Study design
This is a pragmatic evaluation of the scale-up of ESCAPE-pain using the RE-AIM framework [27,28]. By pragmatic, we refer to an approach that is based in practice (rather than taking a research or theoretical perspective) using routine monitoring data collected as part of an AHSNs’ national programme from April 2014 to December 2019. Table 1 outlines how the RE-AIM framework has been applied within the study to measure Reach, Effectiveness, Adoption, Implementation and Maintenance.
[Table 1 Mapping the RE-AIM framework to the study]
ESCAPE-pain programme
ESCAPE-pain is an EBI integrating education and exercise for people with chronic knee and/or hip pain and OA, which promotes self-management to improve quality of life and function [23–26]. People attend in groups of 10-12 people, twice a week, over six weeks (12 sessions). Each session is led by a trained facilitator and comprises 20-25 minutes of structured education about OA and self-management strategies, and 30-45 minutes of exercise. Details of the programme are available at http://www.escape-pain.org/. ESCAPE-pain is underpinned by a randomised controlled trial and economic evaluation [23–26].
Scaling-up ESCAPE-pain
NHS England established 15 Academic Health Science Networks (AHSNs) to help accelerate the spread and adoption on innovation in healthcare. In 2014, ESCAPE-pain was selected by the AHSN for south London (Health Innovation Network) as a priority for local scale-up and was resourced by a small team (i.e. 2-3 project managers and administrative support) led by a clinical and programme director. In April 2018, ESCAPE-pain became a national programme for scale-up supported by all 15 AHSNs across England for a 2-year period. Scale-up was coordinated by national programme manager and dedicated resource (e.g. project manager, clinical champion) within each AHSN to support local scale-up.
ESCAPE-pain training course
A 1-day training course was developed to support the scale-up of ESCAPE-pain to help ensure fidelity to the core component of the programme and quality. The course is mandatory for anyone delivering ESCAPE-pain. Participants learn about the evidence-base and ethos underpinning ESCAPE-pain, develop a detailed understanding of the programme’s format, and gain skills and knowledge to support the implementation and delivery of the programme.
Data collection
The AHSNs collect routine data to monitor the scale-up of ESCAPE-pain, which were used to measure outcomes for each domains of the RE-AIM framework. AHSNs receive no participant identifiable data i.e. providers anonymise all data prior to submitting it.
Reach - The number of participants attending each cohort of ESCAPE-pain and the joint affected (i.e. hip or knee OA). Demographic data are not collected. There are no local prevalence data for hip and knee OA available at the level of individual sites to be able to determine a reliable denominator. Nationally, there are an estimated 4.11 million cases of knee OA and 2.46 million cases of hip OA [29].
Effectiveness - Pre-/post-programme clinical outcomes for participants measured using the Knee/Hip Injury and Osteoarthritis Outcome Score (KOOS and HOOS) sub-scales of pain, activities of daily living (ADL), and quality of life (QoL) [30,31].
Adoption - The number of sites and the type of setting (e.g. clinical outpatients, non-clinical community), provider organisation (e.g. NHS, local authority/council, charity, leisure/fitness centre), and professional (e.g. physiotherapist, therapy assistant or fitness instructor) delivering ESCAPE-pain.
Implementation - Self-reported compliance with the core components of ESCAPE-pain, namely (i) a 1-hour session twice a week for 6 weeks (i.e. 12 sessions); (ii) each session contains exercise and structured education; (iii) the programme follows a cohort structure; (iv) the programme must be delivered by a trained facilitator. Facilitators’ self-reported levels of understand of the programme and ability to implement and deliver the programme via a routine post-training questionnaire. Participant adherence measured by the number of people completing the programme. Completion was defined as participants attending 75% of sessions, to match the level of adherence within the clinical trial [23,24,26].
Maintenance - The number of sites continuing or ceasing to deliver ESCAPE-pain at <1 year, 1-2 years and <2 years post-implementation. It is not possible to report on maintenance at an individual level because long-term follow-up data for clinical outcomes are not collected.
Data analysis
Clinical outcome data were available for 3,664 people with knee OA from 72 sites and 209 people with hip OA from 33 sites. Only participants with pre- and post-outcome data were included in the analysis. Data from all sites were analysed as a single dataset. Paired t-test was used to determine the mean difference for each subscale and effect size was calculated using Cohen’s D. Data were analysed using R v3.5.1. Data are presented as mean change in KOOS or HOOS points (confidence intervals, CI), where an increase in scores indicates an improvement. All other data were analysed using descriptive statistics.