Preliminary process evaluation findings for the Fracture in the Elderly Multidisciplinary Rehabilitation - Phase III (FEMuR III) randomised controlled trial (RCT), a community-based Rehabilitation package following hip fracture.

Talk Code: 
4D.9
Presenter: 
Penny Ralph
Co-authors: 
Nefyn Williams, Susanna Dodd, Susan Dobson, Ben Hardwick, Dannii Clayton, Rhiannon Tudor Edwards, Joanna Charles, Phillipa Logan, Monica Busse, Ruth Lewis, Toby Smith, Catherine Sackley, Val Morrison, Andrew Lemmey, Patricia Masterson-Algar, Lola Howard, Sophie Hennessy, the FEMuR III team
Author institutions: 
University of Liverpool, University of Bangor, University of Nottingham, Betsi Cadwaladr University Health Board, Norfolk Community and Health Care Trust, Cwm Taf University Health Board, Nottingham City Care, Mid Cheshire Health Trust, University Hospitals of Derby and Burton NHS Foundation Trust, East Kent Hospitals University NHS Foundation Trust

Problem

Hip fracture is a common but debilitating injury which can have physical, psychological and social implications for patients, whilst being costly for health and social care services. Rehabilitation potentially improves recovery and independence. FEMuR III is a pragmatic RCT examining the effectiveness of an enhanced rehabilitation programme compared with usual care following surgical repair. Process evaluation was undertaken to identify factors which impacted on the study’s implementation, context and outcomes.

Approach

FEMuR III utilises a mixed-methods approach using quantitative, standardised outcome measures taken from all sites at baseline, 17 and 52 weeks. The process evaluation focuses on qualitative data exploring context, implementation, mechanisms and outcomes. Participants are older adults (aged ≥60) with mental capacity, recruited on orthopaedic wards recovering from surgical treatment following hip fracture. The enhanced rehabilitation programme incorporated a workbook, goal-setting diary and 6 additional therapy sessions compared with usual care, delivered in the community following hospital discharge following surgical repair. These preliminary findings are primarily based on semi-structured interviews with 32 patients (19 usual; 13 enhanced) and 9 therapists.

Findings

Covid-19 has impacted on several aspects of the study, including access and recruitment of patients and carers, staff redeployment/absence, site stops, and variations in intervention delivery and application. Patients reported access to social and physical spaces curtailed due to lockdown and/ or shielding. Themes relating to the enhanced intervention from both therapists and patients include the importance of goal-setting, of being patient-centred, and regularity and reassurance as motivating factors that supported engagement. Patients viewed extra contact and the opportunity to ask questions and gain reassurance as very important, whilst therapists suggested the opportunity to work more closely to professional values, time with the patient and building therapeutic relations as key. Written materials were seen as less important by patients, however therapists found them particularly useful to help structure support especially when undertaking the intervention over the phone. Patients who received usual care indicated a variable picture; several received very limited or no care when getting home. Usual care themes include frustration and uncertainty around progress, lack of follow up and communication, and a reticence to approach services for being seen as ‘burdensome’.

Consequences

The Covid-19 pandemic has hugely impacted the study, particularly around access to patients, recruitment, staff availability and study momentum, whilst patients have endeavoured to set goals for rehabilitation in a shrinking social and physical environment. Despite this, the qualitative data indicates enhanced intervention patients consistently value and feel they have benefitted from the extra support provided. Usual care patients perceived outcomes have been mixed. Whilst there has been variation in the application of the enhanced intervention, partly due to contextual pressures such as covid19, some variation is inevitable as the intervention was tailored in accordance with patient-directed goals.

Submitted by: 
Penny Ralph
Funding acknowledgement: 
National Institute for Health Research (NIHR)