Patient-clinician digital health interventions for the hip fracture population: a scoping review

Introduction Older adults with hip fracture often require extensive post-surgery care across multiple sectors, making follow-up care even more important to ensure an ideal recovery. With the increased adoption of technology, patient-clinician digital health interventions can potentially improve post-surgery outcomes of hip fracture patients by helping them and their caregivers better understand the various aspects of their care, post-hip fracture surgery. The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes. We also aimed to identify the barriers and enablers to the uptake and implementation of these technologies and to provide strategies for improved use of these digital health interventions. Methods We conducted a scoping review following the six stages of Arksey and O’Malley’s framework and following the PRISMA-ScR reporting format. Searches were conducted in five databases. In addition to hand searching for relevant studies from the references of all included studies, we also conducted a grey literature search to identify relevant primary studies. Screening of titles and abstracts as well as full texts were performed independently by two reviewers. Two reviewers also performed the data extraction of the included studies. Results After screening 3,638 records, 20 articles met the criteria and 1 article was identified through hand searching. Various patient-clinician digital health interventions were described including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices /sensor monitoring (n = 1). Outcomes were varied and included functional status, gait/mobility, quality of life, psychological factors, satisfaction, survival/complications, caregiver outcomes, compliance, technology-user interactions, and feedback on the use of the digital health interventions. For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology. However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler. For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study. These themes included: 1) availability and access, 2) usability, 3) knowledge and skills, 4) acceptability, and 5) usefulness of the digital health intervention. Conclusion Many behavioural factors affect the use of patient-clinician digital health interventions. However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions. The results of this scoping review can help to better understand the factors that may be targeted to increase the use of these technologies by clinicians, patients, and caregivers. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09784-y.


Introduction
Hip fractures are a significant health issue among older adults that require cohesive follow up care to ensure ideal recovery.Post-hip fracture surgery care is often provided across multiple health care sectors and typical follow-up care post-surgery can include pain control and management, osteoporosis assessment and treatment, fall risk prevention interventions, physical rehabilitation, assistive walking devices and/or home modifications, as well as follow-up visits with the orthopaedic surgeon and a primary care provider [1].
Digital health interventions have gained attention as potential tools to support patient-clinician interactions and improve outcomes for individuals with hip fractures [2].With the increased accessibility to technology, patient-clinician digital health interventions are becoming a more viable option to help hip fracture patients and their caregivers as they navigate the modern health care system for their post-hip fracture surgery care [2].
In recent years, the inclusion of digital health technologies into healthcare processes has been identified as a global priority [3].The term 'Digital Health' covers a variety of different tools including clinical decision support systems, electronic health record tools, patientclinician communication applications, educational tools, and novel artificial intelligence (AI) algorithms [4].The World Health Organization classifies patient-clinician digital health interventions as "targeted patient/client communication" technologies [5].This type of technology intervention typically involves the use of various information and communication technologies to support the exchange of knowledge between clinicians and their patients regarding their care [5].Providing technologybased interventions to patients and their caregivers can help improve healthcare delivery processes by better engaging them in managing their care and preventing hospital readmissions [2].
Recent reviews of digital health interventions for older adults with hip fracture found that interventions mainly supported physicians in improving their delivery of clinical care [6], with another meta-analysis of randomized control trials (n = 5) showing that nurse/physician voice telephone calls and educational videos interventions were two times more effective to prevent secondary fractures when compared to usual care (OR 2.13, CI 1.30-3.48)[7].However, there is limited information on the specific components of patient-clinician digital health interventions (e.g., web-based applications, mobile applications, wearable devices, etc.) that are optimal to enhance patient engagement for this cohort.The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes.We also aimed to identify the barriers and enablers to the uptake and implementation and to provide strategies for improved use of these digital health interventions.

Design and methodology
We conducted a scoping review following the six stages of Arksey and O'Malley's framework [8] and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for the Scoping Reviews (PRISMA-ScR) reporting format [9].
We used the Population-Concept-Context (PCC) acronym: P-Population (hip fracture patients 50 years of age or older who had surgical repair), C-concept (post-surgery care (e.g., pain control and management, mobilization, follow-up appointments) using any patient-clinician digital health interventions such as mobile technology, web-based applications, digital communication tools), C-context (care across various health care settings), design (all studies), Language (English or French), and year (all years).

Patient and public involvement
No patients were involved. (

1) Identifying the research question
The following research questions were identified for this review: 1. What is the impact of patient-clinician digital health interventions for older adults with hip fracture on patient outcomes and health care delivery processes?2. What are the barriers and enablers to the use of patient-clinician digital health interventions for clinicians and patients with a hip fracture?3. What strategies exist to improve the use of patientclinician digital health interventions for hip fracture patients?
(2) Identifying the research studies An experienced medical information specialist developed and tested the search strategies through an iterative process in consultation with the review team.The MEDLINE strategy was peer-reviewed by another senior information specialist prior to execution using the PRESS Checklist [12].Using the multifile option and deduplication tool available on the Ovid platform, we searched Ovid MEDLINE ® ALL, Embase Classic + Embase, APA PsycInfo, and EBM Reviews (Cochrane Database of Systematic Reviews, CENTRAL and DARE).CINAHL was searched on Ebsco.All searches were performed on May 15, 2022.The strategies utilized a combination of controlled vocabulary (e.g., "Hip Fractures", "Telemedicine", "Rehabilitation") and keywords (e.g., "broken hip", "digital health", "post-surgical care").Vocabulary and syntax were adjusted across the databases.There were no date or language limits but where possible, animal-only records were removed from the results.Records were downloaded and deduplicated using EndNote version 9.3.3(Clarivate Analytics) and uploaded to Covidence [13].We also performed citation searching of the included studies as well as a targeted grey literature search of clinical trial registries.Specific details regarding the search strategies appear in Appendix 1-search strategies.
(3) Screening the studies Studies were screened by two reviewers (CB, SH) using a two-step process.Specifically, the two reviewers independently screened titles and abstracts (level 1) according to the pre-determined eligibility criteria.For level 2 screening, the same two reviewers independently screened the full texts.Any disagreements were resolved by consensus.
(4) Charting the data Data were extracted using a piloted Microsoft Excel form.Two reviewers (CB, SH) extracted the data from the eligible studies.This included (1) general data (authors, year of publication, title, journal, country, purpose); (2) methodological data (study design, theoretical approach, type of participants, number of participants, description of the patient-clinician digital health intervention, data analysis); (3) study results/outcomes (patient outcomes, health care delivery processes; and (4) barriers and enablers.We used the Intervention Description and Replication (TIDieR) checklist to extract data about the interventions reported in the included studies [14].No risk of bias assessment was performed in this scoping review.
(5) Summarizing and collating the data The general, methodological and results/outcomes of the included studies were analyzed using narrative synthesis to summarise and explain the findings.The data was grouped by interventions, and by outcomes (patient outcomes, health care delivery processes).
The barriers and enablers were analyzed using a qualitative descriptive approach.The Theoretical Domain Framework (TDF) [15,16] guided the qualitative analysis of the barriers and enablers.Two reviewers (CB, SH) independently grouped the data extracted from the included studies into themes and coded each theme as a barrier or an enabler.The themes were then mapped to each of the TDF domains.For each barrier and enabler, frequency and percentage were reported to identify the top domains.Any disagreements were discussed and resolved by consensus.We identified behavioural change techniques [17] that could address the barriers and enablers identified in the review to help guide the uptake of future patient-clinician digital health interventions for older adults with hip fracture transitioning from hospital to rehabilitation to home.Examples of behavioural change techniques included restructuring the physical and social environments, practicing and giving feedback, providing incentives, identifying social and environmental consequences, utilizing verbal persuasion to boost self-efficacy, explaining pros and cons, providing prompts/cues, and providing appropriate social support.

(6) Consulting with stakeholders
As the last stage of the Arksey and O'Malley's framework [8], we consulted with a small number of clinical experts on our team (MG, SP, PB, AH, VFM) and a digital health developer (NexJHealth, nexjhealth.com).No additional patient-clinician digital health interventions were identified.Feedback provided about the review findings was incorporated into the discussion.

Study selection
A total of 3,638 records were retrieved from the search, of which 9 were duplicates, and 3,584 were excluded at the title and abstract stage.This resulted in a total of 45 studies assessed for full-text eligibility.A total of 25 studies were excluded for wrong intervention (n = 16), wrong patient population (n = 6), and full-text not available (n = 3).The reasons for exclusion are noted in Appendix 2-list of excluded studies.In addition, a targeted grey literature search of ClinicalTrials.gov(n = 388), International Clinical Trials Registry Platform (ICTRP) (n = 15) and citation searching (n = 42) was performed.Twenty articles from the database searches met our inclusion criteria as well as one additional recent article (published in 2022) was identified through the citation searching.Thus, a total of 21 articles  were included in this review (Fig. 1-PRISMA diagram).

Patient-clinician digital health interventions
Several types of patient-clinician digital health interventions to facilitate patient-clinician interactions were identified.These included: 1) Telehealth /telerehabilitation programs (n = 6): @ctivehip [18][19][20][21], Hip Hat System [22], Telerehab (TR) [28], CASPAR Health e-system [30], Telerehabilitation program based on a video platform for therapy software program [38], and Mobile App [31].These programs allow for virtual consultations and enabling timely follow-ups.Real-time video conferencing facilitates direct communication between patients and clinicians, allowing for the assessment of progress, medication management, and addressing concerns or questions.
3) Web-based resources (n = 2): Online hip fracture caregiver resource center [23][24][25], and Digital patient health hub [26,27].These educational resources can be in the form of videos, and educational modules, providing patients with information about their condition, treatment options, rehabilitation exercises, and self-care practices.4) Wearable devices /sensor monitoring (n = 1) [35].Remote monitoring devices enable clinicians to remotely assess patients' vital signs, activity levels, and adherence to treatment protocols.
How well?

Gail/Mobility
Greater improvements in the telerehabilitation group were demonstrated in the 2-min walking test (86.1%) and walking speed (65.6%)

Participants Categories Themes
Ariza-Vega 2021a [18] @ctivehip Caregivers Feedback on the usefulness of the program (1) the telerehab program was perceived to be useful for older adults' functional recovery without being onerous for family (2) there was room for improvement in the telerehab program (regular checking and monitoring by health professionals, more variety of exercises, difficulty of exercises, limited internet access in some locations, no (3) positive points to program (good for communication with health professionals, easy to use, helpful) Ariza-Vega 2021b [19] @ctivehip Caregivers Needs of caregivers (Perceptions regarding the hip fracture and recovery process and reasons for choosing or declining the telerehab program) Caregivers' responses to the hip fracture and recovery process: (1) concern about survival and recovery (2) uncertainty, anxiety, and stress (3) communication and resources: looking for answers The reasons for choosing the telerehab program were: (1) to enhance recovery after fracture, (2) gain knowledge for managing at home, and (3) the convenience of doing exercises at home The reasons for declining the telerehab program were: (1) perceived challenges with technology; (2) lack of time to support family member (with hip fracture) with technology, for example, navigating the website; (3) caregivers' perception that family members would not want to complete exercises at home; (4) preference of in-person rehab, even if it had associated costs; or (5) no expected need for the program Nahm 2012a [23] Online hip fracture caregiver resource center (OHRC)

Patients and caregivers
Challenges and strategies to recruiting older adult hip fracture patients, and caregivers Challenges: Identifying eligible dyads: we found that locating family CGs often required additional assistance from the clinical staff since CGs were often not present when the research nurse visited the patient on the unit and the clinical; Composite Eligibility Criteria for the Dyad: During the early recruitment phase, we found that the number of eligible dyads in the selected three inner-city hospitals was smaller than expected; Brief Hospital length of stay: Enrollment of older adult hip fracture patients and their CGs in this acute phase is challenging and resource intensive.Usually, our research nurse did not have an opportunity to introduce the study to the patient until the second visit; Caregivers' Stress Level and Busy Schedule: These CGs were stressed and physically and mentally exhausted.Thus, some CGs perceived participation in an online study to be an additional stressor and burden Strategies: Identifying eligible dyads: Informing necessary clinical staff about the study and establishing rapport between the study field staff and the clinical staff are critical in recruiting dyads; Composite Eligibility Criteria for the Dyad: Our investigative team confirmed the importance of monitoring and developing strategies for the recruitment process; Brief Hospital length of stay: Support from the hospital staff was especially helpful in dealing with the patient's short hospital stay and the dyads' busy schedules; Caregivers' Stress Level and Busy Schedule: Field research nurses must be appropriately trained to understand the situation and make proper judgments when they approach participants Several caregivers (four units) reported that support from their family and friends helped them a great deal to cope with the stressful situation ("I've found that lots of family support and visits from friends helped both of us to cope").Others found that relaxation techniques, exercise or taking a walk, or reading helped them cope with the stress (five units) Digital patient health hub Patients, caregivers and staff Feedback on the application (Barriers and facilitators influencing the use of the application) (1) Capability: Some patients recognized that possessing the necessary knowledge and skills while accessing digital devices can help explore relevant web-based health information, which could enable a better understanding of their health condition.Conversely, there were caregivers who lacked confidence in using digital devices (2) Opportunity: Patients and their family members considered their personal environment and the affordability of resources, such as digital devices, as a major limiting factor.Caregivers saw digital health platforms as an opportunity to provide general health information, including healthy lifestyle, diet, and exercise Motivation: Being older was identified by both patients and their family members as one of the main hurdles.(3) Caregivers identified lack of time in their existing role, which is currently not a part of their job.Participants across all 3 categories identified their existing capabilities as a limiting factor.However, they were also positive about the potential capabilities of a digital solution, such as the availability of information that would reduce the need to visit a physician and access to trustworthy interventions.Staff thought that a digital health solution could potentially improve handover processes through a better exchange of information between specialists and caregivers.Most participants were optimistic about the range of functions that a digital health platform could provide; however, some had reservations such as preferring phone conversations or maintaining conventional face-to-face interactions with the physician.Emotionally, some consumers were unhappy with the services provided through technology-based solutions in comparison with faceto-face interactions.One of the patients identified a potential lack of reinforcement in terms of someone who could teach or handhold, which could be a barrier to using a digital solution.Conversely, some patients thought that it could help them achieve more peace of mind and service satisfaction Jensen 2019 [33] My Hip Fracture Journey Patients and caregivers Feedback on the application (Perspectives of participants on feeling supported or not by the technological solution) (1) regaining physical ability, (2) support of autonomy, (3) the issue of getting old, (4) usability of the tablet and app, and (4) uncertainty about the future and general attitude toward life Backman 2020 [36] MyPath to Home Patients, caregivers, and clinicians Feedback on the application (Challenges and benefits to the use of the application) Participants described that an application, like MyPath to Home, was essential to help manage the personalized needs of geriatric rehabilitation patients during their transition from the hospital to home (1) Challenges included the application adding to their workload, a need for more education about the application, and a need for the app to be more user-friendly and accessible on more devices (2) Benefits included providing the patient with opportunities to be involved in their care Ko 2021 [37] Rehabilitation instructions after hip fracture surgery Clinicians Feedback on the application 1) The application is concise and simple, 2) The video of rehabilitation exercises is easy and helpful for older adults to follow, 3) A function to replay the rehabilitation exercise video is needed, 4) It is necessary to reorganize the exercises by dividing bed exercises into lying and sitting exercises, 5) Goal setting can be difficult for older adults.6) It is necessary to maximize the font size for goal setting, 7) Some of the video quality needs to be improved, 8) The background color of the application is suitable, but the yellow text is not easy to read Verbal persuasion to boost self-efficacy Restructuring the physical environment Accuracy of information is important Environmental context and resources Ko 2021 [37] Restructuring the physical environment Chat feature allowed clinicians to guide and urge patients to exercise, and answer their doubts, and reduce the pressure of patients with medical difficulties

Functions of the digital health tools
The digital health tools' functions were grouped according to the 3 categories of the continuity of care framework [39].The continuity of care framework is defined as "the degree to which a series of discrete healthcare events is experienced as coherent and connected and consistent with the patient's medical needs and personal context" ([39], p.1221).The framework consists of these 3 categories: 1) informational continuity (use of information available to all clinicians to make care appropriate for each patient), 2) management continuity (consistent and coherent coordination between all involved in the care that is responsive to a patient's needs), and 3) relational continuity (a trusting therapeutic relationship between a patient and at least one caring clinician) as key components of high-quality care.Most studies were focused on management continuity (n = 7) or informational continuity (n = 3) only.A total of 11 studies focused on both management and informational continuity.Details of the interventions are found in Table 2.

Outcome measures
The quantitative outcomes reported consisted of patient-related functional outcomes (n = 6), gait/mobility (n = 7), quality of life (n = 2), psychological factors (n = 3), and survival/complications (n = 1).Other quantitative reported outcomes included compliance (n = 2), technology-user interactions (n = 4), and caregiver outcomes (n = 3).The qualitative results from 6 studies [18,26,27,33,36,37] included feedback from participants on the use of the digital health interventions.Overall, the feedback provided areas for improvement as well as benefits to the use of these interventions.Specifically, three studies included feedback from clinicians [27,36,37], two explored specifically the needs of caregivers [19,25] and one study described the challenges with the study recruitment processes [23].All the study outcomes are found in Table 3, 4 and 5.

Barriers and enablers
Sixteen studies identified key barriers and enablers to the use of digital health interventions [18-20, 23-31, 33, 34, 36, 37].For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology [27,36].However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler [26,27,29,37].For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study.Some patients and caregivers saw the lack of availability and access to the digital health intervention as a barrier [18,26,27,30,31,33,36] but others had no problems with the availability or access to the intervention [18,26].Patients and caregivers described limited usability of the technology [19,30,34] where others had no concerns with the usability [18,24,28,36,37].There were also conflicting views with the patients and caregivers perceived knowledge and skills to the use the technology, as a barrier [18, 19, 23, 24, 26-28, 30, 31, 33, 34] or an enabler [18,20,28].Patients and caregivers described mixed views on the acceptability of the technology as a barrier [19,[26][27][28] or enabler [19,[25][26][27]33] and the usefulness of the information as a barrier [18,19,26,31,37] or enabler [18,19,24,25,36].Details of the barriers and enablers as well as the proposed behavioural change techniques are described in Table 6.

Discussion
A total of 21 studies were included in this scoping review.Of the 21 studies, we identified 14 distinct patient-clinician digital health interventions for post-surgery hip fracture patients including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices / sensor monitoring (n = 1).Many interventions focused only on a few post-hip fracture surgery care components such as rehabilitation exercises (n = 13), follow-up and management (n = 9), post-hip fracture education and self-care (n = 4), and caregiver needs (n = 3) rather than on more comprehensive post-care efforts.In addition, we found that the interventions all existed within a specified team within a particular organization rather than across different organizations, similarly to what others found [40].Furthermore, these interventions often (or all) lacked complete descriptions following the TidieR guidelines [14] to allow clinicians to use or to allow researchers to replicate the studies.Overall, more clear descriptions of the interventions are needed so that they can be replicated.
In terms of the functions of the digital health tools used in the included studies, the interventions focused primarily on management and informational categories of the continuity of care framework [39].However, future studies should consider incorporating the relational continuity as an important component of continuity of care.
Although only 3/21 studies in our review specifically included methods to improve clinician engagement, one recent rapid review of transition-focused digital health interventions specifically highlighted the importance of involving clinicians in the design and implementation of these interventions to ensure better uptake [41].Similarly, another review recommended to better engage clinicians in the design and implementation of technologies [42].Further considerations should also be made to inform patients on how to use digital health technology, provide appropriate training to clinicians, and ensure that the adoption of the technology will allow clinicians more time to care for patients [42].
In our scoping review, we were also able to identify key barriers and enablers to the uptake of digital health interventions.The unique key barrier was the acceptability of the technology by the clinicians.Thus, the behavioural change techniques [17] related to this barrier are practicing and giving feedback and utilizing verbal persuasion to boost self-efficacy.The behavioural change techniques [17] were also matched to the other barriers and enablers and consist of restructuring the physical and social environments, providing incentives, identifying social and environmental consequences, explaining pros and cons, providing prompts/cues, and providing appropriate social support.Future studies should consider the inclusion of these behavioural change techniques in the implementation strategies of digital health interventions.

Strengths and limitations
The broad inclusion criteria for this scoping review allowed us to examine a wide variety of patient-clinician digital health interventions for the hip fracture population.However, the studies lacked detailed description of the interventions.However, despite the wide-ranging inclusion criteria, it is possible that some studies with non-significant results were not published.

Conclusion
In our scoping review, we identified existing patientclinician digital health interventions.The findings highlighted many behavioural factors that could affect the uptake and use of these patient-clinician digital health interventions.However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions.The results of this scoping review can help researchers and clinicians to better understand the key factors that can be targeted to help increase the uptake of technology-based intervention use by clinicians, patients, and caregivers.Further research is needed to look at patient-clinician digital health interventions in different patient populations that span across different health care sectors.

Table 1
Characteristics of included studies (n

Table 4
Other study outcomes (quantitative)

Table 6
Barriers and enablers to the use of patient-clinician digital health interventions for older patients with a hip fracture transitioning from hospital to rehabilitation to home