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Patient, Physician, and Consumer Drivers: Referrals for Short Stature and Access to Specialty Drugs

Cuttler, Leona MD*†; Marinova, Detelina PhD; Mercer, Mary Beth MPH*; Connors, Alfred MD§; Meehan, Rebecca PhD*; Silvers, J B. PhD

doi: 10.1097/MLR.0b013e31819e1f04
Original Article

Background: Candidates for specialty drugs, the fastest growing and costliest pharmaceuticals, typically originate with primary care referrals. However, little is known about what drives such referrals—especially for large populations such as short, otherwise normal children (idiopathic short stature). Recent expanded approval of growth hormone (GH) makes more than 585,000 US children eligible for such treatment, potentially costing over $11 billion/y.

Methods: To quantify the relative impact of patient physiological indicators, physician characteristics, and consumer preferences on referrals to endocrinologists (and potential access to GH) for short children, a national study of 1268 randomly selected US pediatricians was conducted, based on a full factorial experimental design in a structured survey.

Results: While patient indicators (height, growth pattern) influenced referrals (P < 0.001), consumer drivers (family concern) and physician attitudes had almost as great an impact—especially for children with less severe growth impairment (P < 0.001). Physician belief that short stature impairs emotional well-being and physician characteristics (female, older, shorter, beliefs about drug company information) increased referrals (P < 0.03–0.001)—independent of growth parameters.

Conclusions: Referral recommendations that create the pool of candidates for the specialty drug GH are heavily swayed by physician characteristics and consumer preferences, particularly in the absence of compelling physiological evidence. This makes most of children with short stature strikingly susceptible to nonphysiological influences on referrals that render them candidates for this specialty drug. Only 1 additional referral per US pediatrician would likely increase GH costs by over $100 million/y.

From the Departments of *Pediatrics and †Bioethics, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, Ohio; ‡Robert J. Trulaske College of Business, The University of Missouri, Columbia, Missouri; §Department of Internal Medicine, MetroHealth Medical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio; and ¶The Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio.

Supported by the National Institutes of Health (NICHD).

Reprints: Leona Cuttler, MD, The Center for Child Health and Policy at Rainbow and Division of Endocrinology, Diabetes and Metabolism and, Rainbow Babies and Children's Hospital, Case Western Reserve University, 11100 Euclid Avenue Rm 737, Cleveland, OH 44106. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.