Implementing Rapid Recovery Programs in Total Hip and Knee Replacement Surgery: Challenges and Opportunities in Austria

Research areas: High tech medicine, HTA-methods & steering instruments

Duration: Q1 2026 to Q2 2026 (6 PM)
Language: English (with German summary)

 

Background:
A reform of the hospital financing system in Austria, effective January 1st, 2025 [1], has created significant pressure to discharge patients as quickly as possible, as hospital stays of up to two days are now reimbursed immediately. To avoid a decline in medical quality, there is an urgent need to implement suitable support programmes nationwide in the coming years. In many countries, Rapid Recovery programs have already been successfully implemented - but not in Austria on a nation-wide scale. Therefore, various hospitals are interested in Rapid Recovery programmes and have already piloted them. However, without a structured protocol in place to support hospitals, any efforts towards successful implementation are personnel-dependent and run the risk of failing due to weaknesses in the care pathway and limited collaboration between service providers.

The Enhanced Recovery After Surgery (ERAS) society [2]has been publishing guidelines for Rapid Recovery programs since 2005, covering a wide range of surgical procedures. However, in real-world settings with differently organised public healthcare systems, the possibilities of implementing all components of these comprehensive guidelines are limited. There is therefore a need to analyse the possibilities that the Austrian healthcare system provides and to offer recommendations for the successful implementation of suitable interventions from these guidelines.

After an expert consultation, Orthopaedics was identified as the most relevant field for analysing the implementation of Rapid Recovery programs. The ERAS Society has guidelines for spinal lumbar fusion and total hip and knee replacement surgery [3], with the latter [4]identified by the experts as the most relevant.

Project aims:
This project aims to identify effective and safe programs and protocols that reduce the length of hospital stay without compromising the quality of care or worsening patient outcomes in the Austrian setting. The goal is to provide recommendations for implementing Rapid Recovery protocols in Austrian hospitals, with all preoperative, intraoperative and postoperative aspects considered.

Research question:
Primary question
How effective and safe are Rapid Recovery measures in total hip and knee replacement surgery compared to the standard of care?

Secondary questions
1)     How can ERAS guidelines for total hip and knee replacement surgery be adapted and implemented within the Austrian public healthcare system to reduce length of hospital stay, while maintaining or improving quality of care and patient outcomes?

2)     What structural and organizational barriers, particularly regarding the interface between inpatient and outpatient care and collaboration between service providers, currently limit the implementation of Rapid Recovery protocols in Austria, and how can these be addressed?

3)     What is the cost-effectiveness of Rapid Recovery components identified in the primary question compared to the standard of care?  

Methods:

1.)   To identify the relevant sources of information, a scoping phase is required, encompassing a review of recommendations from professional societies, publications in PubMed, and discussions with experts, prior to commencing the systematic literature search.

2.)   To answer the primary research question, a Health Technology Assessment (HTA) will be conducted on a stepwise approach:

a.     In the first step we will search for systematic reviews (SR) for elective primary total hip and knee replacement surgery. Based on the evidence and quality, either a review of review or an update of the SR will be conducted using the Cochrane Handbook for Systematic Reviews of Interventions [5].

b.     In case no existing and recent SR with sufficient evidence and quality is found, we will conduct a SR including primary studies and we will use the GRADE approach.

c.      Then, the most relevant elements from the ERAS protocol will be identified.

3.)   To answer the secondary research question part 1 and 2, the identified literature will be screened to identify the main organizational elements that are required to successfully implement rapid recovery programs. If needed, an additional search will be conducted. After identifying the main organisational elements, the most relevant interventions (identified in the primary research question) will be assessed for their implementation.

4.)   To answer the secondary research question part 3, an additional search for cost-effectiveness evidence will be conducted, including only studies that assessed Rapid recovery elements identified as relevant in the primary research question. Subject to the availability of such evidence, key characteristics and results of the identified studies will be summarised. Study quality will be appraised using a suitable checklist.  

Search criteria: Population and comparator as specified in the clinical review protocol above. Intervention restricted to the Rapid recovery elements identified in the primary research question. Setting restricted to health systems comparable to the Austrian healthcare system.

Study design: Relevant health economic study design (cost–utility analysis, cost-effectiveness analysis, cost–benefit analysis, cost–consequences analysis, comparative cost analysis).

Inclusion criteria (PICO for primary research question):

Population	Adult patients undergoing elective primary total hip or knee replacement (THR – total hip replacement/TKR – total knee replacement)
Intervention	Standardized perioperative care according to the ERAS® protocol: Preoperative interventions (prehabilitation): Preoperative information, education, and counselling Preadmission patient optimization Preoperative physiotherapy Preoperative fasting Preoperative carbohydrate treatment Pre- anaesthesia protocol medication Standardized anaesthesia protocol Intraoperative intervention: Surgical technique Standardized anaesthesia protocol Local anaesthetics for infiltration analgesia and nerve blocks Postoperative nausea and vomiting (PONV) prophylaxis Prevention of perioperative blood loss Multimodal oral analgesia Maintaining normothermia Antimicrobial prophylaxis Antithrombotic prophylaxis Postoperative interventions: Perioperative fluid management Postoperative nutritional care Early mobilisation Criteria-based discharge Continuous improvement and audit
Comparison	Conventional standard perioperative care without/only partially structured ERAS protocol
Outcomes	Length of hospital stay, perioperative complication rates, rehospitalization rate (30 days), postoperative function, mobility, mortality, patient-reported outcomes, adverse events, complications related to early discharge
Publication type	Meta-analyses and SR of randomised controlled trials (RCTs), HTAs; If no SR with sufficient evidence and quality is found, primary studies will be searched
(Countries)	North America, Europe
Languages	English, German

Timetable:

Period	Tasks
January – March 2026	Scoping, stakeholder meeting and finalising the project protocol
March – April 2026	Systematic literature search and manual searches Selection of literature
March – April 2026	Data extraction and quality assessment
April – June 2026	Writing the report
June 2026	Internal and external review
July 2026	Layout and publication

References:

[1]        Bundesministerium für Arbeit, Soziales, Gesundheit, Pflege und Konsumentenschutz. LKF-Systembeschreibung 2026. In: Bundesministerium Arbeit, Soziales, Gesundheit, Pflege und Konsumentenschutz, editor. 2026.
[2]        ERAS Society. About us: History. 2026 [cited 03.03]. Available from: https://erassociety.org/about/history/.
[3]        ERAS Society. Orthopedics. 2026 [cited 04.03]. Available from: https://erassociety.org/guidelines/#filter=.orthopaedic.
[4]        Wainwright T. W., Gill M., McDonald D. A., Middleton R. G., Reed M., Sahota O., et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica. 2020;91(1):3-19. DOI: 10.1080/17453674.2019.1683790.
[5]        Higgins J., Thomas J., Chandler J., Cumpston M., Li T., Page M., et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (updated August 2024). 2024. Available from: www.cochrane.org/handbook.