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A National Study of Physician Recommendation Patterns

Leona Cuttler, MD; J. B. Silvers, PhD; Jagdip Singh, PhD; Ursula Marrero, MSSA; Beth Finkelstein, MPH; Grace Tannin, MD; Duncan Neuhauser, PhD

JAMA. 1996;276(7):531-537.

Abstract
Objective.
—To determine current expert opinion and recommendations regarding the controversial issue of the use of growth hormone (GH) to treat short children who do not have classical GH deficiency (non-GHD children).

Study Design.
—Analysis of a national survey mailed to 534 US physician experts on the management of short stature (pediatric endocrinologists) with a response rate of 81.3%.

Main Outcome Measure.
—The experts' GH treatment recommendations.

Results.
—The physicians reported that approximately 58% of their current patients undergoing GH therapy have classical GH deficiency, while 42% have other conditions. The proportion of physicians who recommended GH treatment of short non-GHD children ranged from 1% to 74% over all case scenarios presented. The likelihood of GH being recommended depended on the physiological growth characteristics of the child (ie, the child's height, growth rate, and predicted adult height), contingency factors (ie, strong family wishes or a reduction in GH cost), and physician beliefs (ie, the impact of short stature on well-being, the effectiveness of GH therapy). Each of these factors exerted highly significant, independent, and additive effects on decisions to recommend GH.

Conclusion.
—Our results indicate that many pediatric endocrinologists consider GH treatment appropriate for selected short non-GHD children, going beyond current Food and Drug Administration-approved indications for GH. Decisions to recommend GH for a non-GHD child rest on a combination of medical, social, and perceptual factors; variations in treatment patterns stem from variations in these influences. Future GH use will likely be determined not only by the results of controlled trials, but also by family preferences, producer pricing, and physician perceptions of the value of height and GH therapy.

Author Affiliations
From the Departments of Pediatrics (Drs Cuttler and Tannin and Ms Marrero), Pharmacology (Dr Cuttler), and Epidemiology and Biostatistics (Drs Silvers and Neuhauser and Ms Finkelstein), School of Medicine, and the Weatherhead School of Management (Drs Silvers and Singh), Case Western Reserve University, Cleveland, Ohio.

Footnotes
Reprints: Leona Cuttler, MD, Rainbow Babies and Childrens Hospital, Room 790, Case Western Reserve University, 2101 Adelbert Rd, Cleveland, OH 44106.

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