Ultrasound Screening for Developmental Hip Dysplasia: A Markov Cost-Utility Analysis Comparing 6 Variations of Ultrasound Hip Screening to No Screening Modeled Across the Lifespan.

Abstract

Background: Developmental hip dysplasia (DDH) is now considered the primary cause of early hip arthritis. Complications of missed or delayed DDH may be minimized with early diagnosis and effective nonoperative interventions. The standard of care in the United States for detecting DDH is selective screening whereby ultrasound is only performed in infants with an abnormal physical examination or risk factors. A cost-effectiveness analysis, considering health utilities and lifespan costs, is warranted.

Methods: A Markov model was designed comparing 7 DDH screening strategies: Universal ultrasound screening at birth 2 weeks (USB); selective ultrasound screening at birth/2 weeks (SSB); universal ultrasound screening at 6 weeks (US6); selective ultrasound at 6 weeks (SS6); universal hybrid screening with ultrasound birth 2 weeks for positive examination and at 6 weeks for all others (UHS); a German national model with ultrasound at birth/2 weeks for instability or risk factors and all others at 6 weeks; and a no ultrasound screening. A literature review captured relevant probabilities, costs, and incidences. Society and payer perspectives were analyzed. Deterministic and probabilistic sensitivity analyses were used.

Results: From a societal perspective, US6 was more effective (77.08 vs. 77.06 quality-adjusted life years (QALYs)) yet minimally more costly ($5,629.68 vs. $5,471.50) than SS6. Using a willingness-to-pay threshold of <$100,000/QALY, US6 was more cost-effective than SS6 (incremental cost effectiveness ratio [ICER] = $7,833.45/QALY). From the payer perspective, US6 was again cost-effective relative to SS6 (ICER = $8,224.57/QALY). US6 was overall cost-effective (<$100,000/QALY) in 50.4% of 10,000 probabilistic sensitivity analysis iterations assessing societal costs (vs. 20.8% UHS, 13.2% SS6, 12.6% German, 2.6% USB, and 0.5% SSB) and 50.7% of payer iterations (vs. 21.0% UHS, 13.4% SS6, 12.3% German, 2.3% USB, and 0.4% SSB). UHS was the second most cost-effective (77.06 QALYs, societal = $5,668.58, payer = $4,351.63). Differences in mean costs and QALYs among leading strategies were small.

Conclusion: US6 was the most cost-effective strategy in the base case from both societal and payer perspectives. Given small differences in mean costs and QALYs among leading strategies, implementation feasibility and outcome distribution may be important policy considerations in the US context. A UHS strategy may represent a pragmatic pathway for adoption while preserving broader detection benefits.

Level of evidence: III. See Instructions for Authors for a complete description of levels of evidence.