Introduction {#s1}
============

As various knowledge translation (KT also known as research utilisation, translational medicine and implementation science) interventions are found to be effective in research studies, the need to evaluate their sustainability is becoming increasingly important. In the Knowledge to Action framework proposed by Graham *et al*,[@R1] sustained knowledge use is one of the main components. However, many implementation studies focus on short-term outcomes relevant to a study situation and do not address long-term outcomes in practice and policy domains. For example, in the systematic review of interventions to optimise antibiotic use, of 39 studies included, only 2 reported follow-up beyond 1 year.[@R2] Similarly, a systematic review of audit and feedback found that the follow-up period in studies varied from 3 weeks to 14 months and reported mixed results with respect to sustained change.[@R3] A recent systematic review of sustainability of KT interventions identified 125 articles but few conclusions could be drawn.[@R4] Most studies were retrospective and often lacked a definition or framework for sustainability. The authors synthesised the qualitative information to identify factors influencing sustainability.

Although several definitions of sustainability exist, we have chosen to use the definition of an intervention being in place more than 1 year after implementation or after the research or project funding period is complete. Understanding the sustainability of KT interventions requires a framework analogous to postmarketing surveillance, which is carried out by the pharmaceutical and medical device industries. As seen in the use of spironolactone following the publication of the RALES trial,[@R5] it is important to develop an understanding of how interventions are being implemented in 'real world' settings over time and to monitor their effectiveness. Similar strategies need to be determined for assessing sustainability of KT interventions. Once KT interventions are implemented, their impact on relevant outcomes needs to be monitored, and the intervention itself should be monitored to determine if its 'dose' or 'formulation' needs to be adapted or replaced in the changing healthcare environment. Factors that may influence sustainability may include those related to the stakeholders, the social context of care, the organisational context and public policy.[@R6] However, these have not been fully examined through a scoping review. As such, we propose to complete a scoping review to understand the factors that influence sustainability in healthcare decision-making and to develop a framework for assessing sustainability.

Methods and analysis {#s2}
====================

Protocol {#s2a}
--------

A protocol for our scoping review was compiled using the rigorous methodology proposed by Arksey and O\'Malley,[@R7] and others.[@R8] The draft protocol was circulated for feedback from KT experts, systematic review methodologists and clinicians. It was modified, as necessary, and is available from the authors upon request.

Eligibility criteria {#s2b}
--------------------

We will include experimental (randomised controlled trials (RCTs), quasi-RCTs, non-RCTs), quasi-experimental (controlled before after, interrupted time series) and observational (cohort, case control, cross-sectional) studies examining the impact of a KT intervention targeting chronic disease management in adults after more than 1 year of implementation or after the termination of research/project funding is described. Studies in all settings will be considered, including primary and specialist care; acute and long-term care; inpatient and outpatient care; and regional, provincial, national and international settings. End-users of the KT intervention will include patients, clinicians (from all disciplines), public health officials (including medical officers of health, department chairs and programme managers), healthcare managers and policy-makers (including regional, provincial/state and federal), and will look at any clinical or healthcare system outcomes.

Information sources {#s2c}
-------------------

We will conduct a systematic search of the published and difficult to locate or unpublished (ie, grey) literature within health. The following electronic databases will be searched from inception onwards: Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). A search of the grey literature will be conducted using Google, and relevant discipline-based list servers, including CANMEDLIB and MEDLIB, using guidance from the Canadian Agency for Drugs and Technologies in Health.[@R9] We will search the websites of funding agencies, and healthcare provider organisations from Canada, the USA, the UK and Australia who have similar healthcare systems and/or similar challenges related to chronic disease management. References from included studies and relevant review articles will also be scanned to ensure literature saturation. Team members will also use their linkages with experts in the field to identify additional articles.

Search strategy {#s2d}
---------------

The main (MEDLINE) search strategy was developed by an experienced librarian, circulated to the team and revised, as necessary. Search terms included durability, fidelity, sustainability, institutionalisation, routinisation, longitudinal and long-term. The search was not limited by language, but was limited to adults, chronic medical diseases and humans.

Subsequently, the search strategy was peer reviewed by another experienced librarian using the Peer Review of Electronic Search Strategies (PRESS) Checklist.[@R10] The final search strategy can be found in online supplementary appendix 1, which is available electronically on the journal\'s website, and was adjusted for the other databases, as necessary. The search strategies for the other databases are available from the authors on request.

Study selection {#s2e}
---------------

The eligibility criteria will be pilot-tested on a random sample of titles and abstracts/full-text articles. Subsequently, two investigators will independently review the retrieved abstracts to identify those that meet the inclusion criteria at the title and abstract level of screening. Assessment of potentially relevant full-text articles will be performed by two investigators independently to determine if they meet inclusion criteria.

Data items and data collection process {#s2f}
--------------------------------------

Two investigators will independently read each article and extract relevant data. The main focus of the studies will be categorised or 'charted'[@R6] using the following criteria: What KT interventions (affecting the various stakeholder groups) targeting chronic medical disease management have been found to have sustained impact beyond 1 year on healthcare outcomes?What is the effect of sustained use of a KT strategy targeting chronic medical disease management on the components of the intervention? How is it adapted over time?

Additional categories may be identified through completion of the search and in consultation with the team members. Study quality is generally not conducted during a scoping review because the aim is to identify gaps in the evidence base and to target areas for future systematic review.[@R7] [@R8]

Synthesis {#s2g}
---------

The data arising from our data collection process will be summarised quantitatively (using a simple numerical count) and qualitatively (drawing on the descriptive analytical method) using thematic analysis with the N-Vivo software (V.10). Through this process, we will be able to identify where gaps exist in the literature, as well as the research area(s) which require a systematic review or primary research. We will use our results to (1) determine factors that influence sustainability of KT interventions, (2) determine how sustainability of KT interventions should be measured and (3) develop a framework for assessing the sustainability of KT interventions.

Discussion and dissemination {#s3}
============================

The results of the proposed scoping review will be used to develop a framework for assessing sustainability for chronic disease management of KT interventions. This framework will advance both the science and practice of KT. Furthermore, it will be of utility to researchers, funders and those interested in implementing KT interventions including clinicians, healthcare managers and policy-makers, among others. To our knowledge, there has been no previous attempt to understand the impact of sustained KT interventions or the factors that influence sustainability.

We will ensure broad dissemination of our research findings through multiple KT strategies. These include publications in open-access, peer-reviewed journals, conference presentations, posting our results on our KT Canada website (<http://ktclearinghouse.ca/ktcanada>) and creating user-friendly executive summaries of our results. We will also hold a dissemination meeting with our key stakeholders, including researchers, funders, clinicians, healthcare managers and policy-makers, among others.

Supplementary Material
======================

###### Author\'s manuscript

This scoping review was funded by the Canadian Institutes of Health Research through Knowledge Translation Canada. ACT is funded by a Canadian Institutes of Health Research/Drug Safety and Effectiveness Network (CIHR/DSEN) New Investigator Award in Knowledge Synthesis. JMG is funded by a Tier 1 Canada Research Chair in Health Knowledge Transfer and Uptake. SES is funded by a Tier 1 Canada Research Chair in Knowledge Translation. We thank Becky Skidmore for peer reviewing the literature search.

**Contributors:** ACT helped conceive the study design and also draft the protocol. EC and HA helped draft the protocol. KAM and JMG helped conceive the study and obtain funding for it, as well as edited the draft protocol. LP developed and executed the search strategy and edited the draft protocol. SES conceived the study, obtained funding for it, and wrote the protocol. All authors read and approved the final manuscript.

**Funding:** This work was supported by the Canadian Institutes of Health Research grant number CRI 88368.

**Competing interests:** None.

**Provenance and peer review:** Not commissioned; internally peer reviewed.

**Data sharing statement:** Unpublished study data, such as the search strategies for the other databases, are available upon request to the corresponding author.
