing the fit of key intervention components to the care delivery context as it evolves time. Investigators are advised to plan sustainability efforts early, embrace change inherent in dynamic settings, and carefully track adaptations of intervention components to maximize intervention fit in real-world clinical practice to ensure patients continue to derive benefit from evidence-informed care.