Can a Virtual Clinic Improve the Care of Patients with DDH?
A prospective study from Ireland reviews the operation, referral reasons, treatment outcomes, cost efficiency, and adverse events associated with a virtual clinic for developmental dysplasia of the hip. This study includes 1002 patients referred to the virtual clinic over the course of 3.5 years.
Christina Herrero, MD, and Pablo Castañeda, MD
Murphy E, Fenelon C, Kennedy J, et al. Establishing a virtual clinic for developmental dysplasia of the hip: a prospective study. J Pediatr Orthop. 2020;41 (4):e209-215.
Telemedicine is becoming an invaluable tool for diagnostic, therapeutic, and screening purposes. Ease of access and reduced exposure to infectious organisms has increased the interest in finding ways to incorporate virtual medicine into practice. The goal is to keep patients and providers safe while preventing delays in care, especially when in-person visits may create unnecessary risk or may not be possible. [1-2] One of the most significant challenges is ensuring that the same quality of care is delivered in a time-sensitive fashion and that nothing falls through the cracks during the patient’s treatment course.
In a prospective study, Murphy et al reviewed the operation, referral reasons, treatment outcomes, cost efficiency, and adverse events associated with a virtual clinic for developmental dysplasia of the hip (DDH) in Ireland. As DDH is the most common musculoskeletal diagnosis in newborns – occurring in 6.7 per 1,000 live births in Ireland – this clinic has the potential to significantly impact the way DDH is managed.
The prospective observational study by Murphy et al involves 1002 patients referred to the virtual DDH clinic over the course of 3.5 years. The clinic is staffed with 5 fellowship-trained pediatric hip specialists and 2 clinical nurse specialists (CNS) trained in assessing and managing DDH. A physician and a CNS review every referred case and after this review, patients are triaged to 1 of 4 outcomes:
- Face-to-face visit with a consultant
- Referral to the CNS-led hip clinic
- Remote radiology review
- Direct discharge
Parents can choose a face-to-face visit at any point.
The researchers found that during the study period:
- Median wait times from referral to treatment decision decreased by more than 70%, from 32 to 9 days
- 704 face-to-face visits were avoided
- The direct discharge rate was 24%
- Cost reductions were $170 per patient and $588,084 for the study overall
- Only 18 parents requested a face-to-face visit instead of a virtual visit
- No adverse events were recorded 
Virtual orthopaedic clinics have had success in delivering safe, efficient, and cost-effective care, with good overall follow-up via telemedicine reported for pediatric orthopaedic care. The DDH virtual clinic in the study by Murphy et al is the first of its kind to demonstrate effective and efficient virtual surveillance dedicated to this common pathology. 
Prompt diagnosis and follow-up are critical in the management of patients with DDH, making a virtual clinic a good option due to its ability to decrease costs and allow a timely visit. A virtual clinic removes geographic and social factors that can deter families from keeping follow-up visits and allows greater efficiency for physicians to see patients.  Furthermore, selective and universal ultrasound screening programs can help reduce the later presentation of DDH but have the potential for overtreatment and additional expenses – many of which a virtual clinic can address. [6-7]
There are limitations to the study, as well as unique aspects of the clinic that may make it challenging to apply elsewhere. This type of clinic would be difficult to create in the US as we do not have the same national referral service or national imaging system. It may be applicable on a smaller scale but would require systems to be compatible and transparent for the required communication.
Specific to the paper, Murphy et al acknowledge that the clinic is still in its infancy and there may be late or missed diagnoses that were initially triaged and discharged from the clinic. In addition, patients may choose to follow up at other facilities than the DDH clinic, with the clinic staff not privy to those outcomes.
The paper goes into details of the multidisciplinary structure of the clinic and the theories behind a successful virtual clinic, repeatedly acknowledging the challenges of transitioning people to the mindset that a virtual clinic provides an equal type of care, that they should use the referral service, and that they should take advantage of the virtual component of DDH management.
Patient and parent satisfaction has not yet been evaluated in this cohort. However, Sinha et al  directly compared in-person and virtual visits for pediatric fracture follow-up in suburban and rural Pennsylvania and found equivalent satisfaction, with decreased travel cost and time.
This paper by Murphy et al is a stimulating advancement in pediatric orthopaedics and has excellent potential to improve and diversify the way we manage DDH.
Christina Herrero, MD, is a resident in orthopedic surgery at NYU Langone Health, New York, New York. Pablo Castañeda, MD, is The Elly and Steven Hammerman Professor of Orthopaedic Surgery at NYU School of Medicine and Division Chief, Pediatric Orthopaedic Surgery NYU Langone Health/Hassenfeld Children’s Hospital, New York, New York.
Disclosures: The authors have no disclosures relevant to this article.
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