Walker A1,2, Boaz A1, Hurley M1,2
1St George's, University of London and Kingston University, Faculty of Health, Social Care and Education, London, United Kingdom, 2Health Innovation Network, London, United Kingdom
Background: Scaling-up the implementation of interventions that are effective on a small-scale or under controlled conditions is a priority to achieve system-wide improvements in the quality of care. However, the process by which scaling-up occurs is often haphazard and little is known about how complex interventions transition from research trials to widespread adoption and how this process could be facilitated and accelerated. This is pertinent to physiotherapy where we face implementing complex intervention within increasingly complex contexts.
Purpose: To investigate the factors influencing the spread of an evidence-based, complex intervention for osteoarthritis (ESCAPE-pain) in England.
Methods: A mixed methods approach was used. Forty physiotherapists and managers from 13 organisations in England participated in in-depth interviews. Four National Health Service providers in England were selected to provide in-depth organisational case studies. A fifth in-depth case study was undertaken of a clinical-academic network's role in supporting the spread of ESCAPE-pain, which used interviews, documentation and observations. Qualitative data were managed using NVivo software and analysed using thematic analysis. Data routinely collected by the clinical-academic network to monitor the spread and effectiveness of ESCAPE-pain were used in the study.
Results: The RE-AIM framework was used to structure the findings.
Reach: Between 2014-2018 >6000 people with knee and hip OA participated in ESCAPE-pain.
Effectiveness: Clinical effectiveness has been maintained as ESCAPE-pain has spread into "real world" settings to levels comparable to the clinical trial. All domains of the Knee/Hip Injury and Osteoarthritis Score showed post-intervention improvements across sites.
Adoption: ESCAPE-pain has been adopted by >90 sites in clinical and non-clinical settings (e.g. leisure and community centres). It is delivered predominately by physiotherapists; however, the number of fitness/exercise professionals delivering ESCAPE-pain is increasing.
Implementation: Implementation was driven by senior physiotherapists. There were tensions between adaptation and fidelity. Providers had to balance delivering ESCAPE-pain with the pressures of managing the wider service. The type and extent of adaptation depended on attitudes towards evidence-based interventions and local pressures to deliver short-term cost-savings. A packaged, evidence-based programme was seen as an evolution in physiotherapy practice, which supported better integration of a more holistic approach to management rather than constraining individual practice.
Maintenance: Sites continue to deliver ESCAPE-pain >4 years post-implementation. However, integration problems continued. Poor integration was due to a failure to adapt contextual features or respond to disruptive changes to context. This led to 'fixes' that created inefficiencies. High turnover of frontline staff delivering ESCAPE-pain could erode the practices and ethos associated with it. Training staff was a key quality assurance mechanism.
Conclusion(s): ESCAPE-pain´s clinical effectiveness has been sustained as it has transitioned from trial into “real world” settings and has been successfully adopted into different contexts. Spread has been a slow process requiring sustained, dedicated resources. Packaging knowledge about ESCAPE-pain allowed providers to see it benefits more directly and how to integrate it into existing pathways. Pressure to delivery short-term cost-savings impeded fidelity and sustainability.
Implications: Scaling-up requires sustained, dedicated resources and effective local networks are well placed to facilitate this through supporting knowledge exchange about the intervention and its implement.
Keywords: Implementation, evidence-based practice, osteoarthritis
Funding acknowledgements: The study was funded as part of a doctoral fellowship by the Health Innovation Network.
Purpose: To investigate the factors influencing the spread of an evidence-based, complex intervention for osteoarthritis (ESCAPE-pain) in England.
Methods: A mixed methods approach was used. Forty physiotherapists and managers from 13 organisations in England participated in in-depth interviews. Four National Health Service providers in England were selected to provide in-depth organisational case studies. A fifth in-depth case study was undertaken of a clinical-academic network's role in supporting the spread of ESCAPE-pain, which used interviews, documentation and observations. Qualitative data were managed using NVivo software and analysed using thematic analysis. Data routinely collected by the clinical-academic network to monitor the spread and effectiveness of ESCAPE-pain were used in the study.
Results: The RE-AIM framework was used to structure the findings.
Reach: Between 2014-2018 >6000 people with knee and hip OA participated in ESCAPE-pain.
Effectiveness: Clinical effectiveness has been maintained as ESCAPE-pain has spread into "real world" settings to levels comparable to the clinical trial. All domains of the Knee/Hip Injury and Osteoarthritis Score showed post-intervention improvements across sites.
Adoption: ESCAPE-pain has been adopted by >90 sites in clinical and non-clinical settings (e.g. leisure and community centres). It is delivered predominately by physiotherapists; however, the number of fitness/exercise professionals delivering ESCAPE-pain is increasing.
Implementation: Implementation was driven by senior physiotherapists. There were tensions between adaptation and fidelity. Providers had to balance delivering ESCAPE-pain with the pressures of managing the wider service. The type and extent of adaptation depended on attitudes towards evidence-based interventions and local pressures to deliver short-term cost-savings. A packaged, evidence-based programme was seen as an evolution in physiotherapy practice, which supported better integration of a more holistic approach to management rather than constraining individual practice.
Maintenance: Sites continue to deliver ESCAPE-pain >4 years post-implementation. However, integration problems continued. Poor integration was due to a failure to adapt contextual features or respond to disruptive changes to context. This led to 'fixes' that created inefficiencies. High turnover of frontline staff delivering ESCAPE-pain could erode the practices and ethos associated with it. Training staff was a key quality assurance mechanism.
Conclusion(s): ESCAPE-pain´s clinical effectiveness has been sustained as it has transitioned from trial into “real world” settings and has been successfully adopted into different contexts. Spread has been a slow process requiring sustained, dedicated resources. Packaging knowledge about ESCAPE-pain allowed providers to see it benefits more directly and how to integrate it into existing pathways. Pressure to delivery short-term cost-savings impeded fidelity and sustainability.
Implications: Scaling-up requires sustained, dedicated resources and effective local networks are well placed to facilitate this through supporting knowledge exchange about the intervention and its implement.
Keywords: Implementation, evidence-based practice, osteoarthritis
Funding acknowledgements: The study was funded as part of a doctoral fellowship by the Health Innovation Network.
Topic: Disability & rehabilitation; Musculoskeletal
Ethics approval required: Yes
Institution: St Georges, University of London (SGUL)
Ethics committee: Faculty of Health, Social Care and Education Research Ethics Committee
Ethics number: N/A
All authors, affiliations and abstracts have been published as submitted.
