Published online March 1, 2007
PEDIATRICS
Vol. 119
No. 3
March 2007, pp.
653-654
(doi:10.1542/peds.2006-3667)
Screening for Developmental Dysplasia of the Hip: In Reply
Ned Calonge, MD, MPH
Chair
Diana Petitti, MD, MPH
Vice-chair US Preventive Services Task Force
Schoenecker and Flynn fault the US Preventive Services Task Force (USPSTF) in its assessment that there is insufficient information to make a recommendation about routine screening for developmental dysplasia of the hip. They fault the USPSTF for (1) use of a "flawed" methodology that does not include data from models and (2) failure to recognize current clinical practice in terms of the use of surgery (and, therefore, the resultant risk of complications and, thus, the reach of complications thereof) and the choice of ultrasound versus physical examination screening.
The USPSTF is an independent panel charged by Congress with the responsibility of reviewing the scientific evidence for clinical preventive services and develop evidence-based recommendations for the health care community. The USPSTF bases its recommendations on systematic evidence reviews that follow an established and transparent methodology used by all the evidence-based practice centers that conduct these reviews under contract with the Agency for Healthcare Research and Quality (AHRQ). The USPSTF's methods of summarizing the evidence and deriving a recommendation also adhere to an established and transparent methodology. Information on the background and methods used by the USPSTF can be seen on the AHRQ Web site (www.ahrq.gov/clinic/uspstmeth.htm).
In 2006, the USPSTF examined what is known about the natural history of developmental dysplasia of the hip as well as the evidence for accuracy of screening tools, efficacy of treatment, and harms of screening and treatment. The findings of the USPSTF were published in Pediatrics1,2 and are summarized on the AHRQ Web site (www.preventiveservices.ahrq.gov), where the supporting systematic literature review and evidence synthesis can also be found.
Overall, the USPSTF found that the test characteristics of physical examination as a screening tool were unknown because of the absence of data using appropriate criterion standards, and that although screening (whether by physical examination or ultrasound) does lead to earlier detection, most newborn hips identified as abnormal by physical examination or ultrasound resolve spontaneously without therapy. In addition, the USPSTF found that the evidence of effectiveness of surgical and nonsurgical therapy is poor, and that there are significant potential risks of therapy with avascular necrosis rates reported as high as 60% (and, admittedly, as low as 0%). Note that even if the particular risk of avascular necrosis were zero, no surgical procedure can be seen as harmless, given the risks of anesthesia, etc. Using a model to predict outcomes of different screening or treatment scenarios requires stable and accurate estimates regarding the test characteristics of screening tests and the impact of treatment in certain patients. In reviewing the peer-reviewed published literature, the USPSTF was unable to find reliable estimates of these factors. Given the uncertainties throughout the published literature, there was insufficient evidence for the USPSTF to make an evidence-based judgment about net health benefits (benefits minus harms), thus the "I" recommendation.
Although Schoenecker and Flynn point out how many children might go undiagnosed if screening were to stop, and they downplay "unnecessary anxiety and concern" on the part of parents, in fact both the known and potential harms of screening must be balanced against the benefits in making a summary assessment. The USPSTF could not find enough rigor in the data to assess this balance and conclude that there was a net benefit for the service.
Evidence-based methodology is just that; it draws from what has been studied and demonstrated through rigorous scientific study. The USPSTF methodology does not include expert opinion or the anecdote of experience in lieu of evidence gathered in studies in which bias is minimized. When intervening on the entire population of well patients, we should base our recommendations only on the best evidence of benefit available and should not make a recommendation in the absence of such evidence. We appreciate and respect that there are other physicians who feel differently. However, we look at the work of the USPSTF as setting an evidence-based anchor for preventive services, and this is a vital service in informing health policy.
REFERENCES
- US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement.
Pediatrics. 2006;117
:898
–902[Free Full Text]
- Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force.
Pediatrics. 2006;117(3)
. Available at: www.pediatrics.org/cgi/content/full/117/3/e557
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
