Scaling-up an evidence-based intervention for osteoarthritis in real-world settings: a pragmatic evaluation using the RE-AIM framework

Abstract

Background: Scaling-up and sustaining effective healthcare interventions is essential for improving healthcare; however, relatively little is known about these processes. In addition to quantitative experimental designs, we need approaches that use embedded, observational studies on practice-led, naturally occurring scale-up processes. There are also tensions between having adequately rigorous systems to monitor and evaluate scale-up well that are proportionate and pragmatic in practice. The study investigated the scale-up of an evidence-based complex intervention for knee and hip osteoarthritis (ESCAPE-pain) within 'real-world' settings by England's 15 Academic Health Science Networks (AHSNs). Methods: A pragmatic evaluation of the scale-up of ESCAPE-pain using the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance. The evaluation used routine monitoring data collected from April 2014 to December 2018 as part of a national scale-up programme. Results: Between 2014 and 2018, ESCAPE-pain was adopted by over 110 clinical and non-clinical sites reaching over 9000 people with osteoarthritis. The programme showed sustained clinical effectiveness (pain, function and quality of life) and high levels of adherence (78.5% completing 75% of the programme) within a range of real-world settings. Seven hundred seventy people (physiotherapists and exercise professionals) have been trained to deliver ESCAPE-pain, and 84.1% of sites have continued to deliver the programme post-implementation. Conclusions: ESCAPE-pain successfully moved from being an efficacious "research intervention" into an effective intervention within 'real-world' clinical and non-clinical community settings. However, scale-up has been a gradual process requiring ongoing , dedicated resources over 5 years by a national network of Academic Health Science Networks (AHSNs). Whilst the collection of monitoring and evaluation data is critical in understanding implementation and scale-up, there remain significant challenges in developing systems sufficiently rigorous, proportionate and locally acceptable.

Program evaluation of GLA:D® Australia: Physiotherapist training outcomes and effectiveness of implementation for people with knee osteoarthritis

“…Pain and knee-related quality of life outcomes are consistent with clinical trials evaluating education and exercise-therapy [ [15] , [16] , [17] , 54 ], implementation of GLA:D® in Denmark [ 29 , 34 ] and Canada [ 34 , 56 ], and other similar nationwide implementation initiatives [ 57 , 58 ]. Considering stable or slow worsening of symptoms typically occurs in the longer term for people with knee osteoarthritis [ [5] , [6] , [7] ], including in those receiving usual care in clinical trials [ 11 ], these improvements are important.…”

Implementation of physical activity interventions for people with inflammatory arthritis: an overview and future recommendations

“…The Enabling Self-management and Coping with Arthritic Pain through Exercise (ESCAPE-pain) program is one example of an evidence-based intervention for knee and hip OA that has been widely implemented across the UK [ 50 ]. Integrating self-management education with physical activity, the program [ 50 ] showed sustained clinical and cost effectiveness, yet the ongoing challenge and effort associated with implementation is well reported [ 47 , 51 ]. Challenges included attitudes towards the evidence and evidence-based practice, persuading commissioners and providers to make small upfront investments to secure longer-term benefits and complex and fragmented funding and commissioning structures that created disconnects between commissioners and providers [ 40 ].…”