Participants were 96 clinicians who completed the SABC course online in 2015 and responded to our implementation assessment survey in 2017.
The online course was created by Dr. Kathryn Schmitz, in collaboration with Guenter Klose, and provided in 2015 through a popular online platform for physical therapy continuing education (Klose Training and Consulting website; http://klosetraining.com/course/online/strength-abc). Requirements to complete the course included being a licensed physical or occupational therapist, physician, or registered nurse. In addition, exercise professionals were offered the opportunity to have their credentials and experience with patients with cancer reviewed to discern eligibility. Upon registration and payment ($120), participants received a username and password; they had 3 months of access to the course. The 4-h course covered all aspects of setting up and running the SABC program including how to obtain referrals from oncology clinicians, screen potential patients, coordinate with a certified lymphatic therapist, educate patients about lymphedema, teach the 4-session exercise program, instruct patients on how to log their progress, motivate patients to perform exercises, handle logistical considerations, and manage discharge and wrap-up. The course also provided all the materials needed to set up the program in clinics, including PAL trial results, lymphedema education session in PowerPoint format, lymphedema risk-reduction guidelines, exercise instructions with photos, decision tree for tracking adherence, self-check list for program objectives, guidance for support staff, helpful information about billing codes, and weight training workout logs.
Klose Training and Consulting provided a list with the emails of those who completed the course (n = 395). Using REDCap, a secure web application for building and managing online surveys and databases, an initial email was sent to all individuals that included an invitation to complete the survey, information explaining the purpose of the survey, a link to access the survey online, and a statement about the confidentiality of their responses. Two weeks later, an email reminder was sent to those who had not yet responded the survey. The 10-min survey was conducted between June and December, 2017. No monetary incentive was offered to complete the survey. The survey response rate was 24%. The study was approved by the Institutional Review Board of the Penn State College of Medicine.
Guided by Proctor’s Implementation Outcomes Framework , the survey assessed key indicators of implementation process and success: adoption, sustainability, fidelity, reach, appropriateness, cost, feasibility, and penetration. We chose this framework because it provides a systematic way to evaluate the implementation of innovations in healthcare settings and it is widely used in the literature to evaluate barriers and facilitators to intervention impact [18, 19]. The survey asked whether respondents implemented (adoption) and if they are still implementing (sustainability) the program in their clinics. Those who responded in the affirmative were asked which programmatic components they implemented (fidelity). Respondents chose components from the following list: evaluation by a certified lymphatic therapist, education about lymphedema, 4-session exercise program, symptom monitoring, patient’s motivation, resistance equipment for home exercise, and manage discharge. The survey also asked how many patients completed the program (reach) and how patients got into the program (reach). Response options were referrals from oncology clinics, clinic advertising, local media advertising, or others. The survey assessed whether the program was delivered one-on-one or a group format (appropriateness) and whether clinics were reimbursed by third-party payers (cost). Respondents also reported what barriers they faced to deliver SABC in clinics (feasibility); options were as follows: referrals, lack of patient interest, lack of interest from clinic management, third-party reimbursement, raising money to pay for therapist time, logistical difficulties, front desk staff training, competing demands, or others. The survey also asked whether others in the clinic completed the course (penetration). Respondents also reported what type of resistance equipment patients use at home for exercising (i.e., TheraBand resistance bands, dumbbells, household items, others) and whether the clinic provided the resistance equipment (feasibility).
Descriptive statistics were used to describe participants’ characteristics and survey responses. We assessed whether actual implementation of SABC was associated with reported barriers. We also compared barriers identified by implementers with low versus high reach (determined by the mean number of patients per rehabilitation clinic who received the program as reported by survey participants). We used the Fisher’s exact test in the latter set of analyses exploring implementation barriers due to the small size of some cells. We analyzed survey data using Stata 14.0 (College Station, TX).