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AAOS Now

Published 10/1/2016
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Kevin G. Shea, MD; Charles T. Price, MD

Turning a CPG into a Care Map

AAOS CPG on DDH provides outline for standardized care
Developmental dysplasia of the hip (DDH) is a relatively common pediatric condition, occurring in 3 to 4 of every 1,000 live births. If left untreated, DDH can have lifelong implications—including disability and total hip replacement at a young age. Even if providers suspect DDH, the early signs of this condition are not always obvious; frank hip dislocation only occurs in approximately 1 of 1,000 newborn infants.

The 2014 AAOS clinical practice guideline (CPG) on DDH provides a summary of the most recent research and clinical treatment options for the evaluation of DDH. This guideline provides recommendations for screening and imaging studies for patients with risk factors for DDH.

The subtle presentation of DDH means that clinical decisions—such as when to refer patients to a specialist, what imaging diagnostics are most appropriate, or when to re-evaluate a patient—can be difficult. A lack of provider and staff familiarity with DDH diagnosis and treatment can translate into several problems for patients, providers, staff, and the health system, including the following:

  • Late or missed diagnoses—If patients are not referred to specialists at the correct time, DDH can lead to early hip arthritis.
  • Hardships for patients (particularly from rural areas) who must travel long distances to see specialists when it is unnecessary.
  • Incorrect imaging—If radiographs are taken when ultrasound is more appropriate (or vice versa), or if imaging is not done by appropriately trained staff, diagnostics may have to be repeated, leading to higher costs for patients, potential for unnecessary radiation exposure, inefficient use of staff time, and higher system costs.
  • Signs of DDH by radiographs and ultrasound may be subtle and easily missed if the studies are not interpreted by appropriately trained orthopaedic surgeons and/or musculoskeletal radiologists.

Our solution
The St. Luke's Health System (SLHS), based in Boise, Idaho, includes seven hospitals and numerous clinics across the state. Although it covers a large geographic area, many regions have very low population density. Complex pediatric orthopaedic care is provided in three centers, and many patients may have to drive 2 to 4 hours for specialty care. To standardize care for DDH throughout the region, the Health System developed a standard clinical and imaging pathway.

The DDH care map was developed from the AAOS 2014 Evidence-Based Guideline for Developmental Dysplasia of the Hip and a cooperative effort by SLHS pediatricians, musculoskeletal radiologists, pediatric orthopaedic surgeons, and family practitioners. The care map was designed to offer providers a simple, easy-to-follow tool to promote a standard, evidence-based approach to hip evaluation.

With the DDH care map, the SLHS may optimize the rates of early detection and management of hip dysplasia, provide the right assessment to patients at the right time, and reduce treatment variation through a collaborative approach. This program is also designed to minimize travel for families who require specialized care.

The care map has been reviewed by the medical advisory board of the International Hip Dysplasia Institute (IHDI) and posted on the IHDI website. The website also has training and educational videos for examination of the pediatric hip.

Measuring success
The SLHS identified the following three areas in which changes could improve the treatment of DDH at a population level and designed outcome measures to track success in each.

Primary Care—Historical experience at SLHS found that a significant number of pelvis radiographs and hip ultrasounds were being ordered during the course of care, which is not ideal and may not improve diagnostic or therapeutic outcomes. The following goals seek to address this issue:

  • Provide validated DDH physical examination training to primary care providers (reaching 80 percent at 1 year and 95 percent at 2 years) through the IHDI. Their training video has been demonstrated to improve performance among clinicians, with high retention value of training information at 1-year follow-up. Video viewing will be assigned to providers and tracked through the SLHS online training center.
  • Reduce the number of pelvis radiographs in infants younger than 4 months post due date.
  • Reduce the number of ultrasounds in infants older than 4 to 5 months post due date.

Radiology—Experience has shown that scheduling for some ultrasound procedures created inconvenience and increased travel for families from rural areas. The care map also provides the opportunity to improve the diagnostic reliability of hip imaging (radiographs and ultrasound) by ensuring these tests are performed under ideal circumstances. The program seeks to:

  • Enable 100 percent of patients travelling long distances to Boise to obtain same-day hip ultrasounds. Under normal circumstances, patients may have to wait several days for these studies to be scheduled, but the radiology department has modified its scheduling process to enable same-day appointments for families that had to travel.
  • Ensure that 100 percent of hip radiographs are interpreted by appropriately trained DDH pediatric or musculoskeletal radiology staff and/or pediatric orthopaedic surgeons within the SLHS.
  • Ensure that at least 90 percent of hip radiographs are obtained with the patient positioned properly, to avoid the need for repeat radiographs and increased radiation exposure. Ideal patient positioning during these studies improves the quality of the images, making it easier to provide an accurate assessment of hip development.

Orthopaedics—In the past, occasional missed cases of hip dysplasia have been identified. Earlier identification (before 4 to 6 months of age) is associated with improved outcomes. The program's goal is to:

  • Reduce to zero the number of patients seen in the pediatric orthopaedics clinic with late presentation DDH requiring treatment.

Summary
DDH is a complex problem, but can be treated successfully and economically if identified when the child is younger than 6 to 9 months old. This project used evidence-based decision making to address the complex needs of this patient population, recognize the challenges of providing care in a large geographic area with relatively low population density, and improve patient-centered care.

Kevin G. Shea, MD, is a member of the AAOS Council on Research and Quality. Charles T. Price, MD, is director of the International Hip Dysplasia Institute.

Additional Information: