An equivalence, single-blind (assessor-blind), 2-arm, feasibility RCT with a 1:1 allocation ratio will be conducted to compare an eHealth program to standard care for people undergoing elective THR.

Patients referred to the OsteoArthritis Service Integration System (OASIS) program (n>250/year), a central intake program administered by Vancouver Coastal Health in Canada, will be approached to participate.

T1 data will be collected at approximately 12 weeks before the THR surgery. Follow-up data will be collected 7-10 days prior to surgery (T2), 30 days and (T3) postsurgery. Figure 1 shows the participant timeline.

The suggested sample size for feasibility RCTs ranges from 12 to 30 per arm [33,34]; therefore, we aim to recruit 40 participants and randomly assign them to the HIPPER group or control group (usual care). Following other feasibility RCTs (eg, [35,36]), descriptive information on feasibility outcomes and means, SDs, and Cohen d effect sizes will be provided to be used in the future multisite RCT.

The feasibility RCT is a vital step to estimate the parameters needed for designing a full-scale RCT [37] that selects the right outcome measures, fidelity of the protocol and randomization, feasibility of recruitment, adherence and response rate, and feasibility of quantitative measures.

The OASIS will send mail to or email patients who are on the waitlist for THR. Patients will be encouraged to contact the researchers to learn more about the study.

Our collaborators at OASIS will send mail to or email the patients who are on a waiting list to attend prehab classes. Interested patients will be encouraged to contact our research center. They will be interviewed by the assessor to determine eligibility. Upon successful screening, participants will be sent a PDF version of the consent form to keep for their record and also a link to the online consent form on Qualtrics, a secure data collection tool. Participants will be asked to sign the online consent form. Participants will be given at least 24 hours to read the consent form before attending the T1 data collection online meeting. After signing the consent form, participants will be asked to attend the T1 data collection online meeting. During this initial meeting, the assessor will help them complete a set of questionnaires using Qualtrics. In addition to the self-reported measures, the assessor will ask participants to complete the 30-sec CST, which is a performance test. Participants will be asked to complete the test at home while communicating with the research coordinator as part of the online meeting. Participants will be video recorded during the 30-sec CST. Immediately after they complete the T1 measures and the 30-sec CST, the assessor will leave the meeting, and the research coordinator will join the participant and use secure online software [38] to randomize the participant. The assessor will remain blind to the randomization result.

To collect the data at T2 and T3, the assessor will send a link to the participants to complete the questionnaires in Qualtrics. In addition, at T2 the assessor will contact the participants to schedule a short online meeting during which the participants will be asked to do the 30-sec CST via videoconference. The assessor will ask the participants to not reveal their group allocation to them.

After participants complete the T1 measures, the assessor will invite the research coordinator to join the Zoom meeting; then, the assessor will leave the meeting. During the meeting, the research coordinator will use the Simple Randomization Service provided by Sealed Envelope [38] to randomize the participant into the HIPPER or control group. The research coordinator will add the participant ID to the account that we created for this trial and then click on the randomize button. Then, the Simple Randomization Service provided by Sealed Envelope [38] will randomize participants into either group A (HIPPER) or B (Control). We will not stratify the sample. Block randomization will be used to ensure equal number of participants will be in each group. The assessor will remain blind to participants’ group allocations. After randomization, the research coordinator will give participants instructions based on their group. In addition, the research coordinator will ask the participants to not reveal their group to the assessor.

Given the nature of the study, it is not possible to blind the participants and the research coordinator to the participant’s group after baseline data collection. However, the assessor will remain blinded throughout the study. The assessor will be responsible for setting up the Qualtrics measures for the participants. In Qualtrics, the survey has been set up with only one arm; therefore, the assessor will not need the participant’s group to schedule the invitations.

After baseline data collection, the assessor will only contact participants to remind them to fill out the questionnaires and perform the 30-sec CST. To address performance bias, participants will be instructed not to discuss their group allocation, and the assessor will reinforce this point before starting each data collection session. The assessors will be asked to track and report any unblinding. If unblinding occurs before the data collection for that session, the assessor will reschedule the session, and another assessor will complete the data collection. If unblinding happens after the data collection at T2 or T3, another assessor will be assigned for the remaining data collection session(s). Using patient-reported and standardized objective measures also decreases risk of performance bias. In addition, the assessor will video record the the 30-sec CST. This test will be scored by the assessor and another researcher (who has not been involved in performing the 30-sec CST). If there is a discrepancy between the assessor’s and the other researcher’s score on the 30-sec CST, a third researcher will be involved to score the 30-sec CST. This will prevent any bias in scoring the 30-sec CST that may arise from the assessor’s assumptions about the participant’s group allocation.

A Data and Safety Monitoring Board (statistician, occupational therapist/physical therapist, person with a THR) will review outcome data and advise the team on safety and any need to modify the study design [44]. The Data and Safety Monitoring Board is independent from the funding agency. More information about the board can be found by contacting the primary investigator.

Interim analyses will be conducted after the first 10 participants complete T2 and after the first 10 participants complete T3.

HIPPER incorporates extensive safety-related material including modified home setup (eg, elimination of scatter rugs) in the educational modules. However, adverse events (eg, falls during the 30-CST test) will be recorded and will be reported to the investigators. This process will be independent from the funding agency. In the very unlikely circumstance in which participants experience a decrease in function, substantial injury, or discomfort from their activities in this study, the investigators or study trainers will contact all participants by phone or email and inform them the study is being stopped and explain the reason. 

Ethics approval was obtained from our university Research Ethics Board (H16-02553) and the Vancouver Coastal Health Research Institute (V16-02553). Any changes in the ethics will be submitted as an amendment to our Research Ethics Board. The assessor will be responsible for collecting consent forms from the participants. A PDF version of the consent form and a link to the online version of the consent form will be sent to the participants at least 24 hours before the T1 appointment. Participant will be given the option to either e-sign the PDF version or add their signature to the online consent form.

Email addresses will be captured because the measures should be sent to the same email address throughout the study; however, when conducting the analyses, all identifiable information will be removed from the data. The e-signed consent forms will be received through an email address provided by our research institute that will only be used for this project. Videos of participants will be labeled using a combination of their participant number and time point. Videos will be zipped, and we will add a password to the zipped file to ensure their security. The consent forms and videos will be password protected and will be saved in our lab drive, which is located on our research institute’s servers in a separate folder than the data and the participants’ contact list. The main participants’ data will be collected with the University of British Columbia Qualtrics, and therefore, the servers are located in Canada. 

The corresponding author will be responsible for the data for at least 5 years after the work is published or otherwise presented. At the end of this 5-year period, the paper copies will be shredded using a bonded company, and the computer files will be deleted. The videos will be zipped, and the zipped filed will be password protected. All videos will be saved in a separate folder on an encrypted and password-protected computer. Specifically, the videos will be only saved on our lab’s drive, which is managed by our research institute’s information technology department. All members of the study team will have access to the data. The list of the study team members can be found by contacting the corresponding author.

Our knowledge translation plan will target clinicians both nationally and internationally (clinicians’ feedback will be used to further improve HIPPER), leveraging existing communication tools such as websites (eg, health authorities in BC), electronic and print newsletters (eg, Physiotherapy Association of BC), presentations at provincial practice forums, webinars for rural clinicians, and social media (eg, Twitter). Building on existing partnerships with Bone and Joint Canada and the Arthritis Health Professions Association, a summary will be prepared for their websites and electronic newsletters to reach a national audience. Abstracts will be submitted to conferences (eg, Canadian Orthopaedic Association Meeting). Manuscripts will be submitted for publication. If HIPPER is effective, we will collaborate with OASIS and will allow HIPPER to be hosted on the OASIS website [45]. OASIS and VCH will be responsible for updating and maintaining the content of HIPPER after the end of the research study.

There is no plan to use professional writers for disseminating the findings of this study. Participants who are interested in finding out about the results of this study will be sent a lay summary of the findings. The protocol of this study will be available to anyone interested.

eHealth is a promising way to address 2 substantial weaknesses in most prehab and presurgical programs, as it can (1) offer learning that is interactive (unlike printed materials) and (2) enable learners to engage over sustained periods (unlike single group sessions). Moreover, eHealth has the potential to improve quality of care for older adults [12,13,46], enhance communication between patients and health care providers [14], reduce costs, and increase access to evidence-based health information. Recent studies have shown that online interventions can substantially increase older adults’ well-being [47] and physical activity levels [48]. In addition, available data show that internet use is growing rapidly among older Canadians. In BC alone, 86% of those aged 45-64 years make up the fastest growing cohort of individuals who need THR [49]. Considering the potential benefits of online education for older adults and the increase in the use of technology, it is reasonable and essential to develop eHealth tools for this population.

HIPPER was developed with the aim to improve access to existing knowledge for patients and their families and provide customized (eg, through understanding patients’ perspectives and having a digital interaction component), interactive (eg, quizzes), and engaging eHealth education (eg, using educational videos and audio) to better prepare patients for THR. In addition, HIPPER will increase patient knowledge and health literacy by facilitating access to prehab education. HIPPER will enable self-paced learning, with the support of family caregivers and from the comfort of the patient’s home, thus reducing the burden on patients, families, and health care providers. It will also allow for standardized information to be delivered regardless of geographical boundaries. In contrast to written educational materials, HIPPER’s content can be quickly updated with minimal financial burden on the health care system. Finally, it will reduce direct clinician contact and travel demands, leading to a reduction in both direct and indirect health care costs.

The results of this feasibility study cannot be generalized to all patients who are preparing for THR. However, considering that more than 85% of patients who undergo hip replacement are >50 years old [50] and more than 90% of BC’s population speaks English [51], we are confident that this study will include a representative sample of THR patients. In our future full RCT, we aim to recruit patients from both urban and rural areas in BC to improve the generalizability of HIPPER. Despite developing the HIPPER modules with a user-centered approach, it is plausible that eHealth approaches may favor younger cohorts with greater computer experience and discourage older adults from participating [52]. While this assumption will be explored statistically, our patient partners’ suggestions for “marketing” to older adults and adding basic computer training in the module introduction may address this issue. We will try to minimize barriers related to technology by sending each participant a guideline on how to use HIPPER, encouraging participants to contact the research assistant for further instruction, and inviting family caregivers to help participants use the online modules. In addition, in the current study, it is not possible to blind the participants to their group as it will be clear to participants what type of intervention they are receiving. Therefore, as other studies have suggested, the effect size might be substantially higher in trials in which participants are not blinded [53,54]. As recommended by previous research [55], to overcome the lack of participants’ blinding, participants who previously attended OASIS webinars or in-person education will be excluded. In addition, participants in the control group will be prevented from accessing the HIPPER modules. Furthermore, the assessors in this study are blinded, and we will ask them to report any unblinding immediately. The assessors will be replaced if they report any potential or actual unblinding.

Finally, participants in the HIPPER group may be directed to the OASIS webinar educations by their surgeon, other health care providers, and other patients. Therefore, our educators at OASIS will be given the names of the participants and will be asked whether the participants attended any webinars. Participants in both HIPPER and control groups will also be asked at T2 whether they attended the OASIS webinars. Similar to previous studies [39], we anticipate a 20% dropout rate, meaning that participants will decline to participate in the study. If we encounter any dropout, we will recruit additional participants to keep the sample size for each group at 20.

This project is a feasibility and preparatory study. The findings will be used to develop a definitive RCT, which will help us test the impact of HIPPER in a larger sample size before making it widely available for patients undergoing THR. If HIPPER is found to be effective in the future trial, we will collaborate with OASIS to host HIPPER on their website and encourage broad dissemination and implementation throughout BC.