Identifying Opportunities, and Motivation to Enhance Capabilities, Influencing the Development of a Personalized Digital Health Hub Model of Care for Hip Fractures: Mixed Methods Exploratory Study.

BACKGROUND: Most older people after a hip fracture injury never return to their prefracture status, and some are admitted to residential aged care facilities. Advancement of digital technology has helped in optimizing health care including self-management and telerehabilitation. OBJECTIVE: This study aims to understand the perspectives of older patients with hip fracture and their family members and residential aged caregivers on the feasibility of developing a model of care using a personalized digital health hub. METHODS: We conducted a mixed methods study in South Australia involving patients aged 50 years and older, their family members, and residential aged caregivers. Quantitative data analysis included basic demographic characteristics, and access to digital devices was analyzed using descriptive statistics. Spearman rank-order correlation was used to examine correlations between the perceived role of a personalized digital health hub in improving health and the likelihood of subsequent use. Findings from qualitative analysis were interpreted using constructs of capability, opportunity, and motivation to help understand the factors influencing the likelihood of potential personalized digital health hub use. RESULTS: This study recruited 100 participants-55 patients, 13 family members, and 32 residential aged caregivers. The mean age of the patients was 76.4 (SD 8.4, range 54-88) years, and 60% (33/55) of the patients were female. Approximately 50% (34/68) of the patients and their family members had access to digital devices, despite less than one-third using computers as part of their occupation. Approximately 72% (72/100) of the respondents thought that personalized digital health hub could improve health outcomes in patients. However, a moderate negative correlation existed with increasing age and likelihood of personalized digital health hub use (Spearman ρ=-0.50; P<.001), and the perceived role of the personalized digital health hub in improving health had a strong positive correlation with the likelihood of personalized digital health hub use by self (Spearman ρ=0.71; P<.001) and by society, including friends and family members (Spearman ρ=0.75; P<.001). Most patients (54/55, 98%) believed they had a family member, friend, or caregiver who would be able to help them use a personalized digital health hub. Qualitative analysis explored capability by understanding aspects of existing knowledge, including willingness to advance digital navigation skills. Access could be improved through supporting opportunities, and factors influencing intrinsic motivation were considered crucial for designing a personalized digital health hub-enabled model of care. CONCLUSIONS: This study emphasized the complex relationship between capabilities, motivation, and opportunities for patients, their family members, and formal caregivers as a patient networked unit. The next stage of research will continue to involve a cocreation approach followed by iterative processes and understand the factors influencing the development and successful integration of complex digital health care interventions in real-world scenarios.

Personal digital health hubs for multiple conditions.

Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.

La multimorbidité est la présence de plus d'une maladie chronique chez un individu. L'aboutissement de la multimorbidité est influencé par des facteurs sanitaires, socio-économiques, culturels et environnementaux. Aborder ces facteurs biopsychosociaux complexes et souvent interdépendants requiert donc un changement de traitement, qui consiste à s'éloigner d'un modèle axé sur les dommages physiques pour se rapprocher d'un modèle de soins intégré et centré sur la personne, allié à une meilleure implication du patient. L'éducation a un impact sur le comportement et peut être utilisée pour renforcer la capacité d'agir des patients et de leurs soignants, ce qui permettra de conférer plus de responsabilités et un meilleur contrôle de la gestion des soins aux patients. Dans ce document, nous réfléchissons à notre propre apprentissage en tant que communauté de professionnels de la santé issus de différentes disciplines. Nous reconnaissons l'importance croissante de l'implication du patient pour stimuler l'évolution des soins de santé, et imaginons un concept de centre de santé numérique et personnalisé via site Web pour la prise en charge intégrée des patients. Grâce à la collaboration entre patients, professionnels de la santé et structures pédagogiques, nous partageons nos premières expériences en matière de mise en œuvre d'un centre de santé regroupant des patients présentant des fractures de la hanche. Nous dévoilons également notre vision d'avenir pour les soins de santé, qui repose sur la cocréation de centres de santé numériques adaptés aussi bien aux besoins des patients qu'à ceux des soignants. Ce concept pourrait faire progresser l'enseignement et la pratique pour les professionnels du secteur, mais aussi améliorer leur efficacité; favoriser la participation des patients et soignants dans les soins auto-administrés; et enfin, permettre la collecte des données fournies par les patients, et nécessaires à la poursuite des recherches et améliorations dans le domaine des soins de santé.

La multimorbilidad es la presencia de más de una enfermedad crónica en un individuo. Los factores medioambientales, culturales, socioeconómicos y los relacionados con la salud, así como el comportamiento de los pacientes, influyen en los resultados de la multimorbilidad. Por lo tanto, se requiere un cambio en el tratamiento desde el modelo de daño físico hacia una atención integrada y centrada en el individuo con una mayor participación del paciente para abordar estos factores biopsicosociales complejos y a menudo interactivos. La educación influye en el comportamiento y se puede utilizar para que los pacientes y sus cuidadores tengan más capacidad de acción, lo que permite una mayor responsabilidad y control sobre la gestión de la atención al paciente. En este documento reflexionamos sobre nuestro propio aprendizaje como comunidad de profesionales de la salud de diferentes disciplinas. Se describe el concepto de un centro de salud virtual personalizado para la atención integrada del paciente, al reconocer la creciente relevancia de la participación y la acción del paciente en el proceso de evolución de la atención médica. Gracias a la colaboración entre las comunidades de pacientes, de salud y de educación, compartimos nuestra experiencia inicial sobre el establecimiento de un centro de salud en torno a una cohorte de pacientes con fracturas de cadera. Asimismo, describimos una visión de la futura atención médica basada en la creación conjunta de centros de salud virtuales que se centran en las necesidades de los pacientes y de los cuidadores. El centro de salud permitiría alcanzar importantes avances y mejoras en la práctica y la educación de la fuerza de trabajo; en el compromiso de los pacientes y los cuidadores con el autocuidado de la salud; y en la recopilación de los datos sobre la salud que los pacientes comunican y que se requieren para la investigación y las mejoras continuas en la atención médica.

Orthopaedic surgeons' perceptions of frailty and frailty screening.

BACKGROUND: Over the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts. METHODS: We used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation. RESULTS: Orthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used. CONCLUSIONS: There is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial.

OBJECTIVE: to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care. DESIGN: parallel randomised controlled trial with integrated health economic study. SETTING: NCFs, in Adelaide South Australia. SUBJECTS: people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture. MEASUREMENTS: primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months. RESULTS: participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056). CONCLUSIONS: the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective. TRIAL REGISTRATION: ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980.

Evaluation of the utility of teaching joint relocations using cadaveric specimens.

BACKGROUND: Like other procedural skills, the ability to relocate a joint is an important aspect of junior doctor education. Changes in the approach to teaching and learning from the traditional apprenticeship-style model have made the teaching of practical skills more difficult logistically. Workshops utilising cadaveric specimens offer a solution to this problem. METHODS: One hundred forty-six fourth year medical students were randomly divided into 5 groups. Each group received a different teaching intervention based on ankle, patella and hip relocation. The interventions consisted of online learning modules, instructional cards and workshops using skeleton models and cadaveric dislocation models. Following the intervention students were given a test containing multiple choice and true/false style questions. A 13-item 5-point Likert scale questionnaire was also delivered before and after the intervention. The data was analysed using one-way analysis of variance (ANOVA) and the Bonferroni post-hoc test. RESULTS: Compared to the instructional cards group, the other 4 groups showed a 10.8-19.2% improvement in total test score (p < 0.01) and an 18.4-25.3% improvement in self-reported understanding and confidence in performing joint relocations (P < 0.01). There was no significant difference in total test scores between groups exposed to cadaveric instruction on the relocation of one-, two- or all three- joints, nor any significant difference between all the cadaveric dislocation groups and the group receiving instruction on the skeleton model. CONCLUSION: The results of the present study suggest that workshops utilising cadaveric dislocation models are effective in teaching joint relocation. In addition, the finding that lower fidelity models may be of equal utility may provide institutions with flexibility of delivery needed to meet financial and resource constraints.

Perspectives of Frailty and Frailty Screening: Protocol for a Collaborative Knowledge Translation Approach and Qualitative Study of Stakeholder Understandings and Experiences.

BACKGROUND: Accompanying the unprecedented growth in the older adult population worldwide is an increase in the prevalence of frailty, an age-related clinical state of increased vulnerability to stressor events. This increased vulnerability results in lower social engagement and quality of life, increased dependency, and higher rates of morbidity, health service utilization and mortality. Early identification of frailty is necessary to guide implementation of interventions to prevent associated functional decline. Consensus is lacking on how to clinically recognize and manage frailty. It is unknown how healthcare providers and healthcare consumers understand and perceive frailty, whether or not they regard frailty as a public health concern; and information on the indirect and direct experiences of consumer and healthcare provider groups towards frailty are markedly limited. METHODS: We will conduct a qualitative study of consumer, practice nurse, general practitioner, emergency department physician, and orthopedic surgeons' perspectives of frailty and frailty screening in metropolitan and non-metropolitan South Australia. We will use tailored combinations of semi-structured interviews and arts-based data collection methods depending on each stakeholder group, followed by inductive and iterative analysis of data using qualitative description. DISCUSSION: Using stakeholder driven approaches to understanding and addressing frailty and frailty screening in context is critical as the prevalence and burden of frailty is likely to increase worldwide. We will use the findings from the Perceptions of Frailty and Frailty Screening study to inform a context-driven identification, implementation and evaluation of a frailty-screening tool; drive awareness, knowledge, and skills development strategies across stakeholder groups; and guide future efforts to embed emerging knowledge about frailty and its management across diverse South Australian contexts using a collaborative knowledge translation approach. Study findings will help achieve a coordinated frailty and healthy ageing strategy with relevance to other jurisdictions in Australia and abroad, and application of the stakeholder driven approach will help illuminate how its applicability to other jurisdictions.

Common pitfalls in syndesmotic rupture management: a clinical audit.

BACKGROUND: Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes. MATERIALS AND METHODS: This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients' notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period. RESULTS: There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient. CONCLUSIONS: The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

"Context, content, and system" supporting digital health hub (DHH)-enabled models of care (MoCs) for fragility hip fractures: perspectives of diverse multidisciplinary stakeholders in South Australia from qualitative in-depth interviews.

Combining thematic analysis and a human-computer persuasive systems framework suggests that hip fracture recovery among older people can be enhanced through person-centered digital health hub models of care focused on behavior change education and integrated care. The findings intend to guide settings involving comorbid conditions and low- and middle-income countries in developing innovative digital health solutions. PURPOSE: The purpose of this study was to understand stakeholders' perspectives on the development of a digital health-enabled model of care for fragility hip fractures and to map out factors that could influence the design and implementation of such a model. METHODS: Qualitative in-depth interviews were conducted with stakeholders from various clinical disciplines, allied health, and computer science. A hybrid process involving thematic analysis of the raw data using inductive coding was the first step. In the second step, the tenets of a theoretical framework (health behavior change supporting systems) were deductively applied to the thematic constructs generated as part of the first step of the analysis. RESULTS: In total, 24 in-depth interviews were conducted with stakeholders. We identified 18 thematic constructs presented under the categories of context, content, and system. Context covered patient characteristics such as frailty, digital literacy, and patient or carer participation, whereas healthcare delivery aspects included the structure and culture of existing practice and the need for innovative holistic models of care. Content outlines the active ingredients and approach in developing a digital health hub, and it highlights the importance of targeted education and behavior change. The system is a complicated matrix crossing different aspects of healthcare and offering a value proposition design through personalization across modes of content delivery. This must foster trust, ensure adequate financing, and support ownership and privacy by establishing appropriate mechanisms for embedding change. CONCLUSION: The findings from this study provide insights around potential factors related to patients, community support, and healthcare delivery influencing the design and next-stage implementation of a digital health hub model of care for fragility hip fractures.

Patient, surgical and hospital factors associated with the presence of a consultant surgeon during hip fracture surgery. Do we know the answer?

BACKGROUND: Provision of quality care can help to reduce adverse health outcomes following hip fracture. While surgical management by either a consultant or junior surgeon has shown inconclusive differences in patient outcomes, consultant presence is often recommended, yet little is known about the factors that influence whether a consultant surgeon is present during hip fracture surgery. The aim of this study is to examine patient, surgical and hospital factors associated with having a consultant surgeon present during hip fracture surgery. METHODS: An examination of hip fracture surgeries of adults aged ≥ 50 years admitted to hospitals in Australia and New Zealand between 1 January 2015 and 31 December 2018 using data from the Australia and New Zealand Hip Fracture Registry was conducted. Multivariable logistic regression was used to examine factors associated with the presence of a consultant surgeon during hip fracture surgery. RESULTS: There were 29 530 hip fracture surgeries 58.1% had a consultant surgeon present (range 8.5-100% by hospital). Patients were more likely to have a consultant surgeon present during surgery if they had private health insurance, were operated on after hours, required total hip replacements or were operated on in hospitals that conducted ≤150 surgeries per year. CONCLUSION: There is variation in the presence of consultant surgeons within Australia and New Zealand during hip fracture surgery, potentially associated with the complexity of surgery and hospital factors. However, further research is needed to determine the optimum level of supervision required based on patient factors and surgical complexity.

The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures.

BACKGROUND AND PURPOSE: The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model. METHODS: Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models. RESULTS: The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 mum in all axes. The precision (95% confidence interval) was less than +/- 16 mum in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123 degrees and a precision of +/- 0.024 degrees. INTERPRETATION: RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our center's RSA system provides evidence to support future clinical RSA fracture studies.

Association between atrial fibrillation and hip fractures and the implications for hip fracture patients: a systematic review.

BACKGROUND: Atrial fibrillation (AF) and hip fractures are both prevalent in the elderly population. The aim of this study was to systematically review the literature regarding the association between AF and hip fractures, and the impact of AF on hip fracture prognosis. METHODS: The literature search was performed using PubMed, MEDLINE, Embase and Scopus. Inclusion was based upon the application of eligibility criteria in duplicate prior to data extraction with a standardized form. RESULTS: A total of 42 studies met the inclusion criteria. AF prevalence was found to vary between 6.5% and 35% in cohorts. Large studies with broad inclusion criteria found the prevalence of AF in hip fracture patients to be approximately 12-15%. There were conflicting results as to whether patients with AF have an increased rate of hip fractures, as compared to patients without AF. Several studies demonstrated that hip fracture patients with AF have increased rates of mortality, both as an inpatient and following discharge, and increased readmission rates. CONCLUSION: AF and hip fractures frequently coexist, and there is evidence to suggest AF is associated with increased readmission and mortality rates in hip fracture patients. Elements of the relationship between AF and hip fractures remain uncertain and further prospective studies on AF and hip fracture cohorts may clarify this relationship. Interventional studies targeting hip fracture patients with AF may be beneficial.

Innovations to improve access to musculoskeletal care.

Innovation is a form of realising a new way of doing something, often ignoring traditional wisdom, in order to meet new challenges. Globally, particularly in emerging economies, the high burden of musculoskeletal conditions and their contribution to multimorbidity continue to rise, as does the gap for services to deliver essential care. There is a growing need to find solutions to this challenge and deliver person-centred and integrated care, wherein empowering patients with the capacity for self-management is critical. Whilst there is an abundance of information available online to support consumer education, the number of sources for credible medical information is diluted by uninformed anecdotal social media solutions. Even with the provision of high-quality information, behavioural change does not necessarily follow, and more robust educational approaches are required. In this chapter, we examine innovation, its management and the strategic directions required to improve musculoskeletal healthcare at macro (policy), meso (service delivery) and micro (clinical practice) levels. We discuss the critical role of consumer agency (patients and their families/carers) in driving innovation and the need to leverage this through empowerment by education. We provide a snapshot of real-world examples of innovative practices including capacity building in consumer and interprofessional musculoskeletal education and practice; recommendations to transform the access and delivery of integrated, person-centred care; and initiatives in musculoskeletal care and implementation of models of care, enabled by digital health solutions including telehealth, remote monitoring, artificial intelligence, blockchain technology and big data. We provide emerging evidence for how innovation can support systems' strengthening and build capacity to support improved access to 'right' musculoskeletal care, and explore some of the ways to best manage innovations. We conclude with recommended systematic steps to establish required leadership, collaboration, research, networking, dissemination, implementation and evaluation of future innovations in musculoskeletal health and care.

A global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education : White paper by the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD).

Rheumatic and musculoskeletal diseases (RMDs) encompass a spectrum of degenerative, inflammatory conditions predominantly affecting the joints. They are a leading cause of disability worldwide and an enormous socioeconomic burden. However, worldwide deficiencies in adult and paediatric RMD knowledge among medical school graduates and primary care physicians (PCPs) persist. In October 2017, the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD), an international think tank of RMD and related experts, met to discuss key challenges and opportunities in undergraduate RMD education. Topics included needs analysis, curriculum content, interprofessional education, teaching and learning methods, implementation, assessment and course evaluation and professional formation/career development, which formed a framework for this white paper. We highlight a need for all medical graduates to attain a basic level of RMD knowledge and competency to enable them to confidently diagnose, treat/manage or refer patients. The importance of attracting more medical students to a career in rheumatology, and the indisputable value of integrated, multidisciplinary and multiprofessional care are also discussed. We conclude that RMD teaching for the future will need to address what is being taught, but also where, why and to whom, to ensure that healthcare providers deliver the best patient care possible in their local setting.

Differentially loaded radiostereometric analysis to monitor fracture stiffness: a feasibility study.

Inability to accurately and objectively assess the mechanical properties of healing fractures in vivo hampers clinical fracture management and research. We describe a method to monitor fracture stiffness during healing in a clinical research setting by detecting changes in fracture displacement using radiostereometric analysis and simultaneously measuring applied axial loads. A method was developed for load application, positioning of the patient, and radiographic setup to establish the technique of differentially loaded radiostereometric analysis (DLRSA). A DLRSA examination consists of radiostereometric analysis radiographs taken without load (preload), under different increments of load, and without load (postload). Six patients with distal femur fractures had DLRSA examinations at 6, 12, 18, and 26 weeks postoperatively. The DLRSA method was feasible in a clinical setting. The method provides objective and quantifiable data for internally fixed fractures and may be used in clinical research as a tool to monitor the in vivo stiffness of healing femoral fractures managed with nonrigid internal fixation.

Utilising Digital Health Technology to Support Patient-Healthcare Provider Communication in Fragility Fracture Recovery: Systematic Review and Meta-Analysis.

The objective of this review is to evaluate the effectiveness of digital health supported targeted patient communication versus usual provision of health information, on the recovery of fragility fractures. The review considered studies including older people, aged 50 and above, with a fragility fracture. The primary outcome was prevention of secondary fractures by diagnosis and treatment of osteoporosis, and its adherence. This review considered both experimental and quasi-experimental study designs. A comprehensive search strategy was built to identify key terms including Medical subject headings (MeSH) and applied to the multiple electronic databases. An intention to treat analysis was applied to those studies included in the meta-analysis and odds ratio was calculated with random effects. Altogether, 15 studies were considered in the final stage for this systematic review. Out of these, 10 studies were Randomised controlled trials (RCT) and five were quasi experimental studies, published between the years 2003 and 2016 with a total of 5037 participants. Five Randomised control trails were included in the meta-analysis suggesting that digital health supported interventions were overall, twice as effective when compared with the usual standard care (OR 2.13, 95% CI 1.30-3.48), despite the population sample not being homogeneous. Findings from the remaining studies were narratively interpreted.

Cocreation of a digital patient health hub to enhance education and person-centred integrated care post hip fracture: a mixed-methods study protocol.

INTRODUCTION: Older people with hip fractures often require long-term care and a crucial aspect is the provision of quality health information to patients and their carers to support continuity of care. If patients are well informed about their health condition and caring needs, particularly posthospital discharge into the community setting, this may support recovery and improve quality of life. As internet and mobile access reach every household, it is possible to deliver a new model of service using a digital education platform as a personal health hub where both patients and their providers of care can establish a more efficient information integration and exchange process. This protocol details proposed research, which aims to develop a 'model of care' by using a digital health solution that will allow delivery of high quality and patient-centred information, integrated into the existing process delivered within the community setting. METHODS AND ANALYSIS: This phase of the study uses a pragmatic mixed-methods design and a participatory approach through engagement of patients, their carers and healthcare providers from multiple disciplines to inform the development of a digital health platform. Quantitative methods will explore health literacy and e-health literacy among older people with hip fractures admitted to the two public tertiary care hospitals in Adelaide, South Australia. Qualitative methods will provide an understanding of aspects of content and context required for the digital health platform to be developed in order to deliver quality health information. The study will use appropriate theoretical frameworks and constructs to guide the design, analysis and overall conduct of the research study. The scope of the study intends to ultimately empower patients and their carers to improve self-management and to better use coordinated services at the community level. This could prevent further falls including associated injuries or new fractures; reduce new hospital admissions and improve confidence and engagement by limiting the psychologically restrictive 'fear of falls'. ETHICS AND DISSEMINATION: The study has been approved by the Human Research Ethics Committee of the Central Adelaide Local Health Network, South Australia (SA) Health, Government of South Australia and the University of Adelaide Human Research Ethics Committee. Findings from the study will be published in suitable peer-reviewed journals and disseminated through workshops or conferences.

A randomized controlled feasibility study to evaluate the effects of a goal-setting coaching intervention using feedback from an accelerometer on sedentary time in older people at risk of falls (SMART-MOVE): a study protocol.

BACKGROUND: Sedentary behaviour and falls are important interrelated health issues in older people. One in three people aged 65 years and above fall at least once a year and sedentary behaviour has been identified as one of the risk factors for falls. Studies have shown that the duration of sedentary time increases with age. These dual problems need to be addressed effectively as the ageing population grows. Accelerometers enable accurate measurement of sedentary time. This study aims to establish the feasibility and effect of an individualized goal-setting health coaching intervention using feedback initially from an accelerometer and then pedometer over a period of 12 weeks (intervention) compared with providing a one-off advice through a brochure (control), on sedentary time in older people with a recent fall or at risk of one. METHODS: A single-blinded randomized controlled feasibility trial involving 80 community-dwelling people aged 65 years and above will be conducted with 40 randomized to the intervention and another 40 to control. Primary outcomes will be the feasibility of the intervention and change in total sedentary time at 12 and 24 weeks. Secondary outcomes include a change in fear of falling based on the falls efficacy scale, gait speed, self-reported sedentary time, the proportion of fallers and number of falls. Four focus groups (two from each arm) will be conducted at the end of the study to evaluate the feasibility and effectiveness of this intervention. Feasibility findings will be primarily descriptive. Mean group differences will be examined using independent samples t test for normally distributed data and nonparametric tests (Kruskal-Wallis and Mann-Whitney U) for non-normally distributed data. Differences in frequency of variables will be compared using chi-square test. Analysis of variance (ANOVA) will be used to test the post-intervention difference between the two groups at 12 and 24 weeks. DISCUSSION: The trial will address a key gap in evidence about sedentary behaviour and falls amongst older people and will evaluate the feasibility of an intervention that could be implemented within the primary health care settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry 12617001186347, Registered 11 August 2017.

Testing the Hip Abductor Muscle Strength of Older Persons Using a Handheld Dynamometer.

OBJECTIVE: To investigate the reliability of a clinically applicable method of dynamometry to assess and monitor hip abductor muscle strength in older persons. DESIGN: Bilateral isometric hip abductor muscle strength measured with a handheld dynamometer, patients supine with the contralateral hip positioned directly against a wall for stabilization. Reliability determined by comparing intra-assessor and inter-assessor results and comparison to a criterion standard (stabilized dynamometer with patients in the standing position). SETTING: UniSA Nutritional Physiology Research Centre. PARTICIPANTS: Twenty-one patients older than 65 years were recruited from the Royal Adelaide Hospital. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), bias, and limits of agreement calculated to determine reliability. RESULTS: Intra-assessor and inter-assessor ICCs were high (0.94 and 0.92-0.94, respectively). There was no intra-assessor bias and narrow limits of agreement (±2.4%). There was a small inter-assessor bias but narrow limits of agreement (0.6%-0.9% and ± 2.3%, respectively). There was a wide variation comparing results to the criterion standard (±5.0%-5.2% limits of agreement), highlighting problems attributed to difficulties that the test population had with the standing position used in the criterion standard test. CONCLUSIONS: Testing older persons' hip abductor muscle strength while in the supine position with optimal pelvic stabilization using a handheld dynamometer is highly reliable. While further studies must be done to assess patients with specific pathologies, this test has potential application to monitor and evaluate the effects of surgical interventions and/or rehabilitation protocols for a variety of conditions affecting hip abductor function such as hip fractures and arthritis.

Outcomes between older adults with atypical and typical femoral fractures are comparable.

INTRODUCTION: Atypical femoral fractures (AFFs) are rare but a serious complication associated with prolonged use of bisphosphonates. However little is known about clinical outcomes of AFFs. The aim of this study is to compare the characteristics and postoperative outcomes between older patients with AFFs and typical femoral fractures (TFFs). METHODS: A retrospective matched cohort study (each AFF was age- and sex-matched with three TFFs) of patients aged 65 years or older who were admitted to The Queen Elizabeth Hospital, South Australia between January 2011 and December 2013 was undertaken. Baseline characteristics of both groups were compared. The primary outcomes evaluated were level of independence in mobility at discharge and 3 months after surgery. Secondary outcomes included length of hospital stay, post-operative complications, rate of surgical revision, discharge destination (after acute hospital stay or rehabilitation), 28-day hospital readmission and 12-month mortality. RESULTS: Ten patients (mean age: 78.1 years) with AFFs were compared with 30 matched TFFs. Patients with AFFs were predominantly female (90%) and 80% had been taking oral bisphosphonate. Nine of the AFFs had their fractures fixed with an intramedullary (IM) nail. The level of independent mobility at discharge (OR 0.31; 95%CI: 0.06-1.71; p=0.26) and at 3 months (OR 0.51; 95%CI: 0.10-2.53; p=0.47) were comparable between the two groups. Only one AFF patient treated with plate and screws required surgical revision, compared with none in the TFF group. Secondary outcomes were not significantly different between the two groups. CONCLUSION: Recovery of mobility and reoperation rates after surgery of patients with AFFs were favourable and did not differ significantly from TFFs. Further consideration should be given to using IM fixation in the management of AFFs in older people.

A combined randomised and observational study of surgery for fractures in the distal radius in the elderly (CROSSFIRE)-a study protocol.

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients. METHODS AND ANALYSIS: This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial. ETHICS AND DISSEMINATION: CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies. REGISTRATION: CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).