To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip.
BACKGROUND
The United States Preventive Services Task Force recently determined that they could not recommend any screening strategies for developmental dysplasia of the hip. Disparate findings in the literature and treatment-related problems have led to confusion about whether or not to screen for this disorder. The purpose of the present study was to determine, with use of expected-value decision analysis, which of the following three strategies leads to the best chance of having a non-arthritic hip by the age of sixty years: (1) no screening for developmental dysplasia of the hip, (2) universal screening of newborns with both physical examination and ultrasonography, or (3) universal screening with physical examination but only selective use of ultrasonography for neonates considered to be at high risk.


METHODS
Developmental dysplasia of the hip, avascular necrosis, and the treatment algorithm were carefully defined. The outcome was determined as the probability of any neonate having a non-arthritic hip through the age of sixty years. A decision tree was then built with decision nodes as described above, and chance node probabilities were determined from a thorough review of the literature. Foldback analysis and sensitivity analyses were performed.


RESULTS
The expected value of a favorable hip outcome was 0.9590 for the strategy of screening all neonates with physical examination and selective use of ultrasonography, 0.9586 for screening all neonates with physical examination and ultrasonography, and 0.9578 for no screening. A lower expected value implies a greater risk for the development of osteoarthritis as a result of developmental dysplasia of the hip or avascular necrosis; thus, the optimum strategy was selective screening. This model was robust to sensitivity analysis, except when the rate of missed dysplasia rose as high as 4/1000 or the rate of treated hip subluxation/dislocation was the same; then, the optimum strategy was to screen all neonates with both physical examination and ultrasonography.


CONCLUSIONS
Our decision analytic model indicated that the optimum strategy, associated with the highest probability of having a non-arthritic hip at the age of sixty years, was to screen all neonates for hip dysplasia with a physical examination and to use ultrasonography selectively for infants who are at high risk. Additional data on the costs and cost-effectiveness of these screening policies are needed to guide policy recommendations.
Mahan
Susan T
ST
Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, Massachusetts 02115, USA. susan.mahan@childrens.harvard.edu
Katz
Jeffrey N
JN
Kim
Young-Jo
YJ
D003661:Decision Support Techniques; D003663:Decision Trees; D005271:Femur Head Necrosis; D006618:Hip Dislocation, Congenital / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D007231:Infant, Newborn; D015997:Neonatal Screening; D009989:Orthotic Devices / Q000009:adverse effects; D015207:Osteoarthritis, Hip / Q000209:etiology; D010808:Physical Examination; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014463:Ultrasonography