Evaluation of Dora Care for Supporting Fracture Liaison Services (FLS)

Fragility fractures are common and are associated with substantial morbidity, mortality, and healthcare costs. Fracture Liaison Services (FLS) are internationally recognised as an effective model for secondary fracture prevention; however, FLS pathways can be resource-intensive and place a significant burden on clinical staff, particularly for standardised intake risk assessment and longer-term follow-up conversations related to medication adherence, side effects, and interval clinical events.

Dora Care is a cloud-based, standalone software product that delivers automated natural-language telephone calls to patients using an AI voice assistant. Dora Care can be configured to conduct structured clinical or administrative conversations where a validated protocol exists and returns a structured summary of the interaction for healthcare teams to review. Dora Care is not intended for clinical diagnosis and, in this study, is used as an adjunct to standard Fracture Liaison Service care rather than a replacement for clinician review.

This prospective, mixed-methods feasibility study evaluates whether Dora Care can support elements of the FLS pathway by assessing agreement between patient-reported information collected by Dora Care and information collected by an FLS clinician during routine care, evaluating safety when Dora Care is deployed in this context, and exploring acceptability and usability for both patients and clinicians.

Study design and setting This is a prospective, single-arm feasibility study conducted in NHS hospital-based Fracture Liaison Services, initially at University College London Hospitals NHS Foundation Trust, with additional potential recruitment sites. All patient participants receive a Dora Care telephone call in addition to their routine FLS telephone consultation.

The study includes two linked components:

Patient pathway component (live, within routine care): Patients receive an automated Dora Care call followed by their standard clinician-led FLS telephone consultation. Patient-reported questionnaires are collected after Dora Care interactions, and a subset of participants is invited to take part in qualitative interviews.

Clinician usability component (simulated): Clinicians review anonymised, mock Dora Care outputs derived from the study and provide feedback via questionnaires and interviews. This component is conducted separately from live patient care to broaden clinician participation and minimise patient safety risk.

Interventions and procedures Participants may contribute data at one or more routine FLS timepoints, including an intake assessment and follow-up assessments during ongoing management.

Prior to the standard clinician consultation, Dora Care conducts an automated telephone call to collect patient-reported information relevant to the FLS pathway. Following the Dora Care call, patients proceed with their routine clinician-led FLS consultation, during which clinicians independently collect and document clinical information as part of standard care. Clinicians are aware that a Dora Care call has taken place but are not provided with Dora Care outputs for the purposes of agreement evaluation.

Patients are invited to complete usability and satisfaction questionnaires following Dora Care interactions, and a subset of patients participates in semi-structured qualitative interviews to explore experience and acceptability. Clinicians participating in the usability component complete questionnaires and interviews based on simulated review of Dora Care outputs.

Data collection and ethics Data are collected from Dora Care call outputs, routine clinician documentation within electronic health records, and participant-completed questionnaires and interviews. Data are pseudonymised and handled in accordance with the Declaration of Helsinki, Good Clinical Practice, ISO 14155:2020, the UK Data Protection Act 2018, and UK GDPR.

The study is conducted as an adjunct to standard care, and participants retain access to usual clinical support throughout. Ethical approval and relevant NHS governance approvals are obtained prior to study initiation, and device-related adverse events and device deficiencies are monitored and reported in accordance with regulatory requirements.

• Medication adherence rate [Time frame: 16 week follow up where available]
• Incidence of patient-reported medication side effects [Time frame: 16 weeks and 24 weeks]
• Incidence of new fragility fractures [Time frame: 16 weeks and 24 weeks]
• Incidence of patient-reported falls [Time frame: 16 weeks and 24 weeks]
• Patient satisfaction scores with Dora Care (adapted Client Satisfaction Questionnaire) [Time frame: Baseline (intake assessment), 16 weeks, and 24 weeks]
• Patient usability scores (System Usability Scale) [Time frame: Baseline (intake assessment), 16 weeks and 24 weeks]
• Qualitative themes from patient interviews on experience and acceptability of Dora Care [Time frame: Through study completion, an average of 12 months]
• Clinician usability scores (System Usability Scale) [Time frame: Through study completion, an average of 12 months]
• Clinician experience themes (qualitative interviews) [Time frame: Through study completion, an average of 12 months]