Cost-effectiveness of screening for developmental dysplasia of the hip in children born in England and Wales.

Abstract

Aims: The aim of this study was to evaluate the cost-effectiveness of screening programmes for identifying developmental hip dysplasia (DDH) in children born in England and Wales.

Methods: The costs and quality-adjusted life-years (QALYs) associated with DDH screening programmes were estimated using a decision-analytic model. Six programmes were modelled from an NHS perspective: 1) Current practice - 'selective' screening: clinical examination with later ultrasound screening (USS) for those with an abnormal examination or specific risk factors (breech birth, first degree family history of DDH); 2) No hip screening: no clinical examination or risk factor assessment; 3) Clinical examination: treatment decisions based solely upon a positive Barlow or Ortolani manoeuvre; 4) Universal USS at birth: USS in the neonatal period in addition to a postnatal check; 5) Universal USS at six weeks: USS in addition to the six-week postnatal check; 6) Sex-stratified screening: clinical examination with selective USS for males and universal USS in the neonatal period for females. The incremental net monetary benefit (INMB) was estimated at a cost-effectiveness threshold of £20,000 per QALY gained. Whether the result was robust to assumptions was assessed using analyses of uncertainty. Secondary outcomes included an estimate of the value of reducing the uncertainty of the decisions.

Results: Universal USS (including stratification by sex) was more clinically effective, but at significant additional cost. Current practice was the most cost-effective screening programme in 96% of modelled simulations. Differences in INMB were statistically significant. The reconfiguration of service so that USS does not require additional hospital visits would reduce marginal losses and introduce uncertainty to the conclusion. The benefit of generating better evidence about a reconfigured USS service was valued at £1.91 per live birth, equating to £11 million over ten years.

Conclusion: Clinical examination with USS for those with an abnormal examination, or specific risk factors, is likely to be the most cost-effective DDH screening programme in the UK. Further research focused on the costs and efficacy of screening programmes could add value for informing future policy decisions.