# Is check-up on demand non-inferior to routine follow-up at one year after total hip or knee arthroplasty in terms of clinical outcomes and cost-effectiveness? Protocol for a randomized stepped-wedge hybrid effectiveness de-implementation trial

## TL;DR

This study compares two post-surgery follow-up strategies for hip and knee replacements to see if a 'check-up on demand' approach is as effective and cost-efficient as routine check-ups.

## Contribution

The study introduces a novel hybrid trial design to evaluate a de-implementation strategy for routine follow-up after joint replacement surgery.

## Key findings

- The trial will assess clinical outcomes and cost-effectiveness of check-up on demand versus routine follow-up.
- It will measure the number of unplanned clinical visits and X-rays at one year post-surgery.
- An economic evaluation will be conducted from both healthcare and societal perspectives.

## Abstract

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are highly effective surgical procedures for patients with end-stage osteoarthritis. Due to population ageing and the rising prevalence of osteoarthritis, the demand for these procedures continues to increase, placing pressure on healthcare systems. Postoperative follow-up care contributes to this burden, yet internationally its timing and frequency after THA and TKA differ substantially. Dutch guidelines recommend routine follow-up (RFU) at 6–12 weeks and 1 year postoperatively. However, most complications are identified based on symptoms, often during unplanned visits. Consequently, the added value of a 1-year routine follow-up visit remains unclear, suggesting that alternative follow-up strategies, such as check-up on demand (COD) might reduce unnecessary visits.

This multicenter hybrid type II effectiveness de-implementation trial uses a stepped-wedge cluster randomized design across 10 Dutch hospitals. All hospitals will sequentially transition from RFU with scheduled follow-up visits at 6–12 weeks and 1 year postoperatively to Check-Up on Demand (COD), in which patients have a scheduled visit at 6–12 weeks and receive a leaflet with instructions on when and how to contact the hospital, without a scheduled 1-year visit. A total of 1,000 patients aged ≥50 years undergoing primary THA or TKA for osteoarthritis will be included. Each participating hospital will recruit 100 patients (50 THA and 50 TKA). The primary clinical outcome is PROMIS physical functioning at 2 years (i.e., 1 year after the 1-year follow-up moment). The primary process outcome is the number of patients who have a clinical visit or X-ray related to surgery at 1 year postoperatively. Secondary outcomes include complications, surgical interventions, additional healthcare consumption, quality of life, pain, satisfaction, and costs. An economic evaluation and budget impact analysis will be conducted from healthcare and societal perspectives. The trial is registered at ClinicalTrials.gov (NCT06971757).