Ethnic and Gender Inequities in the Evaluation of Referred Short Children

Abstract

Aims: To examine ethnicity and gender differences in the evaluation of referred children with short stature and to investigate adherence of the primary care evaluation to published guidelines. Methods: Cross-sectional study in a referral center. 371 short patients aged 2–18 years were included. Outcome measures were patient’s growth characteristics, final diagnosis, and prevalence of pre-referral patient data. Results: The study population was composed of 239 Bedouin children and 132 Jewish children (p < 0.0001). More males (61%) than females were evaluated (p < 0.0001). There were no significant differences between males and females in age and growth parameters at the time of referral. Bedouins, males and females, were significantly shorter than their Jewish counterparts at the time of referral: height SD –2.44 ± 0.73 and –2.62 ± 1.05 versus –2.13 ± 0.55 and –2.21 ± 0.57, respectively (p < 0.05). There were no significant ethnic or gender differences in the final diagnosis. Significant deficiencies in the primary care evaluation of referred short children were found. Conclusions: We demonstrated novel ethnic- and gender-based inequities in the evaluation of referred short children. We found that the current evaluation of short stature in our area does not comply with existing guidelines.

Evaluation of referrals for short stature: A retrospective chart review

“…In an observational study of over 21,000 children referred for short stature from 237 institutions and practices, the mean age at referral was 8.6 years, 69% were male, and the mean height SD was −2.1 (7). Others have reported increased referral rates for males ranging from 61% to 65% (8)(9)(10). In our population, females were referred earlier than males despite the finding that a greater proportion of males had a PED (50.8% versus 32.3% females).…”

“…This retrospective chart review showed that there was a high frequency of GCs at initial assessment of patients referred to our centre for short stature: 72% compared to reported rates of 41 to 59% (8,9). This was likely attributable to our standard clinical practice, wherein following receipt of a referral for short stature, repeated requests were made to the referring physician for previous measurements.…”

“…Reported HDs at referral are very similar, with mean HDs of −2.0 (10). In a cross sectional study in an academic centre of 371 patients referred for short stature, the mean age at referral was 9.8 years, with 61% males and a mean SD of −2.4; there were no significant differences between males and females in age and growth parameters at the time of referral (9).…”

Early recognition of growth abnormalities permitting early intervention

“…In some cases, a lack of trained staff may mean that children are unable to get routine growth checks at school (44). Indeed, as recently as 2011, Yardeni et al showed that adherence to guidelines for evaluation of short stature in the primary clinic referring children to a specialist unit was inadequate; children were frequently referred without important data on previous growth and parental height, and many laboratory tests crucial to the primary care physician's evaluation were lacking (45).…”

Short Stature Diagnosis and Referral

“…However, the study indicated that up to 25% of children with pathological growth failure may not be identified and other factors need to be considered, such as clinical examination and phenotype. There is a strong gender bias in referrals for short stature, with girls much less likely to be referred than boys ( 15 , 16 ) and an ethnic bias may also be present ( 16 ). In all cases, up-to-date growth standards should be used, and wherever possible they should be population specific.…”