Clinician and payer issues in managing growth hormone deficiency

Growth hormone (GH) therapy has an established record of efficacy in the treatment of children with proven GH deficiency. It has also shown benefit, including nongrowth-related benefit, in other nontraditional pediatric uses, but managed care plans hesitate to reimburse clinicians for such uses. In adults and in those individuals who are in transition from GH-deficient children to adults, GH deficiency is sometimes difficult to diagnose. In such cases, growth rate cannot be used to guide therapy and the outcomes measures are either "softer" (e.g., quality of life) or very long term (e.g., bone mineral density changes). Also, there are no long-term data to show GH treatment in adults affects the cardiovascular-associated morbidity and mortality from GH deficiency. However, several cardiovascular risk factors, such as hypercholesterolemia and abdominal adiposity, improve in GH-deficient adults who receive GH treatment. Clinicians and payers often appear at odds with each other over their primary goals for managing the various forms of GH deficiency. However, upon closer examination, both parties do share common treatment goals and strive to do the right clinical thing. Identifying the cost of treatment emphasizes the need for evidence-based medicine.