Idiopathic short stature: decision making in growth hormone use

Tackling access and payer barriers for growth hormone therapy in Saudi Arabia: a consensus statement for the Saudi Working Group for Pediatric Endocrinology

Prompt diagnosis and early treatment are key goals to optimize the outcomes of children with growth hormone deficiency (GHD) and attain the genetically expected adult height. Nonetheless, several barriers can hinder prompt diagnosis and treatment of GHD, including payer-related issues. In Saudi Arabia, moderate-to-severe short stature was reported in 13.1 and 11.7 % of healthy boys and girls, respectively. Several access and payer barriers can face pediatric endocrinologists during the diagnosis and treatment of GHD in Saudi Arabia. Insurance coverage policies can restrict access to diagnostic tests for GHD and recombinant human growth hormone (rhGH) due to their high costs and lack of gold-standard criteria. Some insurance policies may limit the duration of treatment with rhGH or the amount of medication covered per month. This consensus article gathered the insights of pediatric endocrinologists from Saudi Arabia to reflect the access and payer barriers to the diagnostic tests and treatment options of children with short stature. We also discussed the current payer-related challenges endocrinologists face during the investigations of children with short stature. The consensus identified potential strategies to overcome these challenges and optimize patient management.

Parental Concerns on Short Stature: A 15-Year Follow-Up

OBJECTIVES

To compare parental attitudes about short stature over time and determine possible factors that predict changes in attitudes.

STUDY DESIGN

At baseline (1993-1994), we surveyed parents about their attitudes regarding their children's height. We compared parents of children (aged 4-15 years) referred to endocrinologists (referred, 154) with those of children with heights <10th percentile seen by pediatricians during regular visits (control, 240). At follow-up (2008-2009), 103 control and 98 referred parents completed a similar survey. We then made a logistic regression analysis to observe changes in perception. Primary variables included self-esteem, treatment by peers, and ability to cope with current height.

RESULTS

At baseline, referred parents perceived a worse impact of short stature on their children than did controls. At follow-up, instead, referred parents were 3.8 times more likely to report improvement in self-esteem, 2.4 times more likely to report improved treatment from peers, and 5.7 times more likely to report overall ability to cope with height than were unreferred parents. Perception of psychosocial improvement was greater in the referred than the control group. Referral was a stronger predictor of an improved follow-up response than patients' current height or change in height.

CONCLUSIONS

While incorporating parental attitudes into management decisions, clinicians should be aware that parental perceptions may change over time and that referral itself may lead parents to perceive psychosocial improvements over time.

Quality of Life in Adolescent Boys with Idiopathic Short Stature: Positive Impact of Growth Hormone and Aromatase Inhibitors

BACKGROUND

The combination of growth hormone (GH) and aromatase inhibitors (AI) improves linear growth in severely short adolescent boys; however, the effects of this intervention on quality of life (QoL) are unknown. This study assesses whether GH, AI, or their combination impacts the QoL of adolescent males with idiopathic short stature (ISS) from both the adolescent and the parent perspective.

METHOD

A randomized open-label comparator trial was conducted in 76 pubertal males with ISS who received AI, GH, or AI/GH for 24 months. The condition-specific Quality of Life in Short Stature Youth questionnaire was used to assess QoL.

RESULTS

QoL scores were low at baseline in the children's and parents' reports. Within-group testing showed that total QoL scores increased significantly at 24 months in the GH and AI/GH group but not the AI group in the children's report, whereas it increased in all of the groups in the parents' report. Increases in QoL scores were associated with an increase in height SDS.

CONCLUSIONS

Treatment with GH and AI/GH was associated with improved QoL scores as measured from both the patients' and the parents' perspectives, suggesting that the improved growth resulting from the use of these growth-promoting therapies has beneficial psychosocial effects in adolescent males with ISS followed for 24 months.

"Real-world" pediatric endocrine practice; how much is it influenced by physician's gender and region of practice. Results of an international survey

OBJECTIVE

To determine whether hormonal treatments for frequent clinical cases (short stature, delayed and precocious puberty) are prescribed strictly according to clinical guidelines or based on personal tendencies, and whether the decisions correlate with physician's personal demographics (age, sex, and place of practice).

METHODS

Cross-sectional survey, with made-up clinical cases, distributed to pediatric endocrinologists using 2 web-based professional forums, Israeli and an international. The questionnaire included 8 clinical cases and 5 demographic questions regarding the physician. Differences in practice between Israeli and international endocrinologists were assessed, and correlation between the physician's gender and their decisions regarding treatment.

RESULTS

One hundred fifty-five physicians responded, 28% Israeli and 72% international. In girls with early puberty, 60% of international and 26% of Israeli physicians chose not to treat with a gonadotropin-releasing hormone agonist. In girls with short stature, 79% of Israeli and 34% of international physicians offered growth hormone treatment. In girls with early puberty, both male and female physicians responded similarly in the international group, but in the Israeli group 47% of male and 15% of female doctors would not treat. In girls with constitutional growth delay, 67% of Israeli male doctors would not treat with growth hormone compared to 30% of Israeli female physicians.

CONCLUSIONS

Our study demonstrated significant practice differences between Israeli and international pediatric endocrinologists. Within the Israeli group, significant practice differences were seen between male and female physicians. Given that Israeli physicians follow the same clinical guidelines it is clear that a large "grey zone" of clinical cases exist and much of the decisions on treatment are personal and influenced by personal beliefs or gender.

To Prescribe or Not to Prescribe? Consumer Access to Life-Enhancing Products

With rapid biotechnological advances in specialty drugs and direct-to-consumer advertising, consumers are under tremendous pressure to look, perform, feel, and live better. This is often accomplished through the use of life-enhancing products, sometimes referred to as performance-enhancing products, which can be accessed only through a gatekeeper, such as a physician. Integrating consumer and medical research, this article investigates how physicians make trade-offs between objective medical and nonmedical factors to determine consumers' access to life-enhancing products by examining US pediatric endocrinologists' prescription decisions for growth hormone (GH) for healthy but short children. The results of a conjoint study indicate that consumer medical criteria have less impact on a physician's decision to prescribe GH if the consumer requests a prescription or the physician believes in the intangible product benefits, and more impact when the product is more expensive. A physician's length of experience increases the impact of consumer medical criteria and decreases the influence of a consumer's preference for a prescription on the decision to prescribe. Overall, this research shows that not all consumers have equal access to life-enhancing products; their access depends on a complex combination of medical and nonmedical factors related to the consumer, product, and the physician.

Comparison between the growth response to growth hormone (GH) therapy in children with partial GH insensitivity or mild GH deficiency

OBJECTIVES

GH therapy is still controversial, except in severe GH deficiency (SGHD). The objective of this study was to compare the response to growth hormone (GH) therapy in children with partial GH insensitivity (PGHIS) and mild GH deficiency (MGHD) with those with SGHD.

SUBJECTS AND METHODS

Fifteen PGHIS, 11 MGHD, and 19 SGHD subjects, followed up for more than one year in the Brazilian public care service, were evaluated regarding anthropometric and laboratory data at the beginning of treatment, after one year (1st year) on treatment, and at the last assessment (up to ten years in SGHD, up to four years in MGHD, and up to eight years in PGHIS).

RESULTS

Initial height standard deviation score (SDS) in SGHD was lower than in MGHD and PGHIS. Although the increase in 1 st year height SDS in comparison to initial height SDS was not different among the groups, height-SDS after the first year of treatment remained lower in SGHD than in MGHD. There was no difference in height-SDS at the last assessment of the children among the three groups. GH therapy, in the entire period of observation, caused a trend towards lower increase in height SDS in PGHIS than SGHD but similar increases were observed in MGHD and SGHD.

CONCLUSION

GH therapy increases height in PGHIS and produces similar height effects in MGHD and SGHD.