Recruitment of the trial began in January 2018 and data collection is due to be completed within 12 months.

The setting of this study is a private metropolitan hospital in Western Australia with a focus on orthopedic surgeries. In 2017, there were a total of 848 hip surgeries performed in the hospital by 24 orthopedic surgeons. As the hospital is a private hospital, the surgeries are mostly funded through patients’ private insurance.

Patients undergoing a primary elective THA will be invited to take part in the RCT. Patients will be screened and recruited during the usual pre-admission phone call conducted by the pre-admission nurse. Inclusion criteria are as follows: (1) the patient is undergoing a primary elective THA, (2) the patient is able to provide informed consent, (3) the patient is aged 18 years or over, and (4) there is a minimum lead-up time of three weeks prior to surgery. Exclusion criteria include the following: (1) the patient is undergoing a THA revision, (2) a bilateral THA, or (3) THA following a fractured neck of femur, (4) had a previous THA, (5) unable to converse in written or spoken English, (6) has no access to a Web-based device, and (7) has a risk assessment and prediction tool (RAPT) score less than six. The RAPT uses pre-operative patient factors of age, gender, pre-operative ambulatory distance, use of gait aid, community support, and presence of a home caregiver to predict their need for extended care after a THA [13].

One hundred patients will be randomized with a one-to-one treatment allocation to the intervention (n=50) or standard care (n=50) group at the time of consent. Allocation concealment in the order of recruitment will be conducted “off-site” after consent has been obtained. Permuted block randomization will be conducted to ensure an equal number of participants are allocated to each group per week. This will be conducted in weekly blocks of 10. Due to the nature of the research, blinding will not be possible for either the participants or the health care team. The researcher conducting the data analysis, however, will be blinded.

The comparator for the trial, namely standard care, is an Enhanced Recovery Program based on an orthopedic recovery program established in The United Kingdom [14]. It consists of participants receiving paper-based information, attending a 1-hour hospital-based face-to-face pre-operative education session, and a postdischarge follow-up phone call. The education session is presented by a registered nurse, occupational therapist, pharmacist, and physiotherapist and participants are encouraged to bring their support person to the session. Examples of the content in the paper-based information and education session include fall prevention, wound care, showering, healthy eating, returning to work, pain management, and selecting a personal alarm. The postdischarge phone call is conducted within one week of discharge by a registered nurse from the ward. During the phone call the nurse will ask specific questions about how the patient is coping postdischarge, including questions about pain management, wound healing, exercise and mobility, nutrition and hydration, bowel management, and how well the patient is managing daily living activities.

The intervention for the trial is standard care as described above plus the addition of the eHealth education program. The eHealth program was developed specifically for patients undergoing a THA by a multidisciplinary team of clinicians, researchers, and consumer representatives. It provides information about the care requirements during the journey of a hip replacement, advice on well-being, and an exercise program. The information in the eHealth education program is for patients, support persons, relatives, and community health professionals and gives information on what to expect pre-operatively, whilst in hospital, postoperatively, and postdischarge.

Participants will access the eHealth program via a weblink after registration using a username and password. The program is designed to give participants continual access to information, at a time that suits them without them having to come to the hospital. It is recommended that participants use the program on a daily basis starting 2 weeks prior to surgery until 30 days postsurgery. However, the participants may have access to the program up to 4 weeks pre-operatively and will continue to have access until 12 months postsurgery. The eHealth program provides a suite of educational resources including fact sheets, videos, exercise videos, and email reminders about the pre- and postoperative care of a hip replacement. The resources are linked to the participants’ journey with a focus on personal wellbeing and its importance in the pre-operative and postoperative periods. Some examples of the resources included in the eHealth program are preparation for surgery, nutrition, pre- and postoperative exercise regimes, and medication management with additional information provided on walking aids and safety if living with pets. Each day, when the participant logs into their “My Program” window, it will display a list of videos and information as well as exercises that have been allocated for them to view or complete that day (Figure 1).

Each exercise is allocated a specific number of repetitions and sets that the participant is required to perform, and this information is included with the information about the exercise for the participant. Participants have access to the health care team via the program’s email for 4 weeks postdischarge and can invite their regular health care providers (such as their community occupational therapist and physiotherapist) or support person to be part of the program. The health professional team at the hospital can personalize the participant’s program including the exercises by editing in number of sets and repetitions recommended for each exercise.

Intervention fidelity will be assessed using analytics built into the website. After a participant watches a video or reads information, they will be prompted rate it. The program will then mark it as read and record information about how long the participant spent on that piece of information. In addition, after the exercise videos are completed by the participant, they will be prompted to mark them as complete. Automatically generated emails from within the program are sent on a regular basis to inform participants of the information available on the platform and provide instructions pre- and postoperatively. The health care team have access to the platform and can view the website analytics for each participant.

Outcome measures will be collected at four time points, namely at pre-admission, 6 weeks, 3 months and 6 months after the surgery. Figure 2 presents a flow chart of the recruitment and trial participation process and Table 1 outlines the outcome assessments used in this study, as well as the collection time points for the assessments. Participants will be asked to complete the relevant assessments online and an email reminder will be sent to each participant when the assessment is due, followed by a reminder one week later.

A cost-effectiveness analysis comparing the developed eHealth program to standard care will be conducted from the hospital’s perspective on an intention-to-treat basis. Direct costs will include the service delivery costs associated with each program (brochures, photocopying, and Web-based application fees) as well as the cost of follow-up care (the time spent by health professionals organizing and providing face-to-face sessions, replying to emails, making telephone calls, and managing and monitoring online content). Cost data will be collected from pre-admission through to 6 months postdischarge using hospital medical records. Outcomes will include changes in HOOS and quality of life (measured using the EQ-5D-5L). Incremental cost-effectiveness ratios (comparing the difference in cost between the eHealth program and standard care with the difference in the outcomes) will be calculated for HOOS and Quality Adjusted Life Years, and sensitivity analysis will be conducted on the key parameters.

Sample size calculations were conducted based on the primary outcome, the HOOS. Existing data were used to determine the minimal clinically important improvement [18] and SD [19]. Based on a power of 90% and 5% significance level, 42 patients per group are needed. To allow for a dropout rate of approximately 15%, a sample size of 50 per group is required. Therefore, the estimated required sample size for the study is 100 participants.

Data will be reported in accordance with the Consolidated Standards of Reporting Trial (CONSORT). Mean (SD), median (interquartile range) and percentages will be used to describe the characteristics of the study group.

An analysis of covariance will be used to assess the primary outcome. The covariables will include age, gender, type of surgery, length of stay, RAPT score, and other comorbidities. Treatment effects will be calculated on the pre-to-post intervention outcomes at 6 weeks. Further analysis will be performed on the posttreatment effects at 3 months and 6 months postsurgery. The clinical treatment effect of each intervention group will be further analyzed using independent t tests, tests of medians, nonparametric tests, and chi-squared tests on pre-to-post intervention changes across the range of outcome measures and patient satisfaction.