Overcoming Disparities in Growth Evaluations

描述（由申请人提供）：生长是儿童整体健康的敏感标志。虽然矮小经常被认为是正常生长的一种变异，但多种疾病也可能仅表现为生长迟缓。因此，对生长迟缓的及时评估不仅对最终身高，而且对发病率和死亡率都有重要影响。2003年，美国食品和药物管理局批准了生长激素（GH）治疗特发性身材矮小，这是第一个强调身高而不是潜在病理作为治疗合格标准的迹象。几十年的文献支持这样的观察，即身高的社会压力优先影响男性。与此一致的是，GH登记显示女性和少数民族患者的代表性明显不足，寻求内分泌咨询以评估生长迟缓的儿童也是如此。在评估和治疗生长迟缓方面的性别、种族和社会经济差异导致了两个有问题的结果：在健康的、主要是白人男孩中，不适当地使用生长激素来促进社会驱动的身高增加，以及在女孩和种族和社会经济少数群体儿童的潜在疾病诊断方面可能出现不必要的延误。本研究将从两个全新的视角，即初级保健儿科医生（PCP）和患者家庭，来评估对生长迟缓的管理差异。生长研究传统上集中于内分泌中心或生长激素登记处的有限人群，这受到确定偏差的困扰。通过利用强大的技术进步，电子健康记录（EHR）系统，拟议的研究将涵盖所有2至15岁（女孩）或17岁（男孩）的儿童，这些儿童在跨越新泽西州，宾夕法尼亚州和特拉华州的人口异质性初级保健儿科网络中。本研究旨在评估PCP识别和评估生长迟缓儿童的方法，并测试电子警报和决策支持工具在提高PCP生长评估一致性方面的功效。然而，PCP的管理经常受到患者家属的关注和期望的影响。因此，本研究也旨在了解患者-家庭在创造成长摇摇欲坠管理差异中的互补作用。该研究将采用定性和定量相结合的方法，从父母自己那里找出影响他们在成长迟缓时获得评估和治疗的可能性的因素，并分析性别、种族和社会经济因素与这种可能性的关系。只有了解差距的根源，才能制定有效的战略来消除差距。这项研究服务于美国国立卫生研究院的目标，由国会在2000年少数民族健康和健康差异研究和教育法中授权，减少并最终消除健康差异，以及PA-07-392的目标，以减少少数民族和得不到充分服务的儿童之间的健康差异。除了生长迟缓的差异这一具体问题之外，本研究通过展示电子病历在塑造医生实践模式方面的力量，有可能对儿科护理和儿童健康产生重大影响。公共卫生相关性：生长迟缓通常是儿童潜在健康问题的第一个或唯一迹象。然而，由于社会对身高的压力，在接受专家评估和生长激素治疗的儿童中存在性别、种族和社会经济差异。本研究旨在从初级保健儿科医生和家长的角度了解这些差异的根源，并测试电子警报和决策支持工具在提高儿科医生诊断测试和专家转诊的一致性方面的功效。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: Growth faltering is often the first or only sign of an underlying health problem in a child. However, due to social pressures for tallness, there are gender, racial and socioeconomic disparities in the children who receive specialist evaluation and growth hormone treatment. This study aims to understand the roots of those disparities - from the perspectives of both the primary care pediatricians and the parents - and to test the efficacy of an electronic alert and decision support tool in improving the consistency of pediatrician diagnostic testing and specialist referral for growth faltering.