Overcoming Disparities in Growth Evaluations

项目摘要 生长发育是儿童全面健康的一个敏感标志。虽然身材矮小经常是一种变异， 正常生长，多种疾病可单独出现生长迟缓。因此，及时评估增长 步履蹒跚可能会产生重要的后果，不仅对最终身高，而且对发病率和死亡率。2003年 美国食品和药物管理局批准生长激素（GH）治疗特发性身材矮小， 强调身高而不是基础病理作为治疗合格标准的适应症。 几十年的文献支持这样的观察，即社会压力的身高优先影响男性。 与此一致，GH登记研究显示女性和少数民族患者的代表性明显不足， 做内分泌咨询的孩子们对生长发育的评估步履蹒跚。性别、种族和 在评估和处理增长停滞方面的社会经济差异导致两个有问题的结果： 不适当地使用生长激素用于健康的主要是白色男孩的社会驱动的身高增加， 种族和族裔的女孩和儿童潜在疾病的诊断可能出现不必要的延误， 社会经济少数民族。拟议中的研究将评估在管理增长停滞方面的差异 从两个新的角度来看，初级保健儿科医生（PCP）和病人家庭。生长研究表明， 传统上集中于内分泌中心或GH登记处的有限人群，这些人群受到 是由确定性偏见造成的通过利用强大的技术进步，电子健康记录 (EHR)根据该系统，拟议的研究将涵盖所有2岁至15岁（女孩）或17岁（男孩）的儿童， 人口统计学上异质的初级保健儿科网络，跨越新泽西，宾夕法尼亚州和 特拉华州。该研究旨在评估PCP识别和评估儿童的方法 增长步履蹒跚，并测试电子警报和决策支持工具在改善 五氯苯酚生长评价的一致性。然而，PCP的管理往往受到患者家庭的影响 关注和期望。因此，这项研究还旨在了解患者的补充作用- 家庭在创造差异的管理中成长步履蹒跚。使用综合定性- 通过定量方法，这项研究将从父母那里得出影响他们在父母中学习的可能性的因素。 获得对生长迟缓的评估和治疗，并分析性别、种族和社会经济因素 与这种可能性有关。只有了解差距的根源， 旨在消灭他们。这项研究服务于美国国立卫生研究院的目标，由国会在少数民族健康和 2000年健康差异研究和教育法案，减少并最终消除健康 PA-07-392的目标是减少少数民族和得不到充分服务的儿童之间的健康差距。 除了增长不平衡的具体问题外，这项研究有可能对全球经济产生重大影响。 通过展示EHR在塑造医生实践模式方面的力量，促进儿科护理和儿童健康。

PROJECT SUMMARY Growth is a sensitive marker of a child's over-all health. Although short stature frequently construes a variant of normal growth, multiple diseases can present with growth faltering alone. Thus, timely evaluation of growth faltering can have important consequences, not just for final height, but for morbidity and mortality. In 2003, the Food and Drug Administration approved growth hormone (GH) treatment for idiopathic short stature, the first indication that emphasizes height rather than underlying pathology as the qualifying criterion for treatment. Decades of literature support the observation that social pressures for tallness preferentially affect males. Consistent with this, GH registries show marked under-representation of female and racial minority patients, as do children who seek endocrine consultations for the evaluation of growth faltering. The gender, racial and socioeconomic disparities in the evaluation and treatment of growth faltering lead to two problematic outcomes: the inappropriate use of GH for socially driven height enhancement in healthy, primarily white boys, and the potential for unnecessary delays in the diagnosis of underlying disease in girls and children of racial and socioeconomic minorities. The proposed study will evaluate disparities in the management of growth faltering from two novel perspectives, the primary care pediatrician (PCP) and the patient-family. Growth studies have traditionally focused on the circumscribed populations of endocrine centers or GH registries, which are beset by ascertainment bias. By taking advantage of a powerful technological advance, the electronic health record (EHR) system, the proposed study will encompass all children aged 2 years to 15 (girls) or 17 (boys) in a demographically heterogeneous primary care pediatrics network that spans New Jersey, Pennsylvania and Delaware. The study seeks to evaluate PCPs' approach to the identification and evaluation of children with growth faltering, and test the efficacy of an electronic alert and decision support tool in improving the consistency of PCP growth evaluations. However, PCP management is often influenced by patient-family concerns and expectations. Thus, the study also aims to understand the complementary role of the patient- family in creating the disparities in the management of growth faltering. Using a combined qualitative- quantitative approach, the study will elicit, from parents themselves, the factors that affect their likelihood to obtain evaluation and treatment for growth faltering and analyze how gender, racial and socioeconomic factors associate with that likelihood. Only by understanding the roots of disparities can effective strategies be designed to eliminate them. This study serves the NIH goal, mandated by Congress in the Minority Health and Health Disparities Research and Education Act of 2000, of reducing and ultimately eliminating health disparities, and the goal of PA-07-392 to reduce health disparities among minority and underserved children. Beyond the specific issue of disparities in growth faltering, this study has the potential to significantly impact pediatric care and child health by demonstrating the power of the EHR in shaping physician practice patterns.