Process evaluation results of FEMuR III randomised controlled trial (RCT), a community-based rehabilitation following hip fracture surgery

Abstract

Purpose: Proximal femoral (hip) fracture is common, serious, and costly. Increasing the amount and quality of rehabilitation post-hip fracture potentially improves patient outcomes. Process evaluation examined implementation, mechanisms, and context of the FEMuR intervention, a community rehabilitation programme. Despite patient-reported benefits, RCT found no improvement in quantitatively measured outcomes compared with usual rehabilitation care. Materials and methods: Intervention was delivered across 13 sites. Embedded mixed methods evaluation using realist frameworks. Thematic analysis of semi-structured interviews (patients n = 39: intervention n = 20, control n = 19), carers (n = 2), therapists (n = 10), and recruiting staff (n = 7), plus descriptive analysis of workbooks, goal-setting diaries, and therapy records. Results: Additional therapy sessions were valued by patients and staff; patients appreciated tailored, person-centred support. Therapists appreciated time to work holistically. However, there were disparities in intervention delivery. COVID-19 necessitated remote delivery, impacting therapist feedback and risk assessment. Impacting context and mechanism factors included patient motivation, therapist expertise, variable usual care, poor service integration, and pandemic restrictions limiting activities. Conclusions: Despite high levels of acceptability, intervention implementation and fidelity were compromised. Process evaluation revealed important lessons for future rehabilitation research. Capturing patient-centred intangible benefits, accounting for implementation variations, and considering outcomes beyond standard measures are necessary to fully understand effectiveness.