Original Title: Programa de actividades de detección precoz de problemas de salud entre los 0 y 14 años. Efectividad, seguridad y evaluación económica de las diferentes alternativas existentes en la detección precoz de la displasia de cadera en recién nacidos

Authors' objectives: To perform a systematic review of economic evaluation studies regarding the cost-effectiveness of the different options for early detection of hip dysplasia in newborns

Authors' results and conclusions: RESULTS: They have been identified two review papers, one published by the U.S. Preventive Services Task Force and a Cochrane review. No studies were identified comparing screening programs developmental dysplasia of the hip (DDH) compared to the absence of a program of this nature. The results provided by the early diagnosis of DDH in reducing rates of surgery are inconsistent. Despite the existence of risk factors associated with the DDH, the most infants with DDH no risk factors . Include a universal ultrasound screening program of universal clinical examination by DDH increases statistically significant indications of any treatment and no statistically significant differences in the incidence of late diagnosis of DDH. The use of ultrasound to monitor infants with hip instability or mild dysplasia versus follow up with clinical examination, no statistically significant differences in the incidence of late diagnosis of DDC . There are significant differences in reducing any treatment with ultrasound monitoring option. On economic evaluation, the systematic review includes 5 articles of economic evaluation: 3 cost-effectiveness studies and 2 cost analysis studies. The population included was newborn and children. Four studies used a health system perspective and 1 study a social perspective. Three studies used a decision-analysis approach, while in the remaining two studies the model is not described. Primary sources were mainly used for effectiveness data, use of healthcare resources and costs. In the 3 cost-effectiveness studies the following measures of effectiveness were considered: 1) Cost per case detected, the following alternatives were considered: the no-screening approach, universal screening by clinical examination, ultrasound screening of high-risk population, and universal ultrasound screening; 2) Costs per screened child, considering universal clinical examination, selective screening of high-risk population (clinical examination and ultrasound imaging) and universal screening (clinical examination and ultrasound imaging); and 3) Cost per patient, considering clinical examination and the ultrasound approach as the alternative. Clinical examination was the universal screening method with the lowest cost per case detected. One study recommends universal screening by clinical examination; another study recommends universal screening by clinical examination and ultrasound imaging. Finally no recommendation is given in the last one of the three studies. Clinical examination is recommended in one out of the two costs analysis studies whereas ultrasound imaging is recommended in the other one, although this method is a more expensive alternative. The rational behind this is that using ultrasound imaging would reduce the number of surgical interventions. DISCUSSION: Early detection of DDH should be allowed to establish a treatment to reduce or prevent the occurrence of irreversible lesions of the hip joint and its aftermath. Early detection of DDH allows early identification of infants at increased risk of DDH, but there is no evidence that treatments are being implemented to improve the functional outcomes of these patients. Even the use of ultrasound is controversial, as a resource for the early detection of DDH, so that, while scientific society promote their use as a tool for early detection of DDH in case that there are risk factors, other proposed use as universal tool for early detection of DDH. All this in a context that indicates a possible overtreatment and where the work on economic evaluation are inconsistent in their results on the best strategy for early detection of DDH. CONCLUSIONS: No studies were identified comparing alternatives for early detection of DDH versus expectant attitudes. Early detection of DDH is possible, in a context in which the effectiveness and safety of interventions on reducing complications or functional improvements in these patients is unknown. Include universal ultrasound to universal clinical examination does not alter the incidence of delayed diagnosis of DDH. Studies on cost effectiveness of early detection of DDH contemplated the average cost per child detected with DDH or per screening, assuming the success of the intervention in case detection without addressing functional improvements or quality-adjusted life year.

Authors' recommendations: Universal clinical examination for early detection of DDH should be part of screening programs of health problems in the NHS. Incorporating universal ultrasound to universal clinical examination for early detection of DDH is not recommended. Ultrasound can join the universal clinical examination for early detection of DDH, in infants with two of the following risk factors: female gender, breech birth, family history of DDH. The universal clinical examination, by performing maneuvers Barlow and Ortolani, must first be performed in the first 8 weeks of life, this being the time period in which the treatment of DDH is directed to restore the normal growth and development of acetabulum and structures included therein. If one or both maneuvers (Barlow and Ortolani) show instability at least one of the joints in the first 8 weeks of life, can be offered to the family or tutor of the infant, performing an ultrasound monitoring of unstable hip with the repetition of the Barlow and Ortolani maneuvers to week 8 of life, and exploring the Galeazzi sign from week 8 of life. From the 12th week of life, is the exploration of the Galeazzi sign the test of choice for detection of abnormalities of the hip. The use of ultrasound or other technique, can be determined by the orthopedist or orthopedic surgeon to determine the extent of injury and propose appropriate therapeutic option to alterations evidenced. Once the march began in childhood, treatment is given by the character and extent of the injury. Each reference center will protocolized appropriate action, being signs that may reveal lesions formed hip joint, lameness or hiperlordosis lumbar.

Authors' methods: The following databases were searched: PubMed/MEDLINE, EMBASE, NHS Economic Evaluation Database (NHS EED), Health Technology Assessment Database (HTA), and Database of Abstracts of Reviews of Effects (DARE). In addition, the databases of the following health technology assessment agencies were also searched: CCOHTA from Canada, NICE from United Kingdom, HTA programme from United Kingdom, AUnETS from the Spanish National Health System. Subsequently, a manual search from the reference lists of previously identified references was conducted. Systematic reviews and complete economic evaluations were included, defined as cost-utility studies, cost-effectiveness studies, cost -benefit and cost-minimization studies. The selection of studies was done according to the previously defined inclusion and exclusion criteria. Papers were reviewed by two investigators independently. A third researcher participated when discrepancies existed. Heterogeneity of economic evaluation studies did not allow quantitative synthesis of results (meta-analysis).

Project Status: Completed

Year Published: 2012

URL for published report: https://www.iacs.es/wp-content/uploads/2018/03/03_IACS_Displasia_DEF_NIPO.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Health Sciences Institute in Aragon (IACS)

Contact Address: Avda, San Juan Bosco, 13, planta 2

Contact Name: María Pilar Calvo Pérez

Contact Email: direccion.iacs@aragon.es