Screening for developmental dysplasia of the hip in primary care : implementation by simulation

Abstract

Developmental Dysplasia of the hip (DDH) is a disorder which occurs at an early age. Early discovery and treatment of DDH can reduce the chance on joint deviation in the future. Screening on DDH is done at a young age in the Netherlands. Current screening in the Netherlands exists from doing physical hip examination in combination with risk factor assessment. In the Netherlands this screening is organized by youth health care and takes place in infant health care centers (IHC). However, earlier research has shown that current screening on DDH is not valid. A high proportion of the referred children are unnecessary referred (86%). For this reason in the Netherlands, but also in other countries, the replacement of current screening by ultrasound screening is reviewed using method of R. Graf. In 2007, an implementation study has started in the Netherlands in which ultrasound screening is implemented in routine care of IHCs at the age of three months. This thesis describes the (cost-) effectiveness results of the implementation study. In total 15 IHCs participated in two areas, five in an urban area and ten in a rural area. In order to obtain a representative sample, the rural area organizations were located in different villages. The centers in the urban area were located in different social areas such as a high income inner city area, a low income inner city area and three relatively new suburban areas with a mixed population. Parents of 5266 children were asked to participate with their three month old child in this study. In total, 4080 children were screened using ultrasound to detect DDH at the age of three months. The US screening was performed by nurses and physicians working in the preventive IHC centers and by radiographic technicians. All screeners were theoretically trained in the screening method, according to Graf, by a pediatric radiologist and a pediatric orthopedic surgeon in three days. The results showed that there were no more missed cases compared to current screening (0.5%). Also, overall fewer children were referred compared to current screening (12% compared to 19 %) and also fewer children were incorrectly referred (37% compared to 86 %). Between the two regions the most important differences were participation rate (in the urban area 65% and 90% in the rural area), referral rate ( 7% in the urban area and 16% in the rural area) and screen detected cases (5% in the urban area and 10% in the rural area). The introduction of national quality control institute can help to introduce the screening in a safe way in routine practice through out the Netherlands.