The Suitability of Measuring Patient-Reported Outcomes in Older Adults Following a Hip Fracture Using the Short-Form 36 Questionnaire: A Qualitative Description Approach

Abstract

Hip-fractures (HF) in older adults are associated with poor outcomes and high costs. Measuring quality-of-care of HF patients has focused on clinical definitions rather than on measuring outcomes that are meaningful to the patient. Healthcare systems worldwide are increasingly interested in patient-reported outcome measures (PROs). The Short-form (SF36) questionnaire is a recommended measure among older adults however it’s comprehensiveness and uniqueness for specific patients after a HF is not clear. The aims of this study were to: understand the perspective of the older adults experience following HF, to assess the suitability of the SF36 as a PRO for HF and to determine the best timing for questioning. A qualitative description approach was used. This took place in 2 large academic medical-centers in Israel. The inquiry was done in 2 parts by semi-structured interview. A total 15 HF patients were interviewed. Categories and themes emerging from their responses were similar to the 8 domains of the SF36 questionnaire, but the participants added clarity regarding their own needs for setting goals. In the second part, participants agreed that the SF36 reflected common issues and served as an adequate measure for personal-goal setting. The study encourages patient-centered care in older adults recovering from HF, providing evidence that the SF36 is a suitable tool for measuring PROs in HF patients. Healthcare systems focus on clinical-outcome indicators and do not reflect how the patient views his outcomes. This study provides evidence that care should be customized for each person.

• What do we already know about this topic?

• Measuring quality of care and outcomes of patients with hip fractures has focused on clinical definitions rather than on measuring outcomes that are meaningful to the patient.

• How does your research contribute to the field?

• The novelty of our study is that the Short-form-(SF)36 reflected the experience of patients that have recovered from a hip fracture using a qualitative approach; patient-centered information can help facilitate joint decision making regarding the goals of the medical treatment during rehabilitation.

• What are your research’s implications toward theory, practice, or policy?

• Our findings suggest that health professionals can incorporate quality measures and discussions of care plans during the recovery period using the SF36 questionnaire for patient reported outcome measurements (PROs).

Introduction

Hip fractures (HF) in older adults are associated with poor outcomes and high costs.^1,2 Traditionally, clinical definitions are the key measures used to assess quality of care of HF patients^3,4 and not outcomes that are meaningful to patients. ² In recent years there has been an increase in using patient reported outcomes (PROs) in healthcare.^5,6 Patient centered care is one of the acknowledged dimensions of healthcare quality. ⁷ PROs can be combined with personal goal setting and be a key element in goal-oriented patient care. ⁶ Although there has been a growing understanding of the importance of PROs in healthcare, there is still difficulty with their implementation.^8,9 Low response rates have resulted in the lack of representation of clusters of patients and an unbalanced, biased measurement.^10,11 Survey length and complexity have been reported as the most significant barriers in the routine use of PROs. ¹² - In the few countries that measure PROs in HF patients’ response rates are low with an explicit lack of representation in older adults.^13,14 The aging world population and the predictable increase in the incidence of HF emphasize the urgent need to find a solution to improve the compliance rate to tools such as PROs.

The Short Form (SF) 36 is a self-reporting measure that consists of 36 questions in 8 topics: physical functioning, physical role limitation, bodily pain, general health, vitality, social functioning, emotional role limitation, and mental-health.^15-17 Though the SF36 is a general questionnaire it does address specific conditions and functionality, and is also significantly shorter (5-15 vs 20-30 min for completion) than the condition-specific questionnaire, the Osteoporosis Assessment Questionnaire. ¹⁸ It is the most evaluated measure among HF patients ¹⁹ and has been chosen as a PRO in older adults ²⁰ with multiple chronic conditions. ²¹ However, there remains a question about the patient’s perceived adequacy of the SF36 as a PRO for HF patients.

The first step in developing PROs is to understand the patients’ perspectives. Taking a qualitative description approach in this process provides clearer understanding of what is important for the patient for recovering and function. The aims of this article are: (1) to understand the perspective of the patient’s experience of rehabilitation following HF, (2) to assess whether the SF36 tool is an appropriate PRO tool to best measure the outcomes patients are most interested in, and (3) to assess patients’ perspectives regarding the timeline for completing such a questionnaire.

Methods

This study utilized a qualitative description approach ²² who Polit and Beck ²³ found to be appropriate when perusing a focused naturalistic inquiry. Qualitative Description (QD) was used as described by Kim et al ²² as a method to understand a phenomenon in a straightforward manner specifically from the participants perspectives regarding a specific phenomenon (HF recovery). Since this was not a broad topic of inquiry, it met with the need for specific perspectives of HF recovery (semi-structured interviews) using the subject’s own language. As opposed to a narrative approach using participant stories, this study was more focused on what happened in the HF recovery process.

Theoretic purposive sampling of patients following HF was used. Medical records of patients over age 60 hospitalized with HF during the years 2020 to 2021 in 2 large academic medical centers in Israel, were reviewed. Patients with severe dementia, under 60, or those who did not speak Hebrew (the language of the questionnaire) were excluded. Forty-four participants were contacted; 29 of them declined participation for several self-reported reasons: health issues, hearing difficulties, or other reasons. During June to December 2021, 2 groups of participants that had been treated in the rehabilitation department (the first had 2 females and 1 male and the second group had 4 female participants) and 8 individuals, from inpatient and home rehabilitation departments (2 males and 6 females) were interviewed. Making for a total of 15 participants. All the participants were recruited 1 to 1.5 year following the HF. Before the interview took place, informed consent was obtained from all the participants. See Table 1 for description of study participants.

Table 1.

Characteristic of Participants.

	n (%)
Sex
Female	12 (80)
Male	3 (25)
Age (years)
70-75	4 (33)
76-84	9 (60)
85+	1 (6)
Rehabilitation
At home	4 (26)
In hospital	11 (73)

Data Collection

The PI is a female nurse researcher PhDc, MPH, with training in qualitative methods, and the co-PI is a male physician with extensive knowledge and experience in taking care of patients in rehabilitation after a HF. No prior relationship existed between the PI and the participants. The participants in the focus groups were acquainted with the co-PI. Before the interview, the PI introduced herself as a PhDc researcher who is doing the interviews. The PI conducted all the data collection while ensuring consistency throughout the data collection. The PI and co-PI interviewed the groups together, and the PI alone conducted the 8 individual interviews. The other team members, 2 senior male physician researchers with experience in qualitative research and 2 senior orthopedic surgeons that take care of HF patients on a daily bases, participated in data analysis, coding and identifying the themes. A senior female researcher with extensive experience in qualitative research applied the consolidated criteria for reporting qualities research (COREG) ²⁴ review and provided feedback for another level of analysis.

The study used a mix of focus groups as well as individual interviews. Two focus groups were done by video-conference, due to Covid-19 distancing restrictions, with 3 and 4 participants in each group. In addition, 8 individual interviews were conducted.

Open-ended questions concerned the physical and emotional personal goals of rehabilitation as well as the participant’s view of optimal timing for administration of the questionnaire. The open-ended questions were created by a panel of specialists in: geriatrics, orthopedics, rehabilitation, qualitative methods, and research. The specific questions portion of the interview (see Table 2 with the interview guide questions) included verification of whether specific questions in the SF36, that has been found to be valid, sensitive and responsive in patients after HF in several countries and languages including in Hebrew,^25--29 were applicable, in the opinion of the study participant.

Table 2.

Interview Guide Questions.

• What outcomes were most important for you to promote during rehabilitation?

• What functional (physical) goals were important for you to achieve during your rehabilitation? (examples if needed: walking independently, showering and getting dressed on your own, climbing up and down stairs, going to the grocery shop)

• What goals relating to bodily pain were important for you to gain during rehabilitation?

• What emotional goals were important for you to achieve/overcome during your rehabilitation? (examples if needed: depression, nervousness, lack of energy, fatigue)

• Patient-reported outcome measures are usually asked several times throughout the treatment. When do you think it is important to ask them?

Semi-structured interview

The interviews were conducted via video-conference and telephone, with simultaneous note taking. The interviews lasted from 30 to 90 minutes for a total of 14 hours. Interview data continued to be collected until the point of saturation whereby the researchers agreed that the same points were being stated over and over.

Rigor

Rigor and trustworthiness were obtained in several ways. Qualitative Rigor: Used to show trust and confidence in the research team, findings, and conclusions. The Lincoln and Guba Framework ³⁰ from 1985 confirming overall trustworthiness of the presented research was used to demonstrate rigor in this study and described as (1) credibility (believability); (2) transferability (can the results of this study apply to other situations); (3) dependability (would this happen again in another group of participants if the study were repeated); and (4) confirmability (that it is indeed the participants perspectives and not biased by the researcher). ³¹

Establishing researcher authority included the research team involvement. The PI is a research nurse experienced in HF patients. There was an orthopedic surgeon with 40± years of experience, a researcher with 30± years of experience and the co-PI with 20± years of experience in geriatric rehabilitation. According to Forero et al ³⁰ the research team needs to be familiar with the content, have good research skills, be experienced in qualitative research, and finally have a multi-disciplinary approach.

In order to establish credibility, the researcher immersed herself into the ward with HF patients over a period of 8 months. She personally interviewed all of the participants after conducting 1 to 2 pilot interviews to check the semi-structured interview questions for understandability and thoroughness. She subsequently conducted all of the interviews and 2 focus groups; field notes, and observations and subsequently translated the data into English from Hebrew. She transcribed manually all of the English interview data for analysis. The data was reviewed with her research team to check for confirmability. For final confirmability the data was reviewed by an independent peer researcher experienced in analyzing and reporting qualitative research.

The independent peer reviewer confirmed the believability of the data and that this was the perspectives of the participants (confirmability). The data analysis was subsequently submitted to other multi-disciplinary members of the team to assess for transferability and dependability. All agreed that the data did indeed reflect the perspectives of the participants, and could be generalized to other populations. After following these steps the researcher was able to confirm rigor in the findings.

With regards to dependability, the data was compared to the theoretical underpinning of the SF36 and triangulated to demonstrate the congruence of the analysis with the SF36. The peer reviewer worked with the PI to develop categories and themes. Most importantly the peer reviewer was blinded to the content of the SF36 until the final level of data analysis. Thus, confirmability and credibility was assessed after comparing the qualitative analysis with the SF36 parameters.

Data Analysis

Data gleaned from the interviews (individual and group interaction data) were coded and reduced to categories and themes. Words used repeatedly were processed as “codes.” The codes were then collapsed into categories and themes based on construct similarity (see Figure 1). The second part of the interviews’ data were focused on a priori knowledge of the existing themes of the SF36. The participants provided feedback regarding the use of PROs and suggested time of questioning.

Figure 1.

Conceptual map.

In the last stage of analysis, a comparison was done of themes that arose from the data with the themes in the SF36 as PROs for patients after HF. This stage of analysis exemplified the PRO map (see Figure 1).

Ethics Approval

The study was approved by the ethics committees at both medical centers (number SMC-7933-20) and (number HMO-0691-21).

Results

The researchers identified 3 major themes significant to the study participants’ perceptions of goals and outcomes during rehabilitation: (1) Uniqueness (2) Physical needs (3) Roles: physical, social, emotional. From the major themes, 14 categories were identified that corresponded to each theme. See Table 3 for details and supporting quotes.

Table 3.

Summary of Themes and Categories, With Supporting Quotes.

Theme	Category	Supporting quotes
(1) Uniqueness	(1.1) PROs identify needs post HF	“Personal attention and listening to the patient can help lead to tailored treatment. Every person is different; accordingly, it is important to listen and adapt the treatment.” (P8)
		“When you speak and the staff listens to you it is part of the treatment.” (P6)
		“It’s a shame no one asked me the questionnaire 2 year ago” (when he was in rehabilitation.) (P1)
	(1.2) Ageism, falls and fractures, and old-age	“I felt that I am a cliché, that I’m a ‘falling old man’. It depressed me.” (P2)
		“It is very important to ask patients what they want from the treatment, what the patient’s expectations are from the treatment, even though we are older women.” (P11)
(2) Physical needs	(2.1) Physical functioning	“It was important for me to be able to shower alone and climb stairs. . .to get up from the chair alone. . .I like to be independent and I wanted (to return) to be independent.” (P10)
	(2.2) Independence
	(2.3) Therapy	“The therapy was only a few days a week and for only 20 min.” (P15)
		“The physiotherapists were good, but the time with them was not enough.” (P4)
	(2.4) Rehabilitation/training	“The treatments were only in the mornings. We would have liked to have treatments in the afternoon as well.” (P6)
(3) Roles: physical, social, emotional	(3.1) Physical role	“I was disconnected from many things because of the fracture. I did not return to my preoccupations with my family. I did not attend social events, lectures and classes.” (P14)
		“Before the fracture I used to work at home and outside.” (P15)
		“It was very important for me to be able to take care of my dog. To go out on walks with him.” (P5)
	(3.1.1) Bodily pain	“The most important thing is pain management. . .It’s very important and basic to ask (the patient) about pain.” (P8)
		“I was in terrible pain. . .they gave me a pill but it still hurt.” (P1)
	(3.1.2) Vitality	“I did not feel depressed because I was quite determined to get back to myself. Usually when I am determined, it works. . .I was quite positive. I hoped everything would work out.” (P14)
		“Morale is most important.” (P12)
	(3.2) Social role	“I have a broad support system. . .the children came to help, also the grandchildren. It made it very easy for me.” (P15)
		“I was lucky to have a nice roommate. We would do walks along the ward together. We connected with others too.” (P12)
	(3.3) Emotional roles	“I only go out with family.” (P15)
	(3.3.1) Fear of falling	“If I did not have this button (hand-wrist distress button) you would not be talking to me now.” (P14)
		“There is a lot of fear that has to do with the fall. It is a trauma.” (P2)
	(3.3.2) Fear of an uncertain future	“It’s a bomb that falls on you on a clear day. Suddenly a person who was active becomes handicapped.” (P14)
		“The time you spend in the hospital is very scary. You do not know what will happen, how things will end up. It is important to ask the patients (how they feel).” (P9)
	(3.3.3) Moodiness, guilt, and sadness	“I felt depressed, sad and anxious. I lost my confidence but did not get treatment for it. I think this is an issue that is important to address during rehabilitation.” (P4)
		“The mind and moodiness happens because I am not capable of the physical (functions) so I get stressed.” (P15)
		“I felt guilty, I was terribly sad that I was there (in the hospital) I realized that I would no longer be the same person I was before. I was very worried about how I would manage.” (P7)
		“From the outside they did not see (how I felt). I was the ‘main attraction’ in the department. However, on the inside I was in a bad mood.” (P4)
		“I did not feel sad. But I know other people did feel sad.” (P8)

Uniqueness

PROs identify needs post-HF

All the participants agreed that integrating PROs would be helpful for the rehabilitation process. As one stated “Personal attention and listening to the patient, can help lead to ‘tailored’ treatment. Every person is different, accordingly it is important to listen and adapt the treatment” (P8). Another agreed “When you speak and the staff listens to you it is part of the treatment” (P6).

Ageism, falls, fractures, and old-age

Association of the fall and the fracture with self-perception as old and self-reflected ageism was evident in most of the interviews. Some felt that their age would have a negative effect on how the medical staff perceived them, and that the staff would dispute their capabilities or even their goals during rehabilitation. One of the participants summed it by saying, “It is very important to ask patients what they want from the treatment, what the patient’s expectations are from the treatment, even though we are older women” (P11).

Physical Needs

Physical functioning and independence

Focusing on goals that relate to physical functioning during rehabilitation after HF emerged in all the interviews. For most, the goal was to return to the functional abilities they had prior to the fracture, including ability to walk independently, climbing stairs, showering, using the restroom independently and dressing without assistance. To quote “it was important for me to be able to shower alone and climb stairs. . .to get up from the chair alone. . .I like to be independent and I wanted (to return) to be independent” (P10).

Therapy and rehabilitation training

Having sufficient time with the physiotherapist was emphasized as necessary for achieving the goal of regaining physical functioning. Almost all the participants indicated that physio time did not meet their needs. Participants at home rehabilitation indicated that “it was only a few days a week and for only 20 min” (P15). “The physiotherapists were good, but the time with them was not enough” (P4). Participants that received hospital rehabilitation indicated, “The treatments were only in the mornings. We would have liked to have treatments in the afternoon as well” (P6).

Roles: Physical, Social, Emotional

Physical role

Interviewees noted the importance of a return to functioning as they had previously at work or in volunteering roles, as well as in their informal roles as active social and family members. As one interviewee put it, “I was disconnected from many things because of the fracture. I did not return to my preoccupations with my family, did not attend social events, lectures and classes.” (P14).

Bodily pain

Pain management was a key topic in rehabilitation. Hip fracture involves extreme pain; some indicated having received satisfactory pain treatment while others were less satisfied.

Vitality

Vitality was mentioned as an important component in the success of rehabilitation. Vitality enabled the participants to persevere in the hard work necessary to promote a successful rehabilitation process. As stated, “I was quite determined to get back to myself. Usually when I am determined, it works” (P14). Another summarized “Morale is most important” (P12).

Social role

Social support was noted as a contributor to effective rehabilitation. Participants rehabilitating at home cited the support and encouragement from family members as being extremely helpful, while those in hospital rehabilitation centers noted that friendship with other patients in the ward helped them succeed in rehabilitation. As one said, “I have a broad support system. . .the children came to help, also the grandchildren. It made it very easy for me” (P15). Participants that were in hospital rehabilitation centers indicated that their friendship with patients in the ward helped them succeed in rehab. “I was lucky to have a nice roommate. We would do walks along the ward together. We connected with others too” (P12).

Emotional roles

Fear of falling

Most expressed their fear of falling again. Some participants described being alone when they fell: crawling slowly to a nearby phone, calling for help until someone arrived, waiting alone on the floor for hours until a family member found them. These daunting experiences enhanced their fear of another fall. One said that since the fall he takes his cell phone everywhere. Others said they only go out accompanied “I only go out with family” (P15). Another said, “If I did not have this button (hand-wrist distress button) you would not be talking to me now” (P14). They summed it by saying “There is a lot of fear that has to do with the fall. It is a trauma” (P2).

Fear of an uncertain future

The lack of clarity as to “what will happen now” after the fracture and what will be the outcome of the rehabilitation was also a source of fear. Some said that these fears negatively affected their mental health status. “The time you spend in the hospital is very scary. You do not know what will happen, how things will end up. It is important to ask the patients (how they feel)” (P9). Some said that these fears deteriorated their mental health status. One said “I felt depressed, sad and anxious. I lost my confidence but did not get treatment for it. I think this is an issue that is important to address during rehabilitation” (P4).

Mood, guilt and sadness

Interviewees noted that during rehabilitation they felt sad and guilty about falling, understanding that they may not return to their previous functionality. “I felt guilty, I was terribly sad that I was there (in the hospital) I realized that I would no longer be the same person I was before. I was very worried about how I would manage” (P7).

SF36 Feedback

For the second portion of the interview, participants indicated if they felt the topics and questions in the SF36 were consistent with those raised in the interview and, therefore, whether the questionnaire is suitable for measuring PROs in HF patients. The participants emphasized the importance of questions that dealt with physical functioning and role (q. 3-12 and 13-16, respectively), emotional role limitations and mental health (q. 17-19 and 24-26, 28, 30, respectively), pain (q. 21-22), and social functioning (q. 20, 32). Some recommended modifying the questions that dealt with vitality (q. 23, 27, 29, 31), as many older adults have chronic fatigue.

The study participants felt that the SF36 questionnaire should be administered at intervals. Their preferred timetable is described in Figure 2.

Figure 2.

Timeline for SF36 PRO questioning.

Discussion

The novelty of the study is that by using a qualitative description approach to understand the phenomenon of patients recovering from HF, this study validated that the SF36 questionnaire is sufficient for measuring PROs in HF patients. Utilization of a short and noncomplex questionnaire may facilitate patient responsiveness and reduce the risk of “survey fatigue.”^32-34 The participants recommended that the SF36 be completed 3 times throughout the rehabilitation process: 24-48 hours after surgery, 2 weeks post-surgery and 3 months later. Administrating the PROs questionnaire at the appropriate time is essential for the ability to detect change. ³⁵

Langford et al ² in a qualitative study that was conducted among HF patients, emphasize the importance of caregivers focusing on other factors that hinder recovery, besides the HF. Having patient-centered information can help promote joint decision-making between patient and caregivers regarding goals of treatment during rehabilitation. ³⁶ The findings suggested that health professionals can incorporate quality measures and discussions of care plans during the recovery period using the SF36 as a basis for desired PROs. Though there were other issues mentioned by the participants, when the data were analyzed and diagramed there was visual agreement between the data and the SF36 model (Figure 1).

Themes and categories presented in the study were also reported in previous studies conducted with both HF patients and older adults.^2,37-39 The participants emphasized the importance of vitality, having a positive attitude, and high motivation as contributing to the recovery experience. Regaining physical function was attributed to an optimistic and determined attitude, and the expectation of positive outcomes.

In other research studies,^2,39,40 as in this one, participants also reported yearning to return to their previous roles: physical, social and emotional, and the importance of physiotherapy and exercise. Some reported that they set personal goals according to the activities they wanted to be able to achieve; others suggested measuring and keeping daily recovery progress diaries. We suggest that future research investigate the use of PROs for goal setting in patients following a HF.

Fear of falling, re-injuring, and pain management were also mentioned as topics that hindered their recovery. Participants indicated that these factors caused them to move less and hence were a barrier to regaining physical function. They emphasized the importance of therapy to help manage these challenges. ³⁸

Associating the fall with self-reflected ageism and recognizing it as a traumatic event was also a topic of discussion. Expressing a sense of loss of control and fear of old-age. This was often done with emotions and a show of frustration.^39,41

Rehabilitation after HF is a dynamic process characterized by changes in the individual’s physical and mental state. ⁴¹ Measuring PROs that are succinct but precise can help assess the required categories for clinical intervention in the rehabilitation process. This process can promote patient-centered care.

Limitations

This study also has limitations. The participants were all Hebrew speakers. We suggest that future research should explore the relevance of the study’s findings in populations of different cultures and languages. The interviews were not audio recorded. While detailed notes and quotes were transcribed by the interviewer, the transcripts do not reflect a verbatim account of the participants’ responses. These may have caused a recorder’s bias.

This study had a relatively small sample. Qualitative research diminishes the need for a large sample size and complicated statical analyses. In this kind of methodology, the validity and verification of the meanings come from the patients themselves. The benefit of using this approach, is that small sample-sizes can be used, and though it is time consuming, it is cost effective and efficient

Conclusions

To conclude, the findings underline the importance of PROs in patients after HF and that the SF36 questionnaire is a suitable tool for this purpose. Using a short single questionnaire can increase compliance to PROs and enable accurate measurement on a diverse and wide-scale population. Healthcare systems traditionally focus on clinical outcome indicators and not on how the patient views his outcomes. This study puts the focus on the patient and the validity comes from the patients’ perspective. Thus, credibility, which is the essence of qualitative research, is supported by the feedback loop.

As nurse and physician researches, we always need to reflect back to the patients and patient-centered evidence. Quantitative measures are important, yet without the under driven evidence from the patients themselves, the information is unidimensional. Doing this type of research provides preliminary confidence that our analysis is pertinent, and reflects the actual phenomena.