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As a result of an aging population, there has been an increasing incidence of hip fractures worldwide. In the Netherlands, in order to improve the quality of care for elderly patients with hip fractures, the multidisciplinary Centre for Geriatric Traumatology was established in 2008 at the Department of Trauma Surgery at Ziekenhuisgroep Twente hospital (located in Almelo and Hengelo in the Netherlands).
Though the Dutch Hip Fracture audit is used to monitor the quality of care for patients with fractures of the hip, only 30.7% of patients complete registration in the 3-month follow-up period. Mobile apps offer an opportunity for improvement in this area. The aim of this study was to investigate the usability and acceptance of a mobile app for gathering indicators of quality of care in a 3-month follow-up period after postoperative treatment of hip fracture.
From July 2017 to December 2017, patients who underwent surgical treatment for hip fracture were recruited. Patients and caregivers, who were collectively considered the participant cohort, were asked to download the app and answer a questionnaire. Participants were divided into two groups—those who downloaded the app and those who did not download the app. A telephone interview that was based upon the Unified Theory of Acceptance and Use of Technology was conducted with a subset of participants from each group (1:1 ratio). This study was designated as not being subject to the Dutch Medical Research Involving Human Subjects Act according to the appropriate medical research ethics committees.
Of the patients and caregivers who participated, 26.4% (29/110) downloaded the app, whereas 73.6% (81/110) did not. Telephone interviews with the subset of participants (n=24 per group) revealed that 54.0% (13/24) of the group of participants who did not download the app had forgotten the study. Among the group who downloaded the app, 95.8% (23/24) had the intention of completing the questionnaire, but only 4.2% (1/24) did so. The reasons for not completing the questionnaire included technical problems, cognitive disorders, or patient dependency on caregivers. Most participants in the group who downloaded the app self-reported a high level of expertise in using a smartphone (22/24, 91.7%), and sufficient facilitating conditions for using a smartphone were self-reported in both groups (downloaded the app: 23/24, 95.8%; did not download the app: 21/24, 87.5%), suggesting that these factors were not barriers to completion.
Despite self-reported intention to use the app, smartphone expertise, and sufficient facilitating conditions for smartphone use, implementation of the mobile app was infeasible for daily practice. This was due to a combination of technical problems, factors related to the implementation process, and the population of interest having cognitive disorders or a dependency on caregivers for mobile technology.
As a result of an aging population, the global incidence of hip fractures has been increasing with an estimated 6.25 million per year expected by 2050 [
The proportion of patients who register to provide information regarding functional recovery is poor; only 30.7% of Dutch Hip Fracture Audit registrations are completed [
There has been ongoing worldwide interest in home telemonitoring to support the health and vitality of the community-dwelling elderly population which has led to promising strategies for improving health care and health management [
The primary goal of this study was to investigate the real-world use of a mobile app for monitoring postoperative functional recovery after hip fracture. The secondary goals were to analyze mobile app usability and acceptance among elderly patients and their caregivers. Usability and acceptance were considered to facilitate conditions for use, but were not presumed to lead automatically to use.
The mobile app platform was developed by technical experts, is currently used, and has previously been used in studies of postoperative outcome with a high rate of use [
Patients with a hip fracture who had undergone surgical treatment between July 2017 and December 2017 at the Centre for Geriatric Traumatology of the Department of Trauma Surgery at Ziekenhuisgroep Twente hospital were recruited to participate in the study and asked to download the app in addition to their regular 3-month outpatient visit (the recruitment process is summarized in
Study design flowchart.
One week later, participants received a code by mail to activate the questionnaire in the downloaded app. Completion of the questionnaire was restricted to a period between 12 weeks and 18 weeks after their operation. A push notification with a request to complete the questionnaire was sent to the participant 12 weeks after they had been discharged from the hospital. A push notification was also sent to the health care provider at 17 weeks for unfilled questionnaires.
Completed questionnaires were saved in OpenLine (a specialized health care hosting center) in accordance with Dutch legislation with respect to security standards. The local researcher applied for the data from the hosting center. Participants were anonymized and coded using a study number without any reference to patient number or date of birth. Only the local researcher had access to the participant study numbers. All data were treated confidentially and saved to the secured hospital network with a password.
To investigate usability and participant acceptance of the mobile app, an interview questionnaire was developed (
Two questions regarding participant recollection of the intended purpose of the study and feedback on the use of the app were added to the interview. These questions were added because we were interested in obtaining feedback on the app and on the duration of the interval from when the information was given (from July 2017 to December 2017) to when the telephone interview took place (in May 2018). A single researcher conducted all interviews. Participants were given the option to stop the telephone interview at any time.
Data were collected from the clinical charts of the patients who participated themselves or whose caregivers participated. Age, gender, type of fracture, American Society of Anesthesiologists physical classification status, Charlson Comorbidity Index [
Statistical analyses were performed using SPSS software (version 22.0; IBM Corp). We used thematic analysis with a deductive theoretical approach to analyze the written answers to the recalled purpose of the study and feedback questions [
This study was been designated as an observational study not subject to the Dutch Medical Research Involving Human Subjects Act by the appropriate medical research ethics committees.
Categorical variables are described as numbers with corresponding percentages. Continuous variables are described as the mean with standard deviation, or for nonparametric data, as the median with interquartile range.
Patient characteristics are shown in
Baseline patient characteristics.
Characteristics | All (N=110) | Downloaded app (n=24) | Did not download app (n=24) | Chi-square ( |
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Age (years), mean (SD) | 80.5 (10.4) | 82.0 (8.7) | 78.4 (10.8) | 1.28 (46) | .21 | ||||||
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1.0 (1) | >.999 | ||||||
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Male | 31 (28.2) | 7 (29.2) | 7 (29.2) |
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Female | 79 (71.8) | 17 (70.8) | 17 (70.8) |
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0.595 (2) | >.999 | ||||||
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Neck of femur | 64 (58.2) | 13 (54.2) | 14 (58.3) |
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Pertrochanteric | 40 (36.4) | 10(41.7) | 10 (41.7) |
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Subtrochanteric | 6 (5.5) | 1 (4.2) | 0 (0.0) |
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1.0 (1) | >.999 | ||||||
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1-2 | 40 (36.4) | 9 (37.5) | 9 (37.5) |
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3-4 | 70 (63.6) | 15 (62.5) | 15 (62.5) |
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1.0 (3) | >.999 | ||||||
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0-1 | 32 (29.1) | 7 (29.2) | 8 (33.3) |
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2-3 | 13 (11.8) | 2 (8.3) | 3 (12.5) |
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>4 | 6 (5.4) | 1 (4.2) | 0 (0.0) |
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Unknown | 59 (53.6) | 14 (58.3) | 13 (54.2) |
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Dementia, n (%) | 13 (11.8) | 0 (0.0) | 5 (20.8) | 0.06 (1) | .05 | ||||||
Prefracture Katz ADLb score (out of 6), median (IQR) | 1.0 (2.0) | 1.2 (1.6) | 2.2 (2.3) | — | .10 | ||||||
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0.578 (4) | .73 | ||||||
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Freely mobile without aids | 40 (36.4) | 8 (33.3) | 6 (25.0) |
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Mobile outdoors with one aid | 2 (1.8) | 1 (4.2) | 0 (0.0) |
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Mobile outdoors with two aids or frame | 30(27.3) | 8 (33.3) | 7 (29.2) |
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Some indoor mobility but never goes outside without help | 36 (32.7) | 7 (29.2) | 10 (41.7) |
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No functional mobility (using lower limbs) | 1 (0.9) | 0 (0.0) | 1 (4.2) |
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Unknown | 1 (0.9) | 0 (0.0) | 0 (0.0) |
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0.327 (2) | .50 | ||||||
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Independent | 87 (79.1) | 21 (87.5) | 19 (79.2) |
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Care home | 7 (6.4) | 2 (8.3) | 1 (4.2) |
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Nursing home | 14 (12.7) | 1 (4.2) | 4 (16.7) |
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Protected housing | 2 (1.8) | 0 (0.0) | 0 (0.0) |
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aASA: American Society of Anesthesiologists.
bKatz ADL: Katz Index of Independence in Activities of Daily Living.
Of the participants (29/110, 26.4%) who downloaded the mobile app, only 1 (1/29, 3.4%) completed the app questionnaire.
Participants characteristics of those who participated in the telephone interviews are presented in
Comparison of baseline characteristics between the use (participants downloaded the app) and nonuse (participants did not download the app) groups.
Variables | Both groups (n=48) | Use (n=24) | Nonuse (n=24) | Chi-square ( |
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Age (in years), mean (SD) | 57.3 (10.3) | 56.9 (9.8) | 57.8 (10.9) | –0.279 (46) | .78 | |
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1.0 (1) | >.999 | |
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Male | 14 (29.2) | 7 (29.2) | 7 (29.2) |
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Female | 34 (70.8) | 17 (70.8) | 17 (70.8) |
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0.133 (4) | .14 | |
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Patient self | 5 (10.4) | 3 (12.5) | 2 (8.3) |
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Partner | 5 (10.4) | 1 (4.2) | 4 (16.7) |
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First-degree relative | 34 (70.8) | 20 (83.3) | 14 (58.3) |
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Second-degree relative | 3 (6.3) | 0 (0.0) | 3 (12.5) |
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Other | 1 (2.1) | 0 (0.0) | 1(4.2) |
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0.008 (2) | .004 | |
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<5 | 3 (6.3) | 2 (8.3) | 1 (4.2) | 0.551 (1) | >.999 |
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5-10 | 8 (16.7) | 0 (0.0) | 8 (33.3) | 0.002 (1) | .004 |
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>10 | 37 (77.1) | 22 (91.7) | 15 (62.5) | 0.016 (1) | .04 |
Use of apps on a smartphone, n (%) | 48 (100) | 24 (100) | 24 (100) | — | >.999 | |
Self-registered expert level, n (%) | 44 (91.7) | 23 (95.8) | 21 (87.5) | 0.296(1) | .61 |
Questionnaire results are presented in
A thematic analysis was conducted to evaluate patient recollection of the study’s purpose. Participant responses (transcribed excerpts are presented in
The study purpose was correctly remembered by 62.5% (15/24) of the use group participants compared to only 20.8% (5/24) in the nonuse group; 50% (12/24) of the participants in the use group said that they did not receive a smart phone notification with the request to complete the questionnaire which suggested a suboptimal implementation process.
Completion of 3-month mandatory functional monitoring is poor among patients with fractures of the hip, which may result in a suboptimal monitoring of quality of care. This single-center pilot study to investigate the use and to analyze the usability and acceptance of a mobile app for monitoring postoperative functional recovery after hip fracture revealed poor results for actual use of the mobile app despite high self-reported intention to use the mobile app, high self-reported expertise in using mobile apps, and conditions that facilitated the use of mobile apps. This suggests that participants had the goal of using the mobile app, but that better support was needed to properly implement the technology in health care.
For many years, apps have been regarded as an alternative to paper questionnaires, but the use of apps may have difficulties as well, especially when implemented in a population of community-dwelling older patients [
The low percentage of app downloads could partially be explained by an inability of the patients or caregivers to correctly remember the information that was provided to them in the hospital possibly as a result of stress [
One participant completed the app questionnaire after downloading the app. This participant showed an active approach by contacting the app developers and completed the questionnaire with assistance from the developers.
A high percentage of the participants (34/48, 70.8%) who were interviewed were caregivers who were first-degree relatives of the patient. Study information was provided independently of whether a caregiver was present at the time of information provision; therefore, it is possible that some first-degree relatives were not provided with the study information if they were absent during recruitment.
The telephone interview findings demonstrated that many in the use group had the intention of completing the questionnaire. This indicates that those participants were motivated to complete the app questionnaire. In the nonuse group (11/24, 45.8%), participants remembered the study, and 10 out of the 11 intended to download the app. Given this result, there seems to be a good level of intention in both groups. Facilitating conditions, such as facilitated help, were high in both groups and were not a restrictive factor for app usage [
Findings revealed intention to use the mobile app, but very low actual usage. The use of a mobile app as it was implemented in this study was not feasible, but the study findings suggested a potential for use if implemented properly. First, technical issues should be solved, and a helpdesk should be made available. Second, it is recommended to involve participants in the development and implementation phases—doing so can optimize ease of use and acquiring feedback during implementation is a feasible goal. Third, information provision needs to be optimized in terms of timing and method of dissemination. It is important to supply additional information after discharge in order to prevent low download rates as a result of patient or caregiver stress during admission [
Selection bias in the downloading group represents a threat to validity, as patients or caregivers already intended to participate in the study by downloading the app.
The use of a mobile app to monitor 3-month postoperative functional outcome of hip fracture was low. Despite intention, expertise, and sufficient facilitating conditions for using smartphones, the implementation of the mobile app in this study was demonstrated to be infeasible. Reasons for this included a technical problem, the implementation process, and population of interest having cognitive disorders or a dependency on caregivers for mobile technology.
Telephone interview questionnaire.
Questionnaire results.
Excerpts from participant responses.
None declared.