This mixed methods co-design and implementation study will be reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement [24]. To address the 3 distinct aims, the study will be conducted across 3 phases informed by the generative co-design framework for health care interventions [25], as outlined in Textbox 1 [26-29]. A learning community will be established, comprising patients, health care staff, administrators, and researchers, to inform and guide each stage of the co-design process.

This study has been approved by the St Vincent Hospital Human Research Ethics Committee (2024/PID00354 LRR 288/24) under the National Health and Medical Research Council of Australia National Mutual Acceptance Scheme. The study has also received research governance approval from La Trobe University (LRR 288/24), with Northern Health research governance to be sought before any direct recruitment of Northern Health staff or patients. Participants will provide consent as follows: (1) written informed consent for patient and staff interviews, and (2) implied consent for the use of data generated through the completion of the DCP. Participants’ privacy and confidentiality will be maintained in accordance with ethical approval conditions and local laws. People with lived experience of joint arthroplasty that participate in the interviews in phase 1 or phase 3 will receive an Aus $20 (US $13.07) gift card following the interview. Individuals who participate in the DCP, as well as organizational and clinical staff, will not receive compensation for their participation.

The study will be conducted at Northern Health, Victoria, Australia [30]. Northern Health is the major provider of acute, subacute, and specialist services in Melbourne’s rapidly growing outer north corridor. The health service caters to a diverse population of patients who speak more than 100 languages. The catchment has lower levels of income, educational attainment, and health literacy and higher rates of unemployment than the Victorian state averages [31]. Northern Health has pioneered digital health integration through initiatives such as the Victorian Virtual Emergency Department [32] and DCPs [22].

The key touchpoints associated with elective arthroplasty in the public health service are illustrated in Figure 1. Each touchpoint provides an opportunity to reinforce education provided by clinicians through electronic or digital resources, codeveloped with patients. For example, when patients are deemed suitable for surgery, there can be long wait periods from the preadmission clinic to the surgery date. This provides an opportunity to deliver evidence-based education and structured prehabilitation, aimed at optimizing physical function, managing comorbidities, supporting psychological readiness, and promoting healthy lifestyle behaviors. At the preadmission clinic, patients could receive additional resources to support their preparation for surgery. These resources might include information on pain management strategies, expectations regarding acute recovery, guidance on postoperative mobilization, and discharge destination. Other potential resources, highlighted in a recent systematic review, that have been used in prehabilitation include, but are not limited to, general hospital and surgical information, daily living and home preparation, and psychosocial and supportive aspects (eg, to reduce fear and anxiety around surgery) [10]. The integration of patient-reported outcomes and remote patient monitoring could enable patients and clinicians to follow the trajectory of recovery with benchmarked standards [33].

Formal participant inclusion and exclusion criteria for phases 1 and 2 of the study are outlined in Textbox 2. For phase 2, people with lived experience of arthroplasty from phase one, as well as Northern Health staff working in perioperative hip or knee arthroplasty surgical care, will be invited to participate in co-design workshops and provide feedback on the development of the DCP consistent with the co-design steps of the generative co-design framework for health care innovation [25].

Developing a protocol that explicitly outlines the co-design methods proposed for the DCP is important, given the inconsistent reporting evident in the existing literature. The umbrella review by Kilfoy et al [13] highlighted that while co-design is widely promoted as a strategy to enhance the effectiveness and sustainability of digital health interventions, its application is inconsistently reported, with details of participant involvement and methodological rigor often lacking. The absence of clear reporting impedes the evaluation, reproducibility, and progression of existing work, restricting the incorporation of equity and stakeholder perspectives in digital innovation. By specifying our co-design approach, this protocol contributes to methodological transparency, strengthens the evidence base, and ensures that the resulting pathway is both credible and transferable to other contexts and settings. Therefore, we present our study protocol for this mixed methods co-design and implementation study that aims to understand the lived experience of people with knee and hip arthroplasty, co-create a DCP and evaluate its feasibility and appropriateness of implementation.

This study will inform the development and ongoing iterative improvements of a DCP for people undergoing arthroplasty, underpinned by the engagement with end users. This engagement aims to address the lack of patient-centric programs in perioperative joint replacement care and allow the health services to better consider patients’ individual needs and preferences [11,13]. The digital nature of the care pathway aims to address access barriers associated with a lack of transportation [14] and allows patients to engage with their ongoing care at any time, regardless of their location [16,17].

The patient-reported outcome measures collected through this DCP will provide a greater understanding of symptom recovery trajectories of people undergoing hip and knee arthroplasty. Our current understanding is limited to isolated studies [33], which may not reflect the current patient outcomes. We hope to supplement this work by capturing rich, real-time data, allowing patient recovery to be mapped and compared with benchmarked trajectories over time. The data obtained will also inform patient education regarding realistic recovery expectations and timelines, and underpin the development of further resources to support this. Although this study aims to evaluate the DCP over the first 6 months of its implementation, the objective is to integrate the pathway into ongoing standard-of-care practices. As a result, the DCP will undergo continual refinement on an iterative basis to adapt to the changing landscape of the health care system [22].

This mixed methods co-design implementation study is consumer-driven, with patients and carers actively involved from problem identification to solution design and evaluation. This approach ensures that the development of a DCP for joint replacement is grounded in lived experience, addressing real gaps in care and unmet needs. By embedding co-design principles and drawing on established frameworks, this study privileges consumer voices, promotes collaboration between patients and clinicians, and increases the likelihood that the resulting pathway will be acceptable, relevant, and sustainable in practice.