Characteristics and Effects of Home-Based Digital Health Interventions on Functional Outcomes in Older Patients With Hip Fractures After Surgery: Systematic Review and Meta-Analysis

Introduction

Hip fractures are a common and serious health issue [1-3], ranking among the top 10 causes of disability among older individuals [4]. The global prevalence is increasing, particularly among Asian people, who have the highest rate of hip fractures [4]. The mortality rate after they receive aggressive management in both surgery and rehabilitation is high, 10% in the first month [2,4] and 12%-36% in the first year [4,5]. Moreover, they have many consequences including functional decline [1], fear of falling [6], and reduced quality of life [2,4,5], and can lead to caregiver burden [1].

Apart from early surgery that can reduce mortality [7], the postoperative or transitional care after hospital discharge to home is also a crucial phase in the care process for patients with hip fracture [8]. The goal of treatment in this population is to improve functional outcomes, enhance independence, and reduce the risk of recurrent falls following surgery. Several home-based interventions, such as rehabilitation [5,9], dietary supplementation to prevent calorie and protein malnutrition [5], home hazard modification [5], fall prevention guidance [5,10], and timely and appropriate patient follow-up (including telephone calls and home visits) [5], as well as patient, family, and caregiver education and support [11], have been found beneficial in postoperative care among older patients with hip fractures. These interventions play a crucial role in improving patient functional ability, enhancing quality of life, reducing unplanned readmissions, minimizing complications and disabilities, and decreasing mortality [12].

Previous research found that combining postsurgical interventions for patients with fragility hip fractures across inpatient and outpatient settings may be able to improve physical function recovery and discovered that 63% of the studies were related to rehabilitation or medication or nutrition supplementation [13].

Over the past couple of decades, advancements in information and communication technologies have brought medical services to virtually all corners of the world [14]. Digital health interventions (DHIs) or the use of digital technology for health [15] has become a field of practice for using routine and innovative forms of information and communication technologies to address health needs [15]. DHIs have the potential to help address problems such as distance and access [15] and have been incrementally changing. DHIs do not only assist health care providers and patients receiving treatment but also benefit perfectly healthy people by providing health assessment [14] and health promotion. A recent review of home-based exercise programs delivered through DHIs for community-dwelling adults older than 65 years, involving a diverse study population with various health conditions, demonstrated improved physical function, particularly in terms of lower extremity strength [16]. Furthermore, many DHIs are specifically designed to detect, monitor, and provide care for specific health conditions [17], aiming to enhance various health aspects at home, even among older patients with hip fractures [18,19]. Previous studies have explored various types of home-based DHIs [18,19] with a focus on different interventions, such as rehabilitation, nutrition, and fall prevention, as well as different outcomes, including functional improvements, adherence to protocols, and the incidence of recurrent falls [9,19,20]. Typically, these previous studies have provided interventions to improve functional outcomes, and many of them have achieved success [16,19,21,22].

The scoping review elucidates the characteristics of DHIs for older adults who have undergone hip fracture surgery, with most studies focusing on physical therapy [23]. These DHIs were typically implemented in acute hospital settings and rehabilitation centers. However, there is a notable lack of information regarding DHIs specifically designed to improve functional outcomes in this population during transitional care settings. As a result, information on the characteristics of home-based DHIs in postoperative care among older patients with hip fractures is currently sparse, and there is a lack of information about specific home-based DHIs for this population [24]. Moreover, there is controversy over the conclusion that home-based DHIs have an impact on functional outcomes. Our systematic review and meta-analysis aimed to provide a general overview of the characteristics and effects of home-based DHIs in postoperative care on functional outcomes among older patients with hip fractures. This will lead to the development of home-based DHIs that can provide care for this population.

Methods

Ethical Considerations

We conducted a systematic review and meta-analysis and then reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines (Multimedia Appendix 1) [25]. This study was approved by the Chiang Mai University Ethics Committee (FAM-2565-09330) and we registered our protocol in PROSPERO (CRD42022370550).

Recruitment

Review Eligibility Criteria

We included the studies that related to (1) older adults (including patients aged 60 years or older) with hip fractures defined as any type of hip fracture, such as femoral neck, intertrochanteric, subtrochanteric fracture, and nonspecified type of hip fracture; (2) postoperative care (including transitional care, postdischarge care, and subacute care); and (3) home-based DHIs. In addition, the included studies that had (4) study design limited to clinical trials or randomized controlled trials (RCTs) and (5) compared between home-based DHIs (intervention) and usual care (comparator) in the English language with no date restriction. The following studies were excluded: patients enrolled in the emergency department but not admitted to the hospital, patients discharged from the hospital to a setting other than home, studies that involved DHIs that did not directly intervene with patients (including database management), and studies with inaccessible full-text or insufficient data for evaluating the characteristics of DHIs or quantitative synthesis.

Search Strategies

This study was systematically searched in 5 electronic medical databases, that is, PubMed, Embase, Cochrane, ProQuest, and CINAHL, with no date restriction. We searched until January 3, 2023. We searched in 3 heading terms including “hip fracture” AND “digital health” AND “post-operative” (Table S1 in Multimedia Appendix 2).

Review Selection

Duplicates were removed automatically by the EndNote X9 program (Clarivate Analytics) and the Rayyan website, as well as manually by SP and NB. Then, 2 authors (SP and NW) independently reviewed and screened all studies in title and abstract for study eligibility and 2 reviewers (SP and NB) independently screened the full paper for study selection. Disagreements were resolved through discussion and agreement with the third author (KP).

Data Extraction

Two authors (SP and NB) independently extracted data from the full original studies using a standard data collection form. Disagreements were resolved through discussion and agreement with the third author (KP). The data extracted included (1) the first author, (2) publication year, (3) study design, (4) study location, (5) population (including the number of patients, age, and sex), (6) the characteristic of home-based DHIs, (7) control group, (8) functional outcomes, and (9) other outcomes.

Characteristics of Home-Based DHIs

The characteristics of home-based DHIs focused on three dimensions, which included (1) purpose and content, (2) mode of delivery, and (3) health care provider. Two authors categorized subgroups in each dimension according to the definition (Table S2 in Multimedia Appendix 2) [17,26,27]. The categorizations possibly reported more than 1 category in each dimension. Purpose and content were categorized into 5 categories including education, telerehabilitation, communication and feedback, behavioral and lifestyle interventions or health coaching, and remote monitoring [17,26,27]. Modes of delivery were categorized into 4 categories including web-based software, telephone call, mobile apps, and sensor-based technology [17,26,27]. Health care providers were categorized into 6 categories including occupational therapists (OTs), physical therapists or physiotherapists (PTs), physicians, nurses, dieticians, and multidisciplinary teams. If the results were unable to be meta-analyzed, we conducted a narrative synthesis to provide an overview of the characteristics and effects of home-based DHIs on functional outcomes in this population.

Outcomes

In the meta-analysis, the studies that reported functional outcomes including Timed Up and Go (TUG) test, Short Physical Performance Battery (SPPB), and Functional Independence Measure (FIM) were considered. TUG is a tool that assesses functional walking ability and predicts fall risk in older adults. The shorter the time taken means better the balance function and walking ability, and the lower the risk of fall [28,29]. SPPB is a comprehensive assessment index that is used to evaluate the motor ability of the older adults and to predict the risk of falls. It consists of 3 parts that measure balance test, gait speed test, and 5 sit-to-stand tests, which assess static and dynamic balance, lower limb strength, and gait speed. The SPPB score runs from 0 to 12 and the higher the score mean the better the overall somatic ability and the lower the risk of fall [28]. FIM is a postdischarge follow-up evaluation test that consists of 18 items that measure patients’ somatic, verbal, social, and cognitive abilities. The score ranges from 18 to 126. Higher scores mean higher levels of functional independence and lower levels of dependence [28].

Data Analysis

In meta-analysis, the outcomes included functional outcomes (such as TUG, SPPB, and FIM) reported as mean and SD at the end of the intervention for both the intervention group and the control group. Because the same methodology and range of outcomes were used in all studies to analyze the outcomes, the summary measure for meta-analysis was the mean difference with 95% CIs. Pooled-effect estimates of each functional outcome of interest were calculated by the random-effects DerSimonian-Laird model. Statistical heterogeneity among included studies was assessed using Cochran Q test and the percentage of total variability across studies due to heterogeneity (I²=0%-40%, low; I²=30%-60%, moderate; I²=50%-90%, substantial, and I²=75%-100%, considerable) [30]. Results of the meta-analysis and forest plot were performed using a standard software package (Stata, version 16.0; StataCorp LLC). P value of <.05 was considered statistically significant.

Risks of Bias

We assessed the quality of each included study using the Risk of Bias 2 assessment tool (RoB 2; The Cochrane Collaboration) for the 14 RCT studies. In addition, 1 non-RCT and 1 quasi-experimental study were evaluated using the ROBINS-I (The Cochrane Collaboration) [31]. The results were visualized using robvis, a visualization tool [32]. This assessment was conducted independently by 2 authors, SP and NB, with any disagreements resolved through discussion and agreement with coauthor KP.

Grading the Quality of Evidence

We graded the quality of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) method [33]. This assessment was conducted independently by 2 authors, SP and NB, with any disagreements resolved through discussion and agreement with the third author, KP. The quality of evidence was categorized into 4 levels: very low, low, moderate, or high.

Results

During the initial literature search, a total of 2125 studies were identified. Among them, 244 studies were clinical trials or RCTs. After screening the titles and abstracts for eligibility criteria, 218 studies were retrieved and further assessed. Subsequently, 22 studies underwent full-text screening. The reasons for excluding studies were as follows: 2 studies involved a population without hip fractures [34,35], 2 study did not include home-based DHIs [36,37], 1 study had insufficient data [38], and 1 study used the same DHIs in both groups [39]. Finally, a total of 16 studies were included in the systematic reviews (Figure 1), with a subset of 6 studies included in the meta-analysis (4 studies for TUG, 4 studies for SPPB, and 2 studies for FIM).

The characteristics of 16 studies are shown in Table 1 and Table S3 in Multimedia Appendix 2 [28,40-51]; 13 studies were 2-arm RCTs (compared DHIs with usual care), 1 study was 3-arm RCT (compared with DHIs add on cognitive behavioral therapy [CBT], only CBT, and usual care) [19], 1 study was non-RCT [52], and 1 study was quasi-experimental study [53], published between 2005 and 2022 (Figure S1 in Multimedia Appendix 2). Studies were conducted in Europe (n=7), America (n=5), and Asia (n=4). The total number of participants in the included studies was 1467.

Figure 2 presents the characteristics of home-based DHIs. In terms of the purpose and content of home-based DHIs, most of the included studies (14 of 16) used multiple categories within each study. Two studies focused solely on communication and feedback. The common categories identified in this dimension were communication and feedback (n=15), education (n=12), telerehabilitation (n=7), health coaching (n=3), and remote monitoring (n=2). Regarding the mode of delivery, the majority of studies (13 of 16) used a single mode of delivery, while 3 studies used combined modes. The reported modes of delivery included telephone calls (n=10), web-based software platforms (n=5), mobile apps (n=3), and sensor-based technologies (n=1). The involvement of health care providers in DHIs varied. PTs were involved in 6 studies, OTs in 3 studies, physicians in 2 studies, nurses in 2 studies, dieticians in 2 studies, and a multidisciplinary team in 1 study.

The majority of research indicates that home-based DHIs have shown a beneficial effect on mobility and physical function, as evidenced by improvements in scores on tests such as TUG, SPPB, and FIM [28,40-43,52]. Furthermore, these studies suggest that home-based DHIs are feasible for enhancing various aspects of hip fractures after surgery, such as improving physical function (daily activities and instrumental activities of daily living) [19,44,53], improved adherence for self-care [45], enhancing nutritional intake and status [46,47], and potentially preventing urinary incontinence and reducing its frequency [48] (Table 1).

Ten of 16 studies had low risk of bias, 4 studies had some concerns, and 2 studies had high risk of bias (Figure 3 [19,28,40-45,47-51] and Figure 4 [52,53]). In the GRADE assessment of the quality of evidence across all outcomes, findings revealed moderate quality of evidence for TUG based on 4 studies, SPPB based on 4 studies, and for FIM based on 2 studies. (Table S4 in Multimedia Appendix 2). The forest plot analysis demonstrated that home-based DHIs resulted in a significant decrease in the TUG score (mean difference=–7.89; 95% CI –10.34 to –5.45; P<.001), improvement in SPPB score (mean difference=1.11; 95% CI 0.51-1.72; P<.001), and improvement in FIM score (mean difference=7.98; 95% CI 5.73-10.24; P<.001). Heterogeneity was low in both TUG (I²=0.00%; P<.53) and FIM scores (I²=12.62%; P<.32). However, substantial heterogeneity was observed in SPPB scores (I²=61.50%; P<.05). These findings are shown in Figures 5-7, respectively.

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Discussion

Principal Findings

In this systematic review, we described the characteristics of home-based DHIs in postoperative care for older patients with hip fractures. Our findings revealed that the majority of home-based DHIs encompassed multiple components in terms of purpose and content. Furthermore, we observed that these interventions were typically delivered through a single mode of delivery and were provided by health care professionals. Importantly, our meta-analysis demonstrated that home-based DHIs were effective in improving functional outcomes for older patients during the postoperative phase of care for hip fractures.

Home-based DHIs in older patients with hip fractures after surgery were first described in 2005. This upward trend can be attributed to the use of DHIs in clinical care for various conditions, including frailty [17], diabetes mellitus [54], and chronic disease [55]. We found that the frequency of research on DHIs for older individuals with hip fractures increased due to the aging population on the continent and the development of DHIs following the COVID-19 pandemic [23]. Subsequently, policy briefs for DHIs were adopted and implemented, incorporating a highly developed health care infrastructure with advanced information technology systems, financial support, and health care provider training [56]. Looking ahead, it is predicted that the role of DHIs will continue to expand in line with the global strategy for digital health 2020-2024 [57] and the WHO guideline recommendations on digital interventions for health system strengthening in 2018 [15].

The majority of studies used multicomponent approaches, considering the purpose and content of home-based DHIs in postoperative care for older individuals with hip fractures. Freitag and Magaziner [24] recommended that postoperative care in this population may require multiple interventions provided individually or through coordinated management. In this study, the most common categories of purpose and content were communication and feedback, combined with education in areas such as rehabilitation [40-42,51-53], fall prevention [50], and osteoporosis [49]. A lack of knowledge and awareness was identified as an important barrier for self-care [58]. During the postoperative period, patients with hip fracture and their caregivers receive numerous recommendations, including early ambulation, exercise and rehabilitation programs, preventing postoperative complications, modifying home hazards, and taking nutrition supplements [24]. Therefore, effective communication skills with specific feedback are crucial for delivering accurate knowledge and information and ultimately leading to positive functional outcomes [24,59,60].

Telerehabilitation was the third most common content of home-based DHIs. It is essential for every patient with a hip fracture to receive rehabilitation in some setting, including outpatient rehabilitation, nursing homes, and home care. Rehabilitation is one of the most crucial aspects of postoperative care, as it contributes to recovering functional outcomes, patient ability, and overall quality of life [24]. Crotty et al [61] found that a home-based rehabilitation program yielded similar outcomes and placed less burden on caregivers compared with a hospital program. Following the COVID-19 pandemic, telerehabilitation has gained even greater significance in clinical care for patients with postoperative hip fracture. According to Seron et al [22], the most common interventions in telerehabilitation include therapeutic exercises, functional training, and education. Therefore, telerehabilitation is a vital option for rehabilitation as it reduces hospital visits, decreases the cost of hospital visits, and still enhances functional outcomes.

The telephone call was the most common mode of delivery in this study and previous studies due to its ease of use, availability in most households, and effectiveness in communicating and providing simple educational information to patients and their families [24,60]. This is especially true in the Thai context, where a high number of older adults do not use the internet in their everyday lives. Therefore, using telephone calls should enhance the chance for accessing care with DHIs. Multiple episodes of telephone calls may increase adherence and functional outcomes more than a single telephone call [43,50]. However, based on our findings, using the telephone alone was less likely to achieve the goal of improving functional outcomes than other modes of delivery for patients with postoperative hip fracture. The limitations of telephone calls include only voice evaluation and advice and the absence of video connection. Telephone calls are limited when health care providers need to assess patients and provide exercise programs through video calls [62]. Therefore, telerehabilitation should use web-based software or mobile apps as the mode of delivery. Both platforms can provide real-time or on-demand video calls and chat, allowing for the delivery of rehabilitation programs, tracking of progress, and modification of the program based on the patient’s status [24].

Most studies used only 1 health care provider who played an important role in this intervention. The top 2 providers were PT and OT, who addressed the population's rehabilitation needs during the recovery phase. They provided instructional materials and self-management guidance at home, leading to improvements in functional abilities, as shown by the results. However, a program that included only dieticians did not have evidence of improving the patients' status. This detail could be an insightful consideration for providers when developing care programs. While nutritional improvement is required following orthopedic surgery [63], focusing solely on nutrition may not be sufficient for patients to recover from their postoperative condition; a combination of nutrition and physical therapy interventions can maximize function [64]. Therefore, to provide home-based DHIs, health care providers should allow patients and families access to a specific scope of care that includes a rehabilitation program. In addition, given the complexity of hip fracture patients, a multidisciplinary approach is essential, typically involving early geriatric assessment [24]. This approach can enhance functional outcomes, reduce hospital stays, and decrease the future need for institutional care. Although the evidence regarding the effectiveness of multidisciplinary teams in this population is unclear [23], holistic care, such as holistic assessment, rehabilitation, and nutrition, remains important.

In the meta-analysis, it was found that home-based DHIs have a positive impact on enhancing functional outcomes by improving scores on tests such as TUG, SPPB, and FIM even after the interventions end [19,28,40-53]. The differences in population caused variances in the mean difference of TUG reduction. Although this study demonstrated that home-based DHIs have a positive impact on enhancing functional outcomes, further studies may be needed across other functional outcomes to provide a comprehensive summary of the results. The characteristics of home-based DHIs that were associated with increased functional outcomes included a combination of telerehabilitation, effective communication and feedback, and educational components. The modes of delivery commonly used were web-based software, and mobile apps, similar to previous literature [23]. Whether it involves a multidisciplinary team or a single health care provider, the inclusion of physical therapy content in home-based DHIs was found to improve functional outcomes. These findings highlight the importance of incorporating rehabilitation or physical therapy content through telehealth care. This may be particularly beneficial in the context of orthopedic surgery, where reduced limb usage can lead to muscle weakness and functional disability [65]. By enhancing movement through appropriate rehabilitation, improvements in range of motion, muscle strength, and overall performance can be achieved [65]. In addition, this study demonstrated that home-based DHIs potentially have a positive impact on improving physical function and activities of daily living, self-care, and nutritional status. Further studies may be needed to provide a comprehensive summary of these results. Future research should aim to include a larger number of studies reporting patient outcomes, ensure consistency in time points for outcome assessment, and explore the effectiveness of DHIs in diverse populations with hip fractures. For example, this could involve studying different underlying health conditions, various types of hip fractures or surgeries, or varying levels of functional impairment. Such research can help identify which subgroups benefit most from home-based DHIs. In addition, further research on cost-effectiveness of home-based DHIs compared with traditional interventions can inform health care decision makers and potentially lead to more widespread adoption of these approaches.

Limitations

In this study, we demonstrated the common characteristics of home-based DHIs that have shown benefits in improving functional outcomes. This finding holds promise for the development of home-based DHIs aimed at enhancing functional outcomes. However, it is important to acknowledge the limitations encountered during the study. First, only a limited number of studies (6 in total) reported the functional outcomes of interest, which may restrict the generalizability of our findings. Second, although a summary analysis of functional results was conducted, the time points at which these outcomes were measured varied among the included studies. The duration of the intervention itself could potentially impact the observed differences in outcomes. Third, most studies did not specify the type of hip fracture and the type of surgery. Their populations were characterized as patients with hip fractures. The specific type of hip fracture was presented only in 2 studies. Consequently, we were unable to conduct a subgroup analysis. Moreover, it is important to note that our study exclusively focused on DHIs used in the care of postoperative populations with hip fractures. This narrow scope may limit the applicability of our findings to nonsurgical hip fracture populations, where the intervention strategies and approaches may differ. Furthermore, our meta-analysis mainly focused on functional outcomes, but there are other factors that impact patient overall outcomes, such as fear of falling, pain control, and caregiver burden, which have not been conclusively examined in this study. These limitations should be taken into consideration when interpreting the results.

Conclusions

Overall, our findings suggest that home-based DHIs, particularly those incorporating telerehabilitation, offer a promising approach to enhance the recovery and functional abilities of older patients following hip fracture surgery. These interventions have the potential to improve the quality of care and patient outcomes in this population. Further research and implementation of home-based DHIs are warranted to fully leverage their benefits in postoperative care for older patients with hip fractures.