Sex, Race, and Measuring Tape: Health Disparities and Growth Hormone Deficiency

Racial and gender disparities in healthcare begin early — including among children who could benefit from treatment for short stature. New research seems to show that white children — especially boys — are offered growth hormone stimulation tests at a significantly higher rate than girls or Black and Hispanic children.

The racial, ethnic, and gender disparities known to exist in the healthcare system are clearly present in the diagnosis and treatment of growth hormone deficiency, according to several recent studies that explore the underlying causes.  

Males are twice as likely as females to receive pediatric growth hormone treatment in the U.S., despite having similar distributions of the height scores used to identify those who might benefit from intervention. To investigate the causes of this disparity. a team of researchers led by Camilia Kamoun, MD, of the Children’s Hospital of Pennsylvania in Philadelphia, reviewed the charts of more than 10,000 children aged 2 to 16 years who had been evaluated for short stature or poor growth at a large tertiary referral center between 2012 and 2019.

In an article published in Hormone Research in Paediatrics, the researchers report that boys were administered growth hormone stimulation testing at a higher rate than girls and that boys were given tests when their heights were closer to normal.

The rate that boys and girls were tested — and therefore diagnosed — was important because once girls were diagnosed with growth hormone deficiency (GHD) they received growth hormone treatment at the same rate as boys, but they were not given GH stimulation testing at the same rate.

Who Worries about Short Stature?

“This is the first study to describe sex differences in GH stimulation testing as a factor contributing to sex disparities in pediatric GH treatment,” the authors write. The authors reviewed potential reasons for the disparity in testing rates, starting with the strong social notion that “short stature is associated with heightened concern when present in boys compared to girls in primary care.”

The greater concern for the condition in boys could contribute to disparities at each step on the road to treatment, they write: “Males are more likely to be screened by primary care clinicians for GHD and to be referred to a pediatric endocrinologist for evaluation of short stature. Pediatric endocrinologists are also more likely to prescribe GH treatment to boys than girls, when this was assessed in theoretical cases of short non-GHD children. In a survey of parents of pediatric primary care patients, the acceptable height cutoff regarding short stature was higher for male versus female heights.”

The researchers conclude that their findings raise “questions about the extent to which sex bias — from children, parents, and/or physicians — as opposed to objective growth data, influence medical decision-making in the evaluation and treatment of short stature.”

They note that overcoming this bias is important because of a study that showed that “in a population of children referred to endocrinologists for evaluation of short stature, 41% of girls, compared with 15% of boys, were found to have organic disease.”

“Critical self-reflection to identify and address sex biases that may impact care is one step clinicians can take to mitigate potential associated harms. Such harms may include underdiagnosis of GHD in girls and overtreatment of short stature in boys,” they conclude.

Racial and Ethnic Angle

A related group from the Children’s Hospital of Philadelphia, this one led by Colin Patrick Hawkes, MD, PhD, performed a similar chart-review study to look at racial and ethnic differences. Published in The Journal of Pediatrics, the study found that non-Hispanic white children were 1.4 times more likely than non-Hispanic black and 1.7 times more likely than Hispanic children to undergo growth hormone stimulation testing.

The researchers conclude that their findings raise “questions about the extent to which sex bias — from children, parents, and/or physicians — as opposed to objective growth data, influence medical decision-making in the evaluation and treatment of short stature.”

But the researchers note that being tested is only one step, and that the imprecision of the test “may introduce an opportunity for bias in treatment decisions.” Patients whose results clearly fell within the generally accepted range for deficiency received treatment at similar rates regardless of race or ethnicity. But the test results can also fall into a “gray zone where GH prescribing is more discretionary.” In these cases, non-Hispanic Black children were less likely than non-Hispanic white and Hispanic children to receive GH treatment.

“Racial and ethnic disparities in care have been found across the spectrum of pediatrics, including across rates of well-child visit attendance and subsequent subspecialty service use,” the authors note, and these disparities could contribute fewer opportunities for children from minority groups to see the needed specialists. The researchers blame the disparities on “overinvestigation” of white children coupled with “underinvestigation and undertreatment of children from minority communities.”

The Burden of Undertreatment

A third paper, this one in the Journal of Managed Care & Specialty Pharmacy, did not look specifically for gender and racial disparities, but it found them anyway. It found that among patients with commercial insurance, 71% of males and 61% of female patients who were diagnosed with growth hormone deficiency were treated. Among Medicaid patients, 66% of white patients and 55% of black patients diagnosed with GHD were treated. The time from diagnosis to treatment provided another measure of the disparity among Medicaid patients.

Researchers found a mean of 138 days in white males, 141 days in Hispanic males, 182 days in black males, 180 days in white females, 188 days in Hispanic females, and 220 in black females.

The rate that boys and girls were tested — and therefore diagnosed — was important because once girls were diagnosed with growth hormone deficiency (GHD) they received growth hormone treatment at the same rate as boys, but they were not given GH stimulation testing at the same rate.

The main thrust of the paper was to look at the significance of the undertreatment, according to Paul Kaplowitz, MD, PhD, one of the authors and professor emeritus of pediatrics at Children’s National Hospital in Washington, D.C. “The paper makes the point that treatment with growth hormone seemed to reduce the cost of nongrowth hormone prescription care,” he tells Endocrine News.

The authors concluded that “untreated GHD is associated with higher non-somatotropin healthcare costs compared with treated GHD, further indicating a need to improve adherence to treatment.”

“The evaluation and treatment of children with short stature should be determined by clinical concern alone, but this is not current practice,” the authors of The Journal of Pediatrics article conclude.

Seaborg is a freelance writer based in Charlottesville, Va. He wrote the January cover story on endocrinology and climate change.

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