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Development of a DDH care pathway for India : a study methodology to guide similar efforts in other countries and for other conditions Li, Jacqueline


Background — Developmental dysplasia of the hip (DDH) represents a range of hip joint instability, present at birth or developed during infancy, ranging from mild instability to a complete dislocation. In India and other Global South countries, DDH is often diagnosed after walking age, requiring more complex and invasive surgeries with greater risk of complications and long-term disability. A DDH care pathway is a decision-making tool that coordinates and standardizes screening, with the aim of reducing late detections. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India. Methods — In Phase I, seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. Group members also developed specialty-specific surveys for local providers in India, which were distributed to organizational memberships. During Phase II, panelists participated in a modified Delphi method to reach consensus on a list of best practice statements regarding DDH screening in the Indian context. Phase III applied the statements to build the care pathway. Results — The entire process was completed within a one-year time span, with all procedures conducted remotely using virtual communication and requiring minimal funds or resources. Specialty surveys demonstrated low awareness about DDH, limited practice of DDH screening, and variability in the quality of ultrasound. The Delphi method concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country’s immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging. Discussion/Conclusion — In Global South countries, there is a need for DDH care pathways that are specific to local contexts. Care pathway development is strengthened through the involvement of a multidisciplinary team of local providers and stakeholders. The methodology requires strategies to identify country-specific barriers to care and facilitate group engagement. The cost- and time-effective approach used in India is feasible and can be applied to other conditions and/or countries wishing to establish care pathways.

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