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

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. 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. 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. 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. The study showed that tailored and flexible individual patient-centred hip fracture rehabilitation care supports motivation and engagement and is valued by both patients and therapists.Consistency, time, and therapeutic alliances enhance patient outcomes, confidence, and self-efficacy.Individualised and appropriate goal setting supports patient motivation, accountability, and progress.Remote delivery has limits around feedback, risk management, and safety whereas a hybrid approach may enhance flexibility without compromising effectiveness.Psychosocial aspects are important for recovery and therapist input has an important role in providing reassurance and emotional support. The study showed that tailored and flexible individual patient-centred hip fracture rehabilitation care supports motivation and engagement and is valued by both patients and therapists. Consistency, time, and therapeutic alliances enhance patient outcomes, confidence, and self-efficacy. Individualised and appropriate goal setting supports patient motivation, accountability, and progress. Remote delivery has limits around feedback, risk management, and safety whereas a hybrid approach may enhance flexibility without compromising effectiveness. Psychosocial aspects are important for recovery and therapist input has an important role in providing reassurance and emotional support.股骨近端（髋部）骨折是一类高发、严重且医疗成本高昂的疾病。提升髋部骨折术后康复的强度与质量，或可改善患者预后。本研究针对社区康复项目FEMuR干预方案的实施、作用机制与实施场景开展过程评估。尽管患者报告称获益，但随机对照试验（Randomized Controlled Trial，RCT）结果显示，与常规康复护理相比，该干预并未在量化测量的预后指标上产生改善效果。该干预方案在13个试点单位落地实施。本研究采用现实主义框架开展嵌入式混合方法评估。对半结构化访谈资料开展主题分析：受访对象包括39名患者（干预组20名、对照组19名）、2名照护者、10名治疗师以及7名招募人员；同时对康复工作手册、目标设定日记及治疗记录开展描述性分析。 患者与工作人员均认可额外的治疗时段；患者对个性化、以患者为中心的支持服务表示满意。治疗师则受益于能够开展整体化照护的充足时间。但干预方案的实施存在不均衡性。新冠疫情（COVID-19）迫使干预转为远程开展，这对治疗师的反馈沟通与风险评估工作造成了影响。影响实施场景与作用机制的因素包括：患者的治疗动机、治疗师的专业能力、常规护理的差异性、服务整合度不足，以及限制线下活动的疫情防控政策。尽管该干预方案的接受度较高，但其实施过程与实施保真度仍受到了影响。 本次过程评估为未来的康复研究提供了重要启示。若要全面评估干预的有效性，需纳入以患者为中心的非量化获益、考虑实施过程的差异性，并纳入标准测量以外的预后指标。 本研究结果表明，个性化且灵活的以患者为中心的髋部骨折术后康复照护，可提升患者的治疗动机与参与度，同时获得患者与治疗师的双重认可。治疗的连贯性、充足的照护时间以及治疗联盟，可改善患者预后、提升其自信心与自我效能感。个性化且合理的目标设定，有助于激发患者的治疗动机、强化其责任感并推动康复进程。远程康复在反馈沟通、风险管理与安全保障方面存在局限，而混合模式（远程结合线下）则可在不影响干预有效性的前提下提升服务灵活性。社会心理层面的支持对患者康复至关重要，治疗师的介入可为患者提供心理疏导与情感支持，发挥着重要作用。 本研究结果表明，个性化且灵活的以患者为中心的髋部骨折术后康复照护，可提升患者的治疗动机与参与度，同时获得患者与治疗师的双重认可。治疗的连贯性、充足的照护时间以及治疗联盟，可改善患者预后、提升其自信心与自我效能感。个性化且合理的目标设定，有助于激发患者的治疗动机、强化其责任感并推动康复进程。远程康复在反馈沟通、风险管理与安全保障方面存在局限，而混合模式（远程结合线下）则可在不影响干预有效性的前提下提升服务灵活性。社会心理层面的支持对患者康复至关重要，治疗师的介入可为患者提供心理疏导与情感支持，发挥着重要作用。