South London Health Innovation Network

An integrated rehabilitation programme for chronic joint pain


Summary

ESCAPE-pain is an integrated rehabilitation programme for the management of osteoarthritis, which combines patient education and self-management with tailored physiotherapy. The rehabilitation programme has been shown to improve physical function to a greater extent than usual primary care and produces similar results to individual outpatient physiotherapy but at a lower cost.
  • 61% of patients in the ESCAPE-pain group had a clinically meaningful improvement in physical function, compared with only 34% in the usual primary care group 
  • ESCAPE-pain saves £319 per patient compared to individual outpatient physiotherapy 
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The Challenge

  • Due to its high prevalence, osteoarthritis is a major cause of suffering, physical and mental ill-health, healthcare expenditure and socioeconomic spending.
  • At many sites across the country, patients are offered physiotherapy and education/self-management classes as separate interventions, often leading to sub-optimal outcomes

The Solution

  • A rehabilitation programme, ‘Enabling Self-management and Coping for Arthritic Pain through Exercise’ (ESCAPE-pain), combines education, self-management and coping advice with an exercise regimen tailored to address each patient’s needs.
  • The programme is delivered to small groups of 6 to 8 patients, as opposed to normal individual physiotherapy, and is run completely by physiotherapists.
  • ESCAPE-pain comprises 10–12 sessions, each consisting of physical exercises with themed discussions on topics such as setting goals and controlling pain. Participants are given tailored exercises to do at home and progress is reviewed during follow-up sessions.
  • To enable continued support for people after completing the programme, ESCAPE-pain has been adapted to be delivered through a mobile website and mobile app.
  • ESACPE-pain has established a dedicated website, where interested sites can download a pack on how to roll out the programme. Since it was first launched in April 2014, over 20 different sites have started to deliver ESCAPE-pain programmes.

Service Performance and Outcomes

  • ESCAPE-pain participants had significantly better physical function than participants continuing usual primary care at 6 months after the end of the programme. A difference in physical function was still observed at 30 months after completing the programme.
  • Immediately after the completion of the programme, 61% of patients in the ESCAPE-pain group had a clinically meaningful improvement in physical function, compared with only 34% in the usual primary care group.
  • ESCAPE-pain is associated with similar improvements in clinical outcomes as individual outpatient physiotherapy, but is considerably cheaper to run (see Financial Performance below).

Financial Performance and Outcomes

  • The ESCAPE-pain programme costs approximately £163 per patient, on top of usual primary care.
  • Compared to usual primary care services, the ESCAPE-pain programme has been shown to be cost-effective if commissioners are willing to pay £800 or more for a clinically meaningful improvement in physical function.
  • Compared to individual outpatient physiotherapy, ESCAPE-pain saves approximately £319 per patient, due to the reduction in costs associated with group therapy and the reduced use of other secondary care facilities.
  • There are approximately 1515 outpatient physiotherapy visits for osteoarthritis in the UK each year. If all of these were replaced by the ESCAPE-pain programme, savings could be as much as £480,000.

Patient Focus and Satisfaction

  • The exercise programme provided by ESCAPE-pain is tailored to address the need of each individual patient.
  • The programme places a great deal of emphasis on the education, self-management and coping advice given to the patients.
  • Patients are encouraged to share their experiences with each other in order to create a supportive group atmosphere.
  • More than 90% of patients surveyed were satisfied with the service and patients were more optimistic following the programme.

Commissioning Priorities


The ESCAPE-pain programme is an example of commissioning best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:

 

  • Guideline endorsed – The ESCAPE-pain programme has been cited in the NICE Guidelines for the Management of osteoarthritis (2014).  It has also been adopted as a case study in NICE’s QIPP programme, which highlights interventions that improve care quality and productivity based on quality improvements, savings, strength of evidence and ease of implementation (2013)
  • Integrated care – ESCAPE pain integrates education, self-management and coping advice with an exercise regimen tailored to address each patient’s needs
  • Active support for self-management – ESCAPE-pain empowers patients to manage their condition, provides tailored exercise programmes for each patient and provides online patient support materials
  • Managing ambulatory care-sensitive conditions – Reduces secondary care visits through active management of a chronic, long-term condition
  • Improving the management of patients with both mental and physical health needs – In addition to the improved physical function of patients on the ESCAPE-pain programme, there is a marked effect on mental health with a lowering of depression and anxiety scores compared to normal primary care 

The service is therefore a best practice model for the management of osteoarthritis that is supported by high quality clinical and economic evidence.


Service diagram