- Email: [email protected]
Management of Adult Growth Hormone Deficiency at Peking Union Medical College Hospital: A Survey among Physicians
Chin Med Sci J September 2016
Vol. 31, No. 3 P. 168-172
CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE
Management of Adult Growth Hormone Deficiency at Peking Union Medical College Hospital: A Survey among Physicians△ Hong-bo Yang1, Meng-qi Zhang2, Hui Pan1, and Hui-juan Zhu1* 1
Department of Endocrinology, 2Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
Key words: adult growth hormone deficiency; management; continued medical education Objective To evaluate physicians’ attitude and knowledge about the management of adult growth hormone deficiency (AGHD) at Peking Union Medical College Hospital and impact factors associated with better decision-making. Methods A 21-question anonymous survey was distributed and collected at Peking Union Medical College Hospital, a major teaching hospital in Chinese Academy of Medical Sciences. Data of physicians’ educational background, clinical training, patient workload per year and continuing medical education in AGHD were collected. Factors associated with appropriate answers were further analyzed by multivariate regression models. Results One hundred and eighteen internal medicine residents, endocrine fellows, attending physicians and visiting physicians responded to the survey. Among them, 44.9% thought that AGHD patients should accept recombinant human growth hormone replacement therapy. Moreover, 56.8% selected insulin tolerance test and growth hormone-releasing hormone-arginine test for the diagnosis of AGHD. Logistic regression analysis of physician demographic data, educational background, and work experience found no consistent independent factors associated with better decision-making, other than continued medical education, that were associated with treatment choice. Conclusions The physicians’ reported management of AGHD in this major academic healthcare center in Beijing was inconsistent with current evidence. High quality continued medical education is required to improve Chinese physician management of AGHD.
Chin Med Sci J 2016; 31(3):168-172 Received for publication September 25, 2015. *Corresponding author Tel: 86-10-69155100, Fax: 86-10-69155073, E-mail: [email protected] △Supported by National Natural Science Foundation of China (81400774) and PUMC Youth Fund (33320140164 and 3332016128).
Vol. 31, No.3
A
syndrome.
CHINESE MEDICAL SCIENCES JOURNAL
169
DULT growth hormone deficiency (AGHD) is a
residents, endocrinologists and visiting physicians. The
debilitating condition, associated with reduced
questionnaires were answered anonymously. The response
muscle mass and muscle strength, osteoporosis,
of each question was classified as appropriate if it was
obesity and increased risk factors of metabolic
consistent with the recommendation of the Endocrine
1, 2
AGHD is resulted from tumors, pituitary
Society guidelines1 as follows:
surgery, radiation therapies of the head, traumatic brain
(1) The insulin tolerance test (ITT) and the growth
disease and other hypothalamic-pituitary disease. Re-
hormone-releasing hormone (GHRH)-arginine test should
combinant human growth hormone (rhGH) replacement
be used to establish the diagnosis of AGHD.
therapy provides benefits in body composition and quality of life.
3, 4
(2) If the causes of the GHD in children are structural
The Endocrine Society Clinical Guideline on
lesions with multiple hormone deficiencies and proven
Evaluation and Treatment of Adult Growth Hormone Defi-
genetic causes, a low insulin-like growth factor I (IGF-I) level
ciency has been published in 20065 and updated in 2011.1
at least 1 month off rhGH therapy is sufficient documentation
In Chinese population, the incidence rate of pituitary
of persistent GHD without additional provocative testing.
tumor and child-onset growth hormone deficiency (GHD)
(3) rhGH replacement therapy offers significant clinical
was about 1/100 0006 and 1/86467 respectively. But the
benefits in body composition, exercise capacity, skeletal
prevalence of AGHD is unknown. Although there is certain
integrity and the quality of life.
progress in the management of AGHD, variance in practice
(4) rhGH dosing regimens should be individualized
also exists in Chinese physicians. There is no consensus or
rather than weight-based and start with low doses and be
clinical guidelines about AGHD in China so far. And we have
titrated according to clinical response, side effects, and
not found any research articles evaluating quality of care
IGF-I levels.
about AGHD patients in Chinese medical literature data-
(5) Treatment is contraindicated in the presence of an
base, Medline or Embase. In the present study, we inves-
active malignancy. Thyroid and adrenal function should be
tigated the knowledge and attitude of Chinese physicians in
monitored during rhGH therapy of adults with GHD.
the management of AGHD patients in general. Statistical analysis
SUBJECTS AND METHODS
Characteristics of the participants and the responses to each question have been recorded. SPSS 17.0 software
Setting
was used to analyze the data. Categorical variables are
Peking Union Medical College Hospital (PUMCH) is a major
expressed as percentage. Factors associated with appro-
academic healthcare center of modern medicine in Beijing.
priate answers were further analyzed by multivariate
Its endocrinology division is one of the oldest subspecialty
regression models.
8
programs in endocrine disorders in China. Each year our division provides care for 100 000 patients with endocrine disorders in out-patient clinic and 1300 patients in subspecialty wards.
RESULTS Characteristics of respondents The response rate was 93.8% (122/130). Among the 122
Questionnaire
questionnaires collected, 4 of the respondents answered
The questionnaire comprises 21 questions, including the
less than 20% of the clinical questions and were excluded
respondents’ demographic characteristics, education back-
from further analysis. The remaining 118 respondents
ground and clinical experience, level of their hospital, patient
answered all questions and were further analyzed as study
workload seen per year, and experiences of continuing medical
subjects. For valid responses, we identified 61 residents,
education (CME) in recent three years. Questions about the
41 attending physicians, 12 associate professors and 4
knowledge and attitude toward AGHD management were
professors. All of the respondents were working in a
based on the key points recommended by the Endocrine
tertiary academic healthcare center. Among them, 53.4%
Society Clinical Practice Guideline on Evaluation and Treat-
had more than 5 years work experience, 25.4% saw more
1
ment of Adult Growth Hormone Deficiency.
than 10 anterior hypopituitarism patients per year and 9.3% saw more than 10 AGHD patients per year. Only
Subjects
35.6% had had CME of any kind in the disease. Other
The study subjects are physicians working or being trained
features of the respondents’ educational background and
in the department of Endocrinology in PUMCH, including
work experience are listed in Table 1.
170
CHINESE MEDICAL SCIENCES JOURNAL Table 1. Characteristics of respondents (n=118)
Characteristics
No. of respondents (%)
September 2016
Attitude towards AGHD management In all, 53 (44.9%) respondents supported long-term recombinant growth hormone replacement therapy in
Gender Male
31 (26.3)
Female
87 (73.7)
Age (yrs) 20-29
43 (36.4)
30-39
57 (48.3)
≥40
18 (15.3)
Highest medical degree
AGHD patients and 36 (30.5%) respondents were against the replacement therapy. For diagnostic test, 27 (22.8%) chose IGF-I, 67 (56.8%) chose ITT and GHRH-arginine test. For patients with deficiencies in three or more pituitary axes, 57 (48.3%) suggested that provocative testing was optional. For those with irreversible nature of the cause of the GHD in children with structural lesions with multiple hormone deficiencies and those with proven genetic causes,
Bachelor
22 (18.6)
Master
81 (68.6)
57 (48.3%) suggested that a low IGF-I level at least 1
Doctor
15 (12.7)
month off rhGH therapy was sufficient for diagnosis. Fortyfive (38.1%) preferred weight-based growth hormone
Length of work experience (yrs) <5
55 (46.6)
dosing regimens and 53 (44.9%) indicated to start with low
5-10
34 (28.8)
doses and be titrated according to clinical response, side
>10
29 (24.5)
effects and IGF-I levels. In addition, 108 (91.5%) believed that active tumor was contraindicated in rhGH replacement
Work title
therapy.
Resident physician
61 (51.7)
Attending physician
41 (34.7)
Benefits of treatment with growth hormone were highly
Associate professor
12 (10.2)
acknowledged. The benefits of rhGH replacement in impro-
4 (3.4)
vement of body composition, muscle maturation, skeletal
Professor Ministry of health affiliated medical school
integrity and quality of life were believed by 85 (72.0%),
No
22 (18.6)
93 (78.8%), 87 (73.7%) and 106 (89.8%) respondents,
Yes
96 (81.4)
respectively. Eighty-one (68.6%) respondents indicated that
Endocrine training years
rhGH treatment could decrease risk factors of metabolic
<3
48 (40.7)
syndrome. For side effects and risks associated with rhGH
3-5
23 (19.5)
therapy, thyroid and adrenal function during rhGH therapy
>5
47 (39.8)
were suggested to be monitored by 94 (79.6%) and 87
Patient workload of pituitary tumors, per year <5
64 (54.2)
5-10
24 (20.3)
11-50
22 (18.6)
≥50
8 (6.8)
Patient workload of Sheehan syndrome, per year <5
93 (78.8)
5-10
16 (13.6)
>10
9 (7.6)
Patient workload of hypopituitarism, per year <5
61 (51.7)
5-10
31 (26.3)
11-50
22 (18.6)
≥50
4 (3.4)
Patient workload of AGHD, per year <5
92 (78.0)
5-10
15 (12.7)
>10
11 (9.3)
Continuous medical education in AGHD
(73.7%) respondents respectively. For issues and concerns about long-term rhGH replacement therapy, 70 (59.3%) respondents worried about patients’ compliance, 109 (92.3%) respondents worried about the cost, 70 (59.3%) worried about increased risks of tumorigenesis and 78 (66.1%) worried about hyperglycemia. Further, using logistic multivariate analysis we found that CME was the only factor associated with physicians’ attitude towards rhGH replacement therapy (OR=6.75, 95% CI=2.04-22.33, Table 2). Physicians who stated that they had had CME in AGHD were more likely to agree that patients need long-term rhGH therapy. Physicians having CME in AGHD did respond better about the AGHD diagnosis questions, but we found no statistic significance (Table 3).
DISCUSSION Although both pituitary tumors and hypopituitarism are
No
76 (64.4)
not rare,9 AGHD is less recognized and treated in China
Yes
42 (35.6)
comparing with Western countries. There are several
AGHD: adult growth hormone deficiency.
research papers from single centers of China investigating
Vol. 31, No.3
CHINESE MEDICAL SCIENCES JOURNAL
171
Table 2. Attitude towards rhGH therapy among physicians Items
rhGH therapy in AGHD (no.) Should be done
Should not be done
No
25
30
Yes
28
6
<5
24
20
>10
15
5
12
11
7
3
Adjusted OR
95%CI
CME 1.0 (ref.) 6.75
2.04-22.33
Length of work experience (yrs) 1.0 (ref.) 1.58
0.88-1.84
Work title Resident physician Professor
1.0 (ref.) 2.31
0.31-17.23
rhGH: recombinant human growth hormone; OR: odd ratio; 95%CI: 95% confidence interval; CME: continuing medical education. Table 3. Attitude towards diagnosis procedures among physicians with or without CME (n=118) Items
CME Yes [no. (%)]
No [no. (%)]
8 (19)
19 (25)
26 (62)
41 (54)
8 (19)
16 (21)
Diagnostic test IGF-I GHRH-arginine test and ITT Do not know
Patients with deficiencies in three pituitary axes with low IGF-I level Need provocative test
12 (29)
25 (33)
No provocative test
24 (57)
33 (43)
6 (14)
18 (24)
Do not know
Irreversible nature of the cause of the GHD in children with structural lesions and those with proven genetic causes Need provocative test
16 (38)
No provocative test
20 (48)
37 (49)
6 (14)
15 (19)
Do not know
24 (32)
IGF-I: insulin-like growth factor I; GHRH: growth hormone-releasing hormone; ITT: insulin tolerance test; GHD: growth hormone deficiency.
osteoprotegerin and adipocytokines in AGHD.10, 11 However,
therapy. Only 56.8% of the physicians agreed that the ITT
the epidemiological data of AGHD in Chinese population are
and the GHRH-arginine test should be used unless there is
limited, and whether physicians have clear recognition of
a proven genetic/structural lesion persistent from childhood.
the diagnosis and treatment of AGHD is not well known.
Our results show that CME was strongly associated
The current guideline recommended that rhGH repla-
with treatment choice. Physician demographic data,
cement therapy provided significant benefits in body
educational background and work experience had no
composition, skeletal integrity and the quality of life. And
relationship with better decision-making. As we all know,
the final decision to treat AGHD patients requires though-
CME is delivered by faculty who are experts in their clinical
tful clinical judgment with a careful evaluation of the
areas and helps physicians maintain competence and learn
benefits and risks specific to the individual.1 Our results
about new and developing areas of their field. Due to the
show that the physicians’ reported diagnosis and treatment
lack of clinical recognition of AGHD, CME courses
of AGHD at this major academic healthcare center in
specifically developed for AGHD in China are rare, and most
Beijing was often inconsistent with current evidence.
of the CME courses are only available in major academic
Although a high rate of the physicians we investigated
healthcare centers. We therefore propose that the quantity
knew well about the benefits and contraindications of rhGH
of CME be increased. Besides, Chinese literatures in this
treatment, only 44.9% of them thought that AGHD patients
area in recent 5 years are scarce, and need to be updated.
should accept recombinant growth hormone replacement
We hope to improve the clinical recognition of AGHD by
172
CHINESE MEDICAL SCIENCES JOURNAL
high quality CME, so that better-designed multicenter studies can be performed to assess the rhGH treatment
September 2016
Endocrinol Metab 2004; 89:2048-56. 5.
Molitch ME, Clemmons DR, Malozowski S, et al. Evaluation
effect on Chinese adult patients of growth hormone-
and treatment of adult growth hormone deficiency: an
deficient, and then it will be possible to establish the clinical
Endocrine Society Clinical Practice Guideline. J Clin
practice guideline applicable for the Chinese population.
Endocrinol Metab 2006; 91:1621-34. 6.
of central nervous system tumors in China. J Neurosurg
REFERENCES 1.
Molitch ME, Clemmons DR, Malozowski S, et al. Evalua-
1982; 56:555-64. 7.
tion and treatment of adult growth hormone deficiency:
2.
401-5. 8.
Uzunova I, Kirilov G, Zacharieva S, et al. Individual risk
1993; 76:815-6. 9.
study. Exp Clin Endocrinol Diabetes 2015; 123:39-43. 3.
4.
Ahmad AM, Hopkins MT, Thomas J, et al. Body composi-
Wilson JD. Peking Union Medical College Hospital, a palace of endocrine treasures. J Clin Endocrinol Metab
factors of the metabolic syndrome in adult patients with growth hormone deficiency—a cross-sectional case-control
Bao X, Shi Y, Du Y, et al. Prevalence of growth hormone deficiency of children in Beijing. Chin Med J 1992; 105:
an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2011; 96:1587-609.
Huang WQ, Zheng SJ, Tian QS, et al. Statistical analysis
Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, et al. Hypopituitarism. Lancet 2007; 369:1461-70.
10.
Li ZP, Zhang M, Gao J, et al. Study of the correlation
tion and quality of life in adults with growth hormone
between growth hormone deficiency and serum leptin,
deficiency; effects of low-dose growth hormone replacement.
adiponectin, and visfatin levels in adults. Genet Mol Res
Clin Endocrinol 2001; 54:709-17.
2014; 13:4050-6.
Hoffman AR, Kuntze JE, Baptista J, et al. Growth hormone (GH) replacement therapy in adult-onset GH deficiency: effects on body composition in men and women in a double-blind, randomized, placebo-controlled trial. J Clin
11.
Xia J, Li L, Ren W, et al. Correlation of increased plasma osteoprotegerin and cardiovascular risk factors in patients with adult growth hormone deficiency. Int J Clin Exp Med 2015; 8:3184‐92.
Vol. 31, No. 3 P. 168-172
CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE
Management of Adult Growth Hormone Deficiency at Peking Union Medical College Hospital: A Survey among Physicians△ Hong-bo Yang1, Meng-qi Zhang2, Hui Pan1, and Hui-juan Zhu1* 1
Department of Endocrinology, 2Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
Key words: adult growth hormone deficiency; management; continued medical education Objective To evaluate physicians’ attitude and knowledge about the management of adult growth hormone deficiency (AGHD) at Peking Union Medical College Hospital and impact factors associated with better decision-making. Methods A 21-question anonymous survey was distributed and collected at Peking Union Medical College Hospital, a major teaching hospital in Chinese Academy of Medical Sciences. Data of physicians’ educational background, clinical training, patient workload per year and continuing medical education in AGHD were collected. Factors associated with appropriate answers were further analyzed by multivariate regression models. Results One hundred and eighteen internal medicine residents, endocrine fellows, attending physicians and visiting physicians responded to the survey. Among them, 44.9% thought that AGHD patients should accept recombinant human growth hormone replacement therapy. Moreover, 56.8% selected insulin tolerance test and growth hormone-releasing hormone-arginine test for the diagnosis of AGHD. Logistic regression analysis of physician demographic data, educational background, and work experience found no consistent independent factors associated with better decision-making, other than continued medical education, that were associated with treatment choice. Conclusions The physicians’ reported management of AGHD in this major academic healthcare center in Beijing was inconsistent with current evidence. High quality continued medical education is required to improve Chinese physician management of AGHD.
Chin Med Sci J 2016; 31(3):168-172 Received for publication September 25, 2015. *Corresponding author Tel: 86-10-69155100, Fax: 86-10-69155073, E-mail: [email protected] △Supported by National Natural Science Foundation of China (81400774) and PUMC Youth Fund (33320140164 and 3332016128).
Vol. 31, No.3
A
syndrome.
CHINESE MEDICAL SCIENCES JOURNAL
169
DULT growth hormone deficiency (AGHD) is a
residents, endocrinologists and visiting physicians. The
debilitating condition, associated with reduced
questionnaires were answered anonymously. The response
muscle mass and muscle strength, osteoporosis,
of each question was classified as appropriate if it was
obesity and increased risk factors of metabolic
consistent with the recommendation of the Endocrine
1, 2
AGHD is resulted from tumors, pituitary
Society guidelines1 as follows:
surgery, radiation therapies of the head, traumatic brain
(1) The insulin tolerance test (ITT) and the growth
disease and other hypothalamic-pituitary disease. Re-
hormone-releasing hormone (GHRH)-arginine test should
combinant human growth hormone (rhGH) replacement
be used to establish the diagnosis of AGHD.
therapy provides benefits in body composition and quality of life.
3, 4
(2) If the causes of the GHD in children are structural
The Endocrine Society Clinical Guideline on
lesions with multiple hormone deficiencies and proven
Evaluation and Treatment of Adult Growth Hormone Defi-
genetic causes, a low insulin-like growth factor I (IGF-I) level
ciency has been published in 20065 and updated in 2011.1
at least 1 month off rhGH therapy is sufficient documentation
In Chinese population, the incidence rate of pituitary
of persistent GHD without additional provocative testing.
tumor and child-onset growth hormone deficiency (GHD)
(3) rhGH replacement therapy offers significant clinical
was about 1/100 0006 and 1/86467 respectively. But the
benefits in body composition, exercise capacity, skeletal
prevalence of AGHD is unknown. Although there is certain
integrity and the quality of life.
progress in the management of AGHD, variance in practice
(4) rhGH dosing regimens should be individualized
also exists in Chinese physicians. There is no consensus or
rather than weight-based and start with low doses and be
clinical guidelines about AGHD in China so far. And we have
titrated according to clinical response, side effects, and
not found any research articles evaluating quality of care
IGF-I levels.
about AGHD patients in Chinese medical literature data-
(5) Treatment is contraindicated in the presence of an
base, Medline or Embase. In the present study, we inves-
active malignancy. Thyroid and adrenal function should be
tigated the knowledge and attitude of Chinese physicians in
monitored during rhGH therapy of adults with GHD.
the management of AGHD patients in general. Statistical analysis
SUBJECTS AND METHODS
Characteristics of the participants and the responses to each question have been recorded. SPSS 17.0 software
Setting
was used to analyze the data. Categorical variables are
Peking Union Medical College Hospital (PUMCH) is a major
expressed as percentage. Factors associated with appro-
academic healthcare center of modern medicine in Beijing.
priate answers were further analyzed by multivariate
Its endocrinology division is one of the oldest subspecialty
regression models.
8
programs in endocrine disorders in China. Each year our division provides care for 100 000 patients with endocrine disorders in out-patient clinic and 1300 patients in subspecialty wards.
RESULTS Characteristics of respondents The response rate was 93.8% (122/130). Among the 122
Questionnaire
questionnaires collected, 4 of the respondents answered
The questionnaire comprises 21 questions, including the
less than 20% of the clinical questions and were excluded
respondents’ demographic characteristics, education back-
from further analysis. The remaining 118 respondents
ground and clinical experience, level of their hospital, patient
answered all questions and were further analyzed as study
workload seen per year, and experiences of continuing medical
subjects. For valid responses, we identified 61 residents,
education (CME) in recent three years. Questions about the
41 attending physicians, 12 associate professors and 4
knowledge and attitude toward AGHD management were
professors. All of the respondents were working in a
based on the key points recommended by the Endocrine
tertiary academic healthcare center. Among them, 53.4%
Society Clinical Practice Guideline on Evaluation and Treat-
had more than 5 years work experience, 25.4% saw more
1
ment of Adult Growth Hormone Deficiency.
than 10 anterior hypopituitarism patients per year and 9.3% saw more than 10 AGHD patients per year. Only
Subjects
35.6% had had CME of any kind in the disease. Other
The study subjects are physicians working or being trained
features of the respondents’ educational background and
in the department of Endocrinology in PUMCH, including
work experience are listed in Table 1.
170
CHINESE MEDICAL SCIENCES JOURNAL Table 1. Characteristics of respondents (n=118)
Characteristics
No. of respondents (%)
September 2016
Attitude towards AGHD management In all, 53 (44.9%) respondents supported long-term recombinant growth hormone replacement therapy in
Gender Male
31 (26.3)
Female
87 (73.7)
Age (yrs) 20-29
43 (36.4)
30-39
57 (48.3)
≥40
18 (15.3)
Highest medical degree
AGHD patients and 36 (30.5%) respondents were against the replacement therapy. For diagnostic test, 27 (22.8%) chose IGF-I, 67 (56.8%) chose ITT and GHRH-arginine test. For patients with deficiencies in three or more pituitary axes, 57 (48.3%) suggested that provocative testing was optional. For those with irreversible nature of the cause of the GHD in children with structural lesions with multiple hormone deficiencies and those with proven genetic causes,
Bachelor
22 (18.6)
Master
81 (68.6)
57 (48.3%) suggested that a low IGF-I level at least 1
Doctor
15 (12.7)
month off rhGH therapy was sufficient for diagnosis. Fortyfive (38.1%) preferred weight-based growth hormone
Length of work experience (yrs) <5
55 (46.6)
dosing regimens and 53 (44.9%) indicated to start with low
5-10
34 (28.8)
doses and be titrated according to clinical response, side
>10
29 (24.5)
effects and IGF-I levels. In addition, 108 (91.5%) believed that active tumor was contraindicated in rhGH replacement
Work title
therapy.
Resident physician
61 (51.7)
Attending physician
41 (34.7)
Benefits of treatment with growth hormone were highly
Associate professor
12 (10.2)
acknowledged. The benefits of rhGH replacement in impro-
4 (3.4)
vement of body composition, muscle maturation, skeletal
Professor Ministry of health affiliated medical school
integrity and quality of life were believed by 85 (72.0%),
No
22 (18.6)
93 (78.8%), 87 (73.7%) and 106 (89.8%) respondents,
Yes
96 (81.4)
respectively. Eighty-one (68.6%) respondents indicated that
Endocrine training years
rhGH treatment could decrease risk factors of metabolic
<3
48 (40.7)
syndrome. For side effects and risks associated with rhGH
3-5
23 (19.5)
therapy, thyroid and adrenal function during rhGH therapy
>5
47 (39.8)
were suggested to be monitored by 94 (79.6%) and 87
Patient workload of pituitary tumors, per year <5
64 (54.2)
5-10
24 (20.3)
11-50
22 (18.6)
≥50
8 (6.8)
Patient workload of Sheehan syndrome, per year <5
93 (78.8)
5-10
16 (13.6)
>10
9 (7.6)
Patient workload of hypopituitarism, per year <5
61 (51.7)
5-10
31 (26.3)
11-50
22 (18.6)
≥50
4 (3.4)
Patient workload of AGHD, per year <5
92 (78.0)
5-10
15 (12.7)
>10
11 (9.3)
Continuous medical education in AGHD
(73.7%) respondents respectively. For issues and concerns about long-term rhGH replacement therapy, 70 (59.3%) respondents worried about patients’ compliance, 109 (92.3%) respondents worried about the cost, 70 (59.3%) worried about increased risks of tumorigenesis and 78 (66.1%) worried about hyperglycemia. Further, using logistic multivariate analysis we found that CME was the only factor associated with physicians’ attitude towards rhGH replacement therapy (OR=6.75, 95% CI=2.04-22.33, Table 2). Physicians who stated that they had had CME in AGHD were more likely to agree that patients need long-term rhGH therapy. Physicians having CME in AGHD did respond better about the AGHD diagnosis questions, but we found no statistic significance (Table 3).
DISCUSSION Although both pituitary tumors and hypopituitarism are
No
76 (64.4)
not rare,9 AGHD is less recognized and treated in China
Yes
42 (35.6)
comparing with Western countries. There are several
AGHD: adult growth hormone deficiency.
research papers from single centers of China investigating
Vol. 31, No.3
CHINESE MEDICAL SCIENCES JOURNAL
171
Table 2. Attitude towards rhGH therapy among physicians Items
rhGH therapy in AGHD (no.) Should be done
Should not be done
No
25
30
Yes
28
6
<5
24
20
>10
15
5
12
11
7
3
Adjusted OR
95%CI
CME 1.0 (ref.) 6.75
2.04-22.33
Length of work experience (yrs) 1.0 (ref.) 1.58
0.88-1.84
Work title Resident physician Professor
1.0 (ref.) 2.31
0.31-17.23
rhGH: recombinant human growth hormone; OR: odd ratio; 95%CI: 95% confidence interval; CME: continuing medical education. Table 3. Attitude towards diagnosis procedures among physicians with or without CME (n=118) Items
CME Yes [no. (%)]
No [no. (%)]
8 (19)
19 (25)
26 (62)
41 (54)
8 (19)
16 (21)
Diagnostic test IGF-I GHRH-arginine test and ITT Do not know
Patients with deficiencies in three pituitary axes with low IGF-I level Need provocative test
12 (29)
25 (33)
No provocative test
24 (57)
33 (43)
6 (14)
18 (24)
Do not know
Irreversible nature of the cause of the GHD in children with structural lesions and those with proven genetic causes Need provocative test
16 (38)
No provocative test
20 (48)
37 (49)
6 (14)
15 (19)
Do not know
24 (32)
IGF-I: insulin-like growth factor I; GHRH: growth hormone-releasing hormone; ITT: insulin tolerance test; GHD: growth hormone deficiency.
osteoprotegerin and adipocytokines in AGHD.10, 11 However,
therapy. Only 56.8% of the physicians agreed that the ITT
the epidemiological data of AGHD in Chinese population are
and the GHRH-arginine test should be used unless there is
limited, and whether physicians have clear recognition of
a proven genetic/structural lesion persistent from childhood.
the diagnosis and treatment of AGHD is not well known.
Our results show that CME was strongly associated
The current guideline recommended that rhGH repla-
with treatment choice. Physician demographic data,
cement therapy provided significant benefits in body
educational background and work experience had no
composition, skeletal integrity and the quality of life. And
relationship with better decision-making. As we all know,
the final decision to treat AGHD patients requires though-
CME is delivered by faculty who are experts in their clinical
tful clinical judgment with a careful evaluation of the
areas and helps physicians maintain competence and learn
benefits and risks specific to the individual.1 Our results
about new and developing areas of their field. Due to the
show that the physicians’ reported diagnosis and treatment
lack of clinical recognition of AGHD, CME courses
of AGHD at this major academic healthcare center in
specifically developed for AGHD in China are rare, and most
Beijing was often inconsistent with current evidence.
of the CME courses are only available in major academic
Although a high rate of the physicians we investigated
healthcare centers. We therefore propose that the quantity
knew well about the benefits and contraindications of rhGH
of CME be increased. Besides, Chinese literatures in this
treatment, only 44.9% of them thought that AGHD patients
area in recent 5 years are scarce, and need to be updated.
should accept recombinant growth hormone replacement
We hope to improve the clinical recognition of AGHD by
172
CHINESE MEDICAL SCIENCES JOURNAL
high quality CME, so that better-designed multicenter studies can be performed to assess the rhGH treatment
September 2016
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effect on Chinese adult patients of growth hormone-
and treatment of adult growth hormone deficiency: an
deficient, and then it will be possible to establish the clinical
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