title: Physician decisions to discontinue long-term medications using a two-stage framework: the case of growth hormone therapy.
abstract: BACKGROUND
  Physician decisions to discontinue prescription medications for chronic conditions are fundamental determinants of drug use but have been inadequately studied. The decision to stop growth hormone (GH) therapy is an important example because of high cost (approximately $26,000/y for a 48-kg child), complexity of treatment options, and expansion of patient populations.
  
  
  OBJECTIVE
  The aim of this study was to identify the factors that influence physician recommendations in the process of discontinuing therapy.
  
  
  METHODS
  A random sample of half of U.S. pediatric endocrinologists (n = 265) was mailed a survey that included case scenarios of GH-deficient adolescents. Decision options involved a 2-stage framework to 1) initiate change in ongoing GH therapy (by discussing discontinuing GH with the family but not yet stopping treatment), and 2) take action to discontinue ongoing GH therapy (by terminating GH or reducing the dose to adult maintenance level).
  
  
  METHODS
  Physician recommendations.
  
  
  RESULTS
  The response rate was 83.8%. Physiological indices of growth potential (growth velocity, bone age) significantly influenced discontinuation decisions (both P < 0.001). However, family preference, child's height, and physician attitudes exerted independent effects (each P < 0.05). Treatment price had little influence. Together, these variables accounted for 60% to 70% of the variation in recommendations. Their relative influence differed by stage in the discontinuation process.
  
  
  CONCLUSIONS
  The variables in our framework substantially explain discontinuation decisions. The data demonstrate the importance of both physiological and nonphysiological factors. The results suggest that physicians value even small gains as final height approaches, although an additional 20% expenditure may be needed to gain the last 1% to 3% of adult height.
authors.affiliation: Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, USA. lxc15@po.cwru.edu
authors.forename: Leona
authors.initials: L
authors.lastname: Cuttler
authors.forename: J B
authors.initials: JB
authors.lastname: Silvers
authors.forename: Jagdip
authors.initials: J
authors.lastname: Singh
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Tsai
authors.forename: Deborah
authors.initials: D
authors.lastname: Radcliffe
mesh_terms: D000293:Adolescent; D000365:Age Determination by Skeleton; D001827:Body Height / Q000187:drug effects; D002908:Chronic Disease; D003657:Decision Making; D004334:Drug Administration Schedule; D004363:Drug Utilization; D004704:Endocrinology; D019382:Human Growth Hormone / Q000008:administration & dosage* / Q000172:deficiency* / Q000191:economics; D006801:Humans; D008297:Male; D010372:Pediatrics; D010820:Physicians; D011306:Prescription Fees; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000191:economics; D014481:United States
chemical_list: D011994:Recombinant Proteins; D019382:Human Growth Hormone