What Dictates Referrals for Short Stature?

Leona Cutler, MD of Rainbow Babies and Children’s Hospital, Case Western Reserve University, discussed the results of a national cross-sectional study on the referral habits of US pediatricians when it comes to children with short stature. The findings are revealing of the importance of the patient-provider relationship.

Who determines use of treatment for short stature?

• Primary care physicians (pediatricians) referrals determine pool of candidates
• The impact of referrals is huge — six million US children have heights ≤ 5th percentile
• Referrals determine the pool of candidates for evaluation, management, and treatment

The importance of referrals

In the UK, there is evidence that the process “is suboptimal” resulting in variation, inappropriate referral, failure to refer, and increased costs and morbidity.

Referrals of children in US are a major part of medical care. 1 in 40 visits to PCPs results in referral, including 20.2% of pediatric visits.

The referral systems for short stature differ markedly across countries, including in the use of guidelines.

In the Netherlands, growth is screened at five years of age, with specific referral guidelines for children under the age of three and those between the ages of three and 10.

In the UK, children’s growth is screened at five years of age. Height < 0.4th centile (-2.66 SD) is currently the cut off, however, NICE has reviewed Dutch guidelines, finds them to be cost-effective, and is considering their use.

In the United States, there is no specific monitoring at five years. Instead, growth is measured at regular well-child checks by primary care physicians, usually the pediatrician; nothing, however, is mandatory.

What influences referrals in general?

- Severity of symptoms and signs

- Organizational structure (financing and guidelines)

- There are, however, inconsistent US data regarding PCP demographics, the availability of specialists, and insurance.

What determines PCP recommendnations to refer short children to pediatric endocrinologists in the US?

Dr. Cutler and colleagues performed a national cross sectional study of 567 US primary care pediatricians using a questionnaire, experimentally designed to systematically assess influences of: child’s growth characteristics, PCP attitudes and demographics, and family attitudes (ie, concern).

Results

The study revealed that:

• US pediatrician referral recommendations are influenced by both the expression of family concern and growth parameters;
• family concern has almost as much impact as a patient being one standard deviation in height from typical growth parameters;
• family concern has a particularly high impact on referrals for children who only have moderate growth impairment;
• age does not have an effect on referrals;
• boys more likely to be referred;
• female, older, and shorter doctors were more likely to refer.