Skip to content

Enhanced recovery following hip and knee arthroplasty: A systematic review of cost-effectiveness evidence

Research output: Contribution to journalArticle

Original languageEnglish
Article numbere032204
Number of pages12
JournalBMJ Open
Issue number1
DateAccepted/In press - 4 Dec 2019
DatePublished (current) - 15 Jan 2020


Objectives: To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

Design: Systematic review of cost–utility analyses.

Data Sources: Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database, and EconLit, January 2000 to August 2019.

Eligibility Criteria: English-language peer-reviewed cost–utility analyses of enhanced recovery pathways, or components of one, compared to usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

Data extraction and synthesis: Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria (CHEC) list, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Assessment of the Validation Status of Health-Economic (AdViSHE) decision models tools; for trial-based studies the Cochrane Collaboration’s tool to assess risk of bias. No quantitative synthesis was undertaken.

Results: We identified 17 studies: five trial-based and 12 model-based. Two analyses evaluated entire enhanced recovery pathways and reported these to be cost effective compared to usual care. Eleven pathway components were more effective and cost-saving compared to usual care, two were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

Conclusions: Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

Registration: International Prospective Register of Systematic Reviews: CRD42017059473

    Research areas

  • cost-effectiveness, economic evaluation, hip replacement, knee replacement, osteoarthritis, systematic review

Download statistics

No data available



  • Full-text PDF (final published version)

    Rights statement: This is the final published version of the article (version of record). It first appeared online via BMJ at Please refer to any applicable terms of use of the publisher.

    Final published version, 2.11 MB, PDF document

    Licence: CC BY


View research connections

Related faculties, schools or groups