Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups

Roberts, Jessica Louise and Din, Nafees Ud and Williams, Michelle and Hawkes, Claire and Charles, Joanna and Hoare, Zoe and Morrison, Val and Alexander, Swapna and Lemmey, Andrew and Sackley, Catherine and Logan, Phillipa and Wilkinson, Clare and Rycroft-Malone, Jo and Williams, Nefyn (2017) Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups. BMJ Open, 7 (10): e014362. ISSN 2044-6055

Abstract

OBJECTIVES: To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture.DESIGN: Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams.SETTING: North Wales.PARTICIPANTS: Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13).RESULTS: The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring.CONCLUSIONS: A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III).TRIAL REGISTRATION NUMBER: ISRCTN22464643, Pre-results.