Protocol for a scoping review to explore governance for national hip fracture clinical audits

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The global incidence of hip fracture is rising. National hip fracture audits facilitate improvements in patient outcomes and care quality. There is a wealth of literature regarding hip fracture care, evidence-based standards, use of registry/clinical audit data for improvement, benchmarking and outcomes. There is however a gap in the literature for describing how to establish the governance for a national hip fracture audit. Objective This scoping review aims to identify the core governance components for national clinical audits (NCAs) of hip fractures. Methods The Joanna Briggs Institute guidance will be used in conducting the review and Preferred Reporting Items for Systematic Reviews extensions for Scoping Reviews (PRISMA-ScR) guidance for scoping reviews will be followed. has been used. Articles published in English, between 1988–2024 and indexed in MEDLINE (Ovid), Embase (Elsevier) and CINAHL (EBSCOHost) will be included in this review. Two reviewers will independently screen the articles, with any disagreements resolved by a third reviewer. Data extraction will be conducted by two reviewers and shared with external stakeholders to ascertain whether there is documentation or reports that were missed and preliminary analysis will be shared to validate the data we have extracted. The results will be disseminated widely through publication in an international peer reviewed journal and through the Global Fragility Fracture Network (FFN) Hip Fracture Audit Special Interest Group. Conclusions By identifying the core components for the governance of NCAs for hip fracture it is hoped that application of these components will support the existing NCAs for hip fracture to enhance their current governance and aid in the establishment of NCAs in the future. 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HRB Open Res 2025, 8 :24 ( https://doi.org/10.12688/hrbopenres.14050.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Revised Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] Louise Brent https://orcid.org/0000-0001-9129-235X 1,2 , Cris Ojeda-Thies 3,4 , Fidelma Fitzpatrick https://orcid.org/0000-0002-3204-5962 5,6 , Niamh Merriman https://orcid.org/0000-0002-5327-7762 7 , Elaine Byrne https://orcid.org/0000-0001-7322-277X 8 Louise Brent https://orcid.org/0000-0001-9129-235X 1,2 , Cris Ojeda-Thies 3,4 , [...] Fidelma Fitzpatrick https://orcid.org/0000-0002-3204-5962 5,6 , Niamh Merriman https://orcid.org/0000-0002-5327-7762 7 , Elaine Byrne https://orcid.org/0000-0001-7322-277X 8 PUBLISHED 25 Apr 2025 Author details Author details 1 Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland 2 National Office of Clinical Audit, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Department of Traumatology and Orthopaedic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain 4 Department of Surgery, School of Medicine, Complutense University of Madrid, Madrid, Spain 5 Royal College of Surgeons in Ireland Department of Clinical Microbiology, Dublin, Leinster, Ireland 6 Department of Clinical Microbiology, Beaumont Hospital, Dublin, Leinster, Ireland 7 University College Dublin School of Public Health Physiotherapy and Sports Science, Dublin, Leinster, Ireland 8 Centre for Positive Health Sciences, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland Louise Brent Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Cris Ojeda-Thies Roles: Conceptualization, Methodology, Writing – Review & Editing Fidelma Fitzpatrick Roles: Conceptualization, Supervision Niamh Merriman Roles: Methodology, Writing – Review & Editing Elaine Byrne Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Ageing Populations collection. Abstract Background Hip Fractures are serious injuries leading to increased morbidity and mortality. The global incidence of hip fracture is rising. National hip fracture audits facilitate improvements in patient outcomes and care quality. There is a wealth of literature regarding hip fracture care, evidence-based standards, use of registry/clinical audit data for improvement, benchmarking and outcomes. There is however a gap in the literature for describing how to establish the governance for a national hip fracture audit. Objective This scoping review aims to identify the core governance components for national clinical audits (NCAs) of hip fractures. Methods The Joanna Briggs Institute guidance will be used in conducting the review and Preferred Reporting Items for Systematic Reviews extensions for Scoping Reviews (PRISMA-ScR) guidance for scoping reviews will be followed. has been used. Articles published in English, between 1988–2024 and indexed in MEDLINE (Ovid), Embase (Elsevier) and CINAHL (EBSCOHost) will be included in this review. Two reviewers will independently screen the articles, with any disagreements resolved by a third reviewer. Data extraction will be conducted by two reviewers and shared with external stakeholders to ascertain whether there is documentation or reports that were missed and preliminary analysis will be shared to validate the data we have extracted. The results will be disseminated widely through publication in an international peer reviewed journal and through the Global Fragility Fracture Network (FFN) Hip Fracture Audit Special Interest Group. Conclusions By identifying the core components for the governance of NCAs for hip fracture it is hoped that application of these components will support the existing NCAs for hip fracture to enhance their current governance and aid in the establishment of NCAs in the future. READ ALL READ LESS Keywords Scoping review, hip fracture, clinical audit, governance Corresponding Author(s) Louise Brent ( [email protected] ) Close Corresponding author: Louise Brent Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Brent L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Brent L, Ojeda-Thies C, Fitzpatrick F et al. Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.12688/hrbopenres.14050.2 ) First published: 04 Feb 2025, 8 :24 ( https://doi.org/10.12688/hrbopenres.14050.1 ) Latest published: 25 Apr 2025, 8 :24 ( https://doi.org/10.12688/hrbopenres.14050.2 ) Revised Amendments from Version 1 Following feedback from the peer reviewer a more detailed description of clinical governance was described as well as further details about the rational for selection of methodology, a more detailed PCC (Population, Concept, Context) was provided for the inclusion criteria. Following feedback from the peer reviewer a more detailed description of clinical governance was described as well as further details about the rational for selection of methodology, a more detailed PCC (Population, Concept, Context) was provided for the inclusion criteria. To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table. READ REVIEWER RESPONSES Introduction Globally there are millions of fragility fractures each year due to osteoporosis and this is growing annually due to the increased ageing of populations around the world, resulting in ever growing costs and reduction in quality of life. These fractures are associated with significant disability and increased mortality 1 . Hip fractures are considered one of the most devastating fragility fractures and therefore the development of hip fracture audits have been recognised as key drivers for improvement in patient care and outcomes 2 . The first national clinical audit (NCA) for hip fracture was established in 1988 in Sweden, entitled Rikshöft 3 . It would take a further five years before the second national hip fracture audit was established in Scotland in 1993 4 . In 2024, there are a growing number of NCAs, mainly in Europe, with other large regional data collection with many participating hospitals. Additionally, there are several countries with emerging hip fracture audits. The Global Fragility Fracture Network (FFN), which is a global network of multidisciplinary activists committed to improving the prevention, care and recovery from fragility fractures, was established in 2011. To improve international comparability, the Global FFN advocates for a minimum common dataset across all existing and emerging hip fracture audits 5 , representing the simplest dataset that all national audits should aim to collect. Findings from this scoping review can be used to compliment the Hip Fracture Registry Toolbox: A collaboration between the Asia Pacific Hip Fracture Registry Toolbox (APFFA) Hip Fracture Registry Working Group and the FFN Hip Fracture Audit Special Interest Group published in 2020. This toolkit focuses mainly on the areas with emerging hip fracture audits and draws some learnings from a small number of the established audits 6 Substantial research attention has been paid to incidence of hip fracture, hip fracture quality indicators 7 , differences in hip fracture care 8 and outcomes 9 , 10 . However, there are considerably less publications focusing on the governance of a national hip fracture clinical audit and no review of the core governance components required when establishing a NCA for hip fracture. Clinical governance involves systems of accountability through which healthcare teams are measured for the quality, safety and experience of patients in the care they have delivered 11 . Governance means that healthcare staff can specify the clinical standards for delivery and indicate the measurements made to demonstrate that what was set out to be done was done. Governance provides a critical framework for ensuring that clinical audits meet established standards including, clear accountability, continuous quality improvement, transparency, interdisciplinary working, leadership, supporting performance and ultimately contribute to quality improvement efforts 12 . Evidence from established NCA’s have demonstrated reduction in mortality, costs and improvement in patient outcomes 2 – 4 As interest in hip fracture and fragility fracture care has grown through engagement with organisations like the Global FFN, hip fracture audits have been leveraged to drive these global campaigns to improve care quality. Due to the exponential growth in the number of emerging hip fracture NCAs, there is a need to describe the governance requirements for such audits to support the existing and offer guidance to future NCAs for hip fracture. To address the gap in knowledge, this scoping review is being conducted. Scoping reviews are a useful approach for describing a complex concept or subject and a way to summarise the findings 13 . The aim of this review is to identify governance components that are integral to establishing a NCA for hip fracture. Methods This scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for conducting scoping reviews 14 , 15 and subsequent JBI guidance for engagement with knowledge users 16 . This methodology was chosen due to its transparency, through publication of a pre-defined protocol and explicit data extraction and analysis, as well as its alignment with international reporting standards, such as the PRISMA-ScR. JBI methodology for scoping reviews includes the following stages: 1) Defining and aligning the objective(s) and question(s) 2) Developing and aligning the inclusion criteria with the objective(s) and question(s) 3) Describing the planned approach to evidence searching, selection, data extraction, and presentation of the evidence 4) Searching for the evidence 5) Selecting the evidence 6) Extracting the evidence 7) Analysis of the evidence 8) Presentation of the results 9) Summarising the evidence in relation to the purpose of the review, making conclusions, and noting any implications of the findings. The findings of the scoping review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines 17 . Engagement The reviewers in this study work either in the field of hip fracture care and audit and /or are experts in conducting scoping reviews. All reviewers are interested in improving the care and outcomes of hip fracture patients. The lead author has worked in hip fracture care since 2001 and has 15 years of experience in hip fracture audit. Through the management of the Irish Hip Fracture Database (IHFD) under the operational governance of the National Office of Clinical Audit, the lead author has worked closely in its initiation, maturation and collaborates internationally with many of the established national hip fracture audits and has held central roles in the Global FFN as the former General Secretary (2019–2022) and is a member of the Global FFN Hip Fracture Audit Special Interest Group. This group comprises of nominated representatives from each of the established or emerging national hip fracture audits, international FFN representatives, and senior figures from the Global FFN administration 18 . The IHFD, a clinically led web-based audit established in Ireland in 2012, has a multidisciplinary governance committee that oversees the audit, and includes public and patient representation and senior healthcare managers. The IHFD is clinically endorsed by the Irish Gerontological Society and Irish institute of Trauma and Orthopaedic Surgery 19 . Through this experience and connections with the Global FFN Hip Fracture Audit Special Interest Group and the IHFD, knowledge users will be engaged at specific stages to: help in identifying national clinical audits for hip fracture review all findings from the scoping review and support the validation of the findings disseminate the findings from this scoping review to the international hip fracture community and through academic partnerships. Knowledge users who make significant contribution to this scoping review will be eligible for authorship on the final manuscript. Review questions The broad research question identified for this research is entitled ‘Understanding governance for national hip fracture clinical audit, a scoping review’. Specifically, the review questions are: I. What hip fracture NCAs are described in the literature? II. What components of governance for hip fracture NCA have been described internationally? Inclusion criteria The inclusion criteria will follow the PCC mnemonic (Population, Concept and Context) for scoping reviews 15 . Population The population for this review includes NCA’s for hip fracture. A hip fracture is a break in the upper quarter (or to 5cm below the lesser trochanter) of the femur often referred to as a ‘broken hip’ or a ‘fractured neck of femur’ 19 . Hip fracture will be defined based on definitions used across hip fracture NCAs such as: 1 - Intracapsular non-displaced; 2 - Intracapsular displaced; 3 – Trochanteric; 4 – Subtrochanteric; 5 – Other. Concept The concepts of interest are NCAs governance, including those also referred to as registries or databases for hip fracture, that collect data to quality assure, benchmark and improve the care and outcomes of hip fracture patients. Only NCAs will be included to be truly reflective of the whole population being audited. A hip fracture audit will be considered as being at country level if it includes the country’s name or the word ‘national’ in the title or it is reported as the accepted country-wide structure for data collection. Non-nationally representative regional will be excluded from this review. Each audit must demonstrate audits systematic and continuous data collection. Context This review will provide an international view of governance for NCA of hip fractures. Consideration will be given to the different health systems in the scoping review eg. funding structures. Evidence sources Eligible NCAs for hip fracture will be identified from peer-reviewed literature and through searches of relevant websites such as the FFN. This will be further corroborated by the FFN Hip Fracture Audit Special Interest Group. Relevant studies A comprehensive search strategy will be designed in collaboration with an information specialist, incorporating MeSH terms relating to hip fracture and clinical audit (see Table 1 ). Additional relevant articles will be identified by examining the reference lists of included studies (backward citation searching) and by identifying studies that cite the included articles (forward citation searching). A search of the grey literature pertaining to NCA’s for hip fracture will also be included. The search strategy will use electronic databases including: MEDLINE (Ovid) Embase (Elsevier) CINAHL (EBSCOHost) To ensure that sources are relevant, date restrictions will be applied from 1988 onwards as the first hip fracture NCA was established in Sweden. Language will be restricted to English only. Abstracts for conferences and editorials will be excluded. A comprehensive search strategy will be designed in collaboration with an information specialist. Table 1 provides a sample MEDLINE search string, which will be adapted for other databases. Citations from included articles will also be reviewed and considered for inclusion. Table 1. Sample MEDLINE Search String. 1 hip fracture$.mp. or *Hip Fractures/ 2 clinical audit$.mp. or *Clinical Audit/ or (national adj3 audit$) 3 1 AND 2 4 limit 3 to yr="1988 – present date" Study selection Two reviewers will undertake an independent review of the titles and abstracts of all identified citations and any discrepancies will be resolved by a third reviewer who will help to reach a consensus. The full text review will be completed by two reviewers independently using the inclusion and exclusion criteria and a third reviewer will be consulted where disagreements occur. Citations excluded during the full-text review stage will be documented together with the reasons for their exclusion as part of the PRISMA flow diagram 20 . Data extraction A standardised extraction form will be developed specifically for this review. Two reviewers will test and calibrate the extraction form on three papers and then two reviewers will independently extract data for the remaining full texts. Data extraction checked for accuracy and omissions by a third reviewer. Covidence a web based tool will be used to streamline the primary screening and data extraction processes. Data synthesis and presentation All identified NCAs for hip fracture will be described. A list of emerging hip fracture audits and large representative regional hip fracture audits will also be included to signpost potential future areas for study. Data will be presented in tables identifying the presence of core components for the governance of NCAs for hip fracture in each audit. Identified core governance components for hip fracture NCAs will undergo descriptive analysis and be reported as frequencies. Recommendations for key governance components based on the available data will be compiled by the reviewers. Dissemination of findings The findings will be presented at national hip fracture meetings, international fragility fracture or related conferences and through the FFN Hip Fracture Audit Special Interest Group. Discussion This study will build on a larger piece of work to describe the work of the IHFD since its inception in 2012. The scoping review findings will contribute to future studies aimed at describing the hip fracture NCA governance components from the Irish context. The findings from this scoping review will be of interest to the existing NCAs for hip fracture and will be very useful for emerging national hip fracture audits or countries that have yet to embark on establishing a NCA for hip fracture as it can act as a guide on how best to approach setting up a NCA. It will provide guidance to support their development and specify key features that are common in developed audits that are important. Study status Formal screening of search results against the eligibility criteria is ongoing. Ethics Ethical approval and written consent were not required for this study. Data availability No data are associated with this article. Acknowledgements The authors would like to thank information specialists Killian Walsh and Paul J Murphy, Royal College of Surgeons in Ireland, Library for this assistance with developing the search strategy. Faculty Opinions recommended References 1. Borgström F, Karlsson L, Ortsäter G, et al. : Fragility fractures in Europe: burden, management and opportunities. Arch Osteoporos. 2020; 15 (1): 59. PubMed Abstract | Publisher Full Text | Free Full Text 2. Royal College of Physicians: National Hip Fracture Database annual report 2015. London: Royal College of Physicians, London, 2015. Reference Source 3. Thorngren KG: National registration of hip fractures in Sweden. In: European instructional lectures . Berlin, Heidelberg: Springer Berlin Heidelberg, 2009; 9 . : 11–18. Publisher Full Text 4. Currie CT, Hutchison JD: Audit, guidelines and standards: clinical governance for hip fracture care in Scotland. Disabil Rehabil. 2005; 27 (18–19): 1099–105. PubMed Abstract | Publisher Full Text 5. Johansen A, Ojeda-Thies C, Poacher AT, et al. : Developing a minimum common dataset for hip fracture audit to help countries set up national audits that can support international comparisons. Bone Joint J. 2022; 104–B (6): 721–728. PubMed Abstract | Publisher Full Text | Free Full Text 6. Mitchell PJ, Ang SB, Mercado-Asis LB, et al. : Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region. Arch Osteoporos. 2022; 17 (1): 115. PubMed Abstract | Publisher Full Text | Free Full Text 7. Voeten SC, Krijnen P, Voeten DM, et al. : Quality indicators for hip fracture care, a systematic review. Osteoporos Int. 2018; 29 (9): 1963–1985. PubMed Abstract | Publisher Full Text | Free Full Text 8. Werner M, Macke C, Gogol M, et al. : Differences in hip fracture care in Europe: a systematic review of recent annual reports of hip fracture registries. Eur J Trauma Emerg Surg. 2022; 48 (3): 1625–1638. PubMed Abstract | Publisher Full Text | Free Full Text 9. Zuckerman JD: Hip fracture. N Engl J Med. 1996; 334 (23): 1519–25. PubMed Abstract | Publisher Full Text 10. Grigoryan KV, Javedan H, Rudolph JL: Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma. 2014; 28 (3): e49–55. PubMed Abstract | Publisher Full Text | Free Full Text 11. Health Service Executive Quality Improvement Division: Framework for improving quality in our health service: Part 1: introducing the framework. Quality Improvement Division, Health Service executive, Dublin, 2016. Reference Source 12. Health Service Executive: Clinical governance information leaflet. Quality and Patient Safety Directorate, Health Service Executive, Dublin, 2024. Reference Source 13. Davis K, Drey N, Gould D: What are scoping studies? A review of the nursing literature. Int J Nurs Stud. 2009; 46 (10): 1386–400. PubMed Abstract | Publisher Full Text 14. Peters MD, Godfrey C, McInerney P, et al. : Scoping reviews. JBI Manual Evid Synth. 2020; 10 . Publisher Full Text 15. Peters MDJ, Marnie C, Tricco AC, et al. : Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020; 18 (10): 2119–2126. PubMed Abstract | Publisher Full Text 16. Pollock D, Alexander L, Munn Z, et al. : Moving from consultation to co-creation with knowledge users in scoping reviews: guidance from the JBI scoping review methodology group. JBI Evid Synth. 2022; 20 (4): 969–979. PubMed Abstract | Publisher Full Text 17. Tricco AC, Lillie E, Zarin W, et al. : PRISMA extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018; 169 (7): 467–473. PubMed Abstract | Publisher Full Text 18. Fragility Fracture Network. Reference Source 19. National Office of Clinical Audit: Irish hip fracture database national report 2023. National Office of Clinical Audit, Dublin, 2024. Reference Source 20. Moher D, Liberati A, Tetzlaff J, et al. : Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009; 151 (4): 264–9, W64. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 04 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland 2 National Office of Clinical Audit, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland 3 Department of Traumatology and Orthopaedic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain 4 Department of Surgery, School of Medicine, Complutense University of Madrid, Madrid, Spain 5 Royal College of Surgeons in Ireland Department of Clinical Microbiology, Dublin, Leinster, Ireland 6 Department of Clinical Microbiology, Beaumont Hospital, Dublin, Leinster, Ireland 7 University College Dublin School of Public Health Physiotherapy and Sports Science, Dublin, Leinster, Ireland 8 Centre for Positive Health Sciences, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland Louise Brent Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Cris Ojeda-Thies Roles: Conceptualization, Methodology, Writing – Review & Editing Fidelma Fitzpatrick Roles: Conceptualization, Supervision Niamh Merriman Roles: Methodology, Writing – Review & Editing Elaine Byrne Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 25 Apr 2025, 8:24 https://doi.org/10.12688/hrbopenres.14050.2 version 1 Published: 04 Feb 2025, 8:24 https://doi.org/10.12688/hrbopenres.14050.1 Copyright © 2025 Brent L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Brent L, Ojeda-Thies C, Fitzpatrick F et al. Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.12688/hrbopenres.14050.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 25 Apr 2025 Revised Views 0 Cite How to cite this report: Pedersen AB and Jensen SS. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46993 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46993 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 13 May 2025 Alma Becic Pedersen , Aarhus University Hospital, Aarhus, Denmark Simon Storgaard Jensen , Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15548.r46993 The protocol is well written. Still, I am not sure what specific outcome or components of governance this paper will cover. This uncertainty could be solved by the authors providing more detailed search strategy incl. specific MeSH terms they ... Continue reading READ ALL The protocol is well written. Still, I am not sure what specific outcome or components of governance this paper will cover. This uncertainty could be solved by the authors providing more detailed search strategy incl. specific MeSH terms they will be looking at in table 1. This is important also in terms of transparency and replicability of study results. Competing Interests: No competing interests were disclosed. Reviewer Expertise: epidemiology, patient safety, registry studies, orthopedic surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Pedersen AB and Jensen SS. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46993 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46993 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Hallen J. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46994 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46994 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 May 2025 Jamie Hallen , Neuroscience Research Australia, Randwick, New South Wales, Australia Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15548.r46994 I have reviewed the revised version and am satisfied that my comments have been addressed. ... Continue reading READ ALL I have reviewed the revised version and am satisfied that my comments have been addressed. I am happy to approve the protocol and wish the authors well with their scoping review. Competing Interests: No competing interests were disclosed. Reviewer Expertise: hip fracture audit I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hallen J. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46994 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46994 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 04 Feb 2025 Views 0 Cite How to cite this report: Pedersen AB and Jensen SS. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r46190 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-46190 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 04 Apr 2025 Alma Becic Pedersen , Aarhus University Hospital, Aarhus, Denmark Simon Storgaard Jensen , Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15427.r46190 Overall: The protocol is well-written and provides a clear, structured approach to conducting a scoping review. It addresses a significant gap in literature and offers a novel contribution to the field. The authors could improve clarity in certain sections ... Continue reading READ ALL Overall: The protocol is well-written and provides a clear, structured approach to conducting a scoping review. It addresses a significant gap in literature and offers a novel contribution to the field. The authors could improve clarity in certain sections and provide further specificity regarding some of the methodological aspects of the protocol to ensure a more robust and transparent review process. Title: Clearly indicates the scope of the paper and specifies the focus on national hip fracture clinical audits as the subject of analysis. However, governance can be” broad” interpreted. Introduction: Page 3, section 1 “Hip fracture is a serious injury associated with high costs and poor outcomes, including both disability and increased mortality”. Consider adding a more recent reference, preferably one providing information on costs like IOF “Broken Bones – Broken Lives” reports or Borgström F, et al., (2020) [Ref-1] Page 3, section 1 “To improve international comparability, the Global FFN advocates …”. This part is very well-constructed and clearly states a gap in the literature. Page 3, section 2 The definition of governance is clear, but it could benefit from further refinement for greater precision. Specifically, the phrase "healthcare teams" could be more focused. Consider specifying that governance involves systems of accountability. Page 3, section 2 While the introduction to governance is clear, the connection to clinical audit could be elaborated. It might help to explicitly state that governance is a critical framework for ensuring that clinical audits meet established standards and contribute to quality improvement efforts. Page 3, section 3 The need for the review is clearly stated, but in terms of justification, the authors could highlight how governance impacts the quality, comparability, or generalizability of data. E.g. refer to improvements based on well-established NCA’s as mentioned in the beginning. Methods: Page 3, section 4 The authors clearly state that the scoping review will follow the Joanna Briggs Institute (JBI) methodology, which is appropriate and well-recognized. However, they could provide a brief explanation or justification of why the JBI methodology was chosen over other potential methodologies Engagement: The lead author’s extensive experience in hip fracture care and audit is well-documented, and the description of their roles in both the Irish Hip Fracture Database (IHFD) and the Global FFN is valuable Page 3, section 6-7 The knowledge user engagement strategy is well thought out, but it would benefit from more specific details about how knowledge users will be involved in the review process. For example, will knowledge users provide feedback during specific stages, such as data extraction or synthesis? Or will their involvement be primarily during the validation phase? Review questions One could consider adding a question that evaluates the impact or effectiveness of governance models on hip fracture audit outcomes, if applicable. Inclusion criteria Page 4, section 2 The authors should clarify how age will be handled or included in the scoping review, as many NCAs set age limits for patient eligibility, which may vary internationally. This is particularly important as age is closely related to many outcomes, such as mortality and recovery rates. For example, the Danish Hip Fracture Registry (DMHFR) includes patients aged 65 and older. Page 4, section 2 The authors should clarify whether ICD codes (e.g., S72 for Fracture of femur, S72.0 for Fracture of neck of femur, S72.1 for Pertrochanteric fracture, S72.2 for Subtrochanteric fracture) will be used to define hip fractures, or how the analysis will be conducted when comparing ICD-based NCAs to those using a 'broad definition' of hip fracture. Page 4, section 3-4 The authors should address how NCAs from healthcare systems with fundamentally different political and funding structures (e.g., state/tax-funded vs. insurance-based systems) may influence both patient treatment and data collection methods, particularly in the context of an international scope. Relevant studies The authors should consider incorporating MeSH terms into the search strategy to enhance the precision and comprehensiveness of the search. The inclusion of citations from the selected articles is mentioned, but it would be helpful to specify whether this will be in a systematic way (e.g., “snowballing approach”). Study selection The role of the third reviewer should be clarified in terms of how disagreements are resolved (e.g., consensus or final decision). Data extraction Consider providing details on tools for data extraction, e.g. COVIDENCE Data synthesis and presentation The process of compiling recommendations for key governance components is important. It might be beneficial to clarify who will be responsible for formulating the recommendations (e.g., the reviewers, expert consensus, or based on the most frequently reported components). Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Partly References 1. Borgström F, Karlsson L, Ortsäter G, Norton N, et al.: Fragility fractures in Europe: burden, management and opportunities. Arch Osteoporos . 2020; 15 (1): 59 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: epidemiology, patient safety, registry studies, orthopedic surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Pedersen AB and Jensen SS. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r46190 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-46190 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Hallen J. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r45747 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-45747 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 04 Mar 2025 Jamie Hallen , Neuroscience Research Australia, Randwick, New South Wales, Australia Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15427.r45747 Thank you for the opportunity to review this scoping review protocol, which aims to identify the core governance components for national hip fracture audits. I agree that a scoping review on this topic is valuable, given the complexities associated with ... Continue reading READ ALL Thank you for the opportunity to review this scoping review protocol, which aims to identify the core governance components for national hip fracture audits. I agree that a scoping review on this topic is valuable, given the complexities associated with national audit governance. Introduction Whilst the focus is on hip fracture audits, national audits / registries exist for many clinical domains. As such, guidance and publications may not be specific to hip fracture audits. The authors should consider including publications that focus on the governance of national audits more broadly. Consider referencing existing work e.g. Asia Pacific Hip Fracture Registry Toolbox Consider revising the definition of governance, which is focused on clinical governance in health care, with reference to health care teams and staff rather than governance as it relates to the topic area (acknowledging that there is some overlap in the principles). Methods The methodology is appropriate for conducting a scoping review of this nature, with reference to use of the up to date PRISMA-ScR reporting guidelines. Inclusion criteria The PCC framework does not appear to adequately frame the scoping review question Population should not include hip fracture patients (as studies related to the patient cohort aren’t the focus of the review). The population focus be the NCA’s for hip fracture (currently described in context). Concept should include governance of NCAs as this is the central idea of the scoping review. Relevant studies The search strategy should be broadened to include more detailed information around the grey literature, as audit governance frameworks may be less commonly published in academic journals / as traditional publications. There is reference to inclusion of concepts related to clinical audits (e.g. registries, databases) but it is unclear how these terms will be factored into the search strategy. As mentioned previously, national guidance for clinical audits may exist without being specific to hip fracture. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: hip fracture audit I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hallen J. Reviewer Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r45747 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-45747 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 04 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 25 Apr 25 read read Version 1 04 Feb 25 read read Jamie Hallen , Neuroscience Research Australia, Randwick, Australia Alma Becic Pedersen , Aarhus University Hospital, Aarhus, Denmark Simon Storgaard Jensen , Aarhus University, Aarhus, Denmark Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Pedersen A et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 13 May 2025 | for Version 2 Alma Becic Pedersen , Aarhus University Hospital, Aarhus, Denmark Simon Storgaard Jensen , Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark 0 Views copyright © 2025 Pedersen A et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The protocol is well written. Still, I am not sure what specific outcome or components of governance this paper will cover. This uncertainty could be solved by the authors providing more detailed search strategy incl. specific MeSH terms they will be looking at in table 1. This is important also in terms of transparency and replicability of study results. Competing Interests No competing interests were disclosed. Reviewer Expertise epidemiology, patient safety, registry studies, orthopedic surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (0) Pedersen AB and Jensen SS. Peer Review Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46993) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46993 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hallen J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 May 2025 | for Version 2 Jamie Hallen , Neuroscience Research Australia, Randwick, New South Wales, Australia 0 Views copyright © 2025 Hallen J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have reviewed the revised version and am satisfied that my comments have been addressed. I am happy to approve the protocol and wish the authors well with their scoping review. Competing Interests No competing interests were disclosed. Reviewer Expertise hip fracture audit I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Hallen J. Peer Review Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15548.r46994) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v2#referee-response-46994 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Pedersen A et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 Apr 2025 | for Version 1 Alma Becic Pedersen , Aarhus University Hospital, Aarhus, Denmark Simon Storgaard Jensen , Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark 0 Views copyright © 2025 Pedersen A et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Overall: The protocol is well-written and provides a clear, structured approach to conducting a scoping review. It addresses a significant gap in literature and offers a novel contribution to the field. The authors could improve clarity in certain sections and provide further specificity regarding some of the methodological aspects of the protocol to ensure a more robust and transparent review process. Title: Clearly indicates the scope of the paper and specifies the focus on national hip fracture clinical audits as the subject of analysis. However, governance can be” broad” interpreted. Introduction: Page 3, section 1 “Hip fracture is a serious injury associated with high costs and poor outcomes, including both disability and increased mortality”. Consider adding a more recent reference, preferably one providing information on costs like IOF “Broken Bones – Broken Lives” reports or Borgström F, et al., (2020) [Ref-1] Page 3, section 1 “To improve international comparability, the Global FFN advocates …”. This part is very well-constructed and clearly states a gap in the literature. Page 3, section 2 The definition of governance is clear, but it could benefit from further refinement for greater precision. Specifically, the phrase "healthcare teams" could be more focused. Consider specifying that governance involves systems of accountability. Page 3, section 2 While the introduction to governance is clear, the connection to clinical audit could be elaborated. It might help to explicitly state that governance is a critical framework for ensuring that clinical audits meet established standards and contribute to quality improvement efforts. Page 3, section 3 The need for the review is clearly stated, but in terms of justification, the authors could highlight how governance impacts the quality, comparability, or generalizability of data. E.g. refer to improvements based on well-established NCA’s as mentioned in the beginning. Methods: Page 3, section 4 The authors clearly state that the scoping review will follow the Joanna Briggs Institute (JBI) methodology, which is appropriate and well-recognized. However, they could provide a brief explanation or justification of why the JBI methodology was chosen over other potential methodologies Engagement: The lead author’s extensive experience in hip fracture care and audit is well-documented, and the description of their roles in both the Irish Hip Fracture Database (IHFD) and the Global FFN is valuable Page 3, section 6-7 The knowledge user engagement strategy is well thought out, but it would benefit from more specific details about how knowledge users will be involved in the review process. For example, will knowledge users provide feedback during specific stages, such as data extraction or synthesis? Or will their involvement be primarily during the validation phase? Review questions One could consider adding a question that evaluates the impact or effectiveness of governance models on hip fracture audit outcomes, if applicable. Inclusion criteria Page 4, section 2 The authors should clarify how age will be handled or included in the scoping review, as many NCAs set age limits for patient eligibility, which may vary internationally. This is particularly important as age is closely related to many outcomes, such as mortality and recovery rates. For example, the Danish Hip Fracture Registry (DMHFR) includes patients aged 65 and older. Page 4, section 2 The authors should clarify whether ICD codes (e.g., S72 for Fracture of femur, S72.0 for Fracture of neck of femur, S72.1 for Pertrochanteric fracture, S72.2 for Subtrochanteric fracture) will be used to define hip fractures, or how the analysis will be conducted when comparing ICD-based NCAs to those using a 'broad definition' of hip fracture. Page 4, section 3-4 The authors should address how NCAs from healthcare systems with fundamentally different political and funding structures (e.g., state/tax-funded vs. insurance-based systems) may influence both patient treatment and data collection methods, particularly in the context of an international scope. Relevant studies The authors should consider incorporating MeSH terms into the search strategy to enhance the precision and comprehensiveness of the search. The inclusion of citations from the selected articles is mentioned, but it would be helpful to specify whether this will be in a systematic way (e.g., “snowballing approach”). Study selection The role of the third reviewer should be clarified in terms of how disagreements are resolved (e.g., consensus or final decision). Data extraction Consider providing details on tools for data extraction, e.g. COVIDENCE Data synthesis and presentation The process of compiling recommendations for key governance components is important. It might be beneficial to clarify who will be responsible for formulating the recommendations (e.g., the reviewers, expert consensus, or based on the most frequently reported components). Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Partly References 1. Borgström F, Karlsson L, Ortsäter G, Norton N, et al.: Fragility fractures in Europe: burden, management and opportunities. Arch Osteoporos . 2020; 15 (1): 59 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise epidemiology, patient safety, registry studies, orthopedic surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (0) Pedersen AB and Jensen SS. Peer Review Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r46190) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-46190 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hallen J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 Mar 2025 | for Version 1 Jamie Hallen , Neuroscience Research Australia, Randwick, New South Wales, Australia 0 Views copyright © 2025 Hallen J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review this scoping review protocol, which aims to identify the core governance components for national hip fracture audits. I agree that a scoping review on this topic is valuable, given the complexities associated with national audit governance. Introduction Whilst the focus is on hip fracture audits, national audits / registries exist for many clinical domains. As such, guidance and publications may not be specific to hip fracture audits. The authors should consider including publications that focus on the governance of national audits more broadly. Consider referencing existing work e.g. Asia Pacific Hip Fracture Registry Toolbox Consider revising the definition of governance, which is focused on clinical governance in health care, with reference to health care teams and staff rather than governance as it relates to the topic area (acknowledging that there is some overlap in the principles). Methods The methodology is appropriate for conducting a scoping review of this nature, with reference to use of the up to date PRISMA-ScR reporting guidelines. Inclusion criteria The PCC framework does not appear to adequately frame the scoping review question Population should not include hip fracture patients (as studies related to the patient cohort aren’t the focus of the review). The population focus be the NCA’s for hip fracture (currently described in context). Concept should include governance of NCAs as this is the central idea of the scoping review. Relevant studies The search strategy should be broadened to include more detailed information around the grey literature, as audit governance frameworks may be less commonly published in academic journals / as traditional publications. There is reference to inclusion of concepts related to clinical audits (e.g. registries, databases) but it is unclear how these terms will be factored into the search strategy. As mentioned previously, national guidance for clinical audits may exist without being specific to hip fracture. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise hip fracture audit I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Hallen J. Peer Review Report For: Protocol for a scoping review to explore governance for national hip fracture clinical audits [version 2; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :24 ( https://doi.org/10.21956/hrbopenres.15427.r45747) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-24/v1#referee-response-45747 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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