Technology Assessment Report commissioned by the NHS R&D HTA Programme on behalf of

the National Institute for Health and Clinical Excellence

Final Protocol (September 2008)

1. Title of the project

Human growth hormone in children

2. Plain English Summary

One of the factors essential for a child’s growth is production of an adequate level of natural growth
hormone by the pituitary gland at the base of the brain. Human growth hormone (HGH), also called
somatropin, is licensed to treat children who have restricted growth due to a range of medical
conditions. Children with growth hormone deficiency (GHD) do not produce enough of this hormone
naturally, so injections of a synthetic form can help to increase their growth rates. Children with
Prader-Willi syndrome (PWS) are characteristically of short stature and have altered body
composition. They may also be growth hormone deficient, so treatment with growth hormone can be
used to replace natural levels of the hormone for these patients. Treatment with HGH is primarily
used to improve body composition and metabolism in children with PWS.

Short stature is also a common feature in children with other conditions such as Turner syndrome
(TS); chronic renal insufficiency (CRI); children born small for gestational age (SGA) or with short
stature homeobox-containing gene (SHOX) deficiency. Children with these conditions may have
reduced sensitivity to normal levels of GH, so supplementary injections of synthetic growth hormone
may help to increase their growth rates.

This review will systematically summarise the results of clinical trials which evaluate the use of
human growth hormone for the treatment of children with GHD, TS, CRI (prepubertal children only),
PWS, and those born SGA or with growth failure associated with SHOX deficiency confirmed by
DNA analysis. The report will include a systematic review of cost effectiveness studies and an
economic evaluation, to give an indication of the cost-effectiveness of HGH for the NHS in England
and Wales.

3. Decision problem
Recombinant human growth hormone (somatropin) is currently recommended by NICE1 for children
with a proven clinical diagnosis of GHD, TS or PWS and for pre-pubertal children with CRI. Since
the last review, somatropin has received marketing authorisation for the treatment of children born
SGA and for children with growth failure associated with SHOX deficiency. The review will update

1
and extend the existing systematic review2 with any new evidence for the use of growth hormone for
children with GHD, TS, PWS or CRI. In addition, evidence for the use of human growth hormone for
children born small for gestational age, or with SHOX deficiency (conditions not considered in the
original review) will be included in this report.

3.1 Background

3.1.1 Growth hormone deficiency

Growth hormone deficiency occurs when the pituitary gland fails to produce sufficient levels of
growth hormone. It can be caused by a variety of factors, but in many cases the cause is unknown
(idiopathic GHD). In some children, failure or reduction in growth hormone secretion is congenital,
and may be accompanied by other pituitary hormone deficiencies. Other children have genetic
mutations such as GH-1 gene mutation (which leads to isolated GHD) or PROP-1 gene mutations
which may lead to multiple hormone deficiency including GHD. In others, growth hormone
deficiency is acquired as a result of: trauma, either at birth or later in childhood; infiltration from
histiocytosis, lymphoma or leukaemia; pituitary or hypothalamic tumours; or following
radiotherapy.2 The diagnosis of GHD includes a height of more than 3 SD below the mean, a height
velocity more than 2SD below the mean for a year or a height velocity of more than 1.5 SD below
the mean for two years.3 Untreated patients have a final height of 134-146cm in males and 128-134
cm in females.4 People with GHD are also at greater risk of cardiovascular disease if they develop an
adverse lipid profile.

The UK Child Growth Foundation estimates that idiopathic GHD occurs in about one in every 3800
births,5 but reliable figures are difficult to obtain for GHD associated with radiotherapy and other
causes. The true incidence may also be higher when difficult to diagnose, borderline cases are taken
into account. An increasing number of children are surviving childhood cancers as treatments
improve, and consequently require treatment with GH to overcome associated GHD. Treatment with
GH is currently recommended by NICE to help increase the growth of children with GHD.1

3.1.2 Turner syndrome

Turner syndrome is characterised by the complete or partial absence of the second sex chromosome
in girls, sometimes with cell populations which differ in genetic make up (cell line mosaicism),6 in
addition to the presence of characteristic physical features.7;8 The condition affects approximately one
in 2500 live-born females.9;10 In the majority of girls with TS, the missing or abnormal second
chromosome causes ovarian failure, preventing sexual maturity. Girls with TS therefore receive
oestrogen replacement therapy as part of their treatment. Not all girls with TS will require GH
treatment and the condition does not involve a deficiency in natural growth hormone secretion,

2
although there may be a relative lack of sensitivity to GH.2 The average adult height deficit of 20cm
in women with TS is mostly due to haploinsufficiency of the SHOX gene.11 Treatment with GH is
currently recommended by NICE to help boost the growth of girls with TS.1

3.1.3 Growth disturbance in children born SGA

There are various thresholds for defining a child as being born SGA, but the European license is for
children whose height is less than -2.5 SD (0.4th centile), which would give an incidence of 0.4% of
children who would fall below this level. More than 80% of babies born SGA will achieve catch-up
growth (growth velocity greater than the median for chronologic age and gender12) during their first
six months.13, with catch-up growth completed within two years for most SGA infants.14;15 However,
babies born prematurely who are SGA may take around four years to achieve catch-up growth.16

It has been estimated that approximately 10% of SGA children remain at a height below -2SD
throughout their childhood.17;18 Children who are born SGA with low birth weight and who do not
achieve catch-up growth by the age of two years face a relative risk of short stature < -2SD at age
eighteen of 5.2. For SGA children with low birth length the relative risk is 7.1.15

Published estimates of the annual incidence of SGA births in Sweden and the Netherlands vary
between 3%17;19 and 5.4%.20 A 2005 audit by the British Society for Paediatric Endocrinology and
Diabetes found 205 patients with a diagnosis of SGA being treated with GH in the UK.21
There are several possible causes for children being born SGA. These include maternal factors, such
as age, parity, medical conditions, smoking, malnutrition, and alcohol abuse; placental factors, and
foetal factors such as chromosomal abnormalities and genetic defects.12 Diagnosis of SGA can be
complicated, requiring accurate knowledge of gestational age. Children classified as SGA may have
concurrent diagnoses, such as familial short stature, TS, GHD or skeletal dysplasia.12 Previous NICE
guidelines did not consider children born SGA, as somatropin was not licensed for this indication at
the time.1 Its European license is for children aged four years and over.

3.1.4 Prader-Willi syndrome

Prader Willi syndrome is a genetic disorder, caused by an abnormality of chromosome 15. It is
characterised by hyperphagia, hypogonadism, short final stature, dysmorphic features,
hypoventilation, behavioural problems and a high risk of obesity.22 Children with this syndrome
often have reduced GH secretion, but this may be linked with obesity. A UK study carried out
between 1998 and 2000 found an overall population rate of 1:52,000, considered to be the lower
bound, with rates varying from 1:42,000 to 1:67,000 for individual counties.23 This study also gave a
birth incidence of 1:20,000, with a lower bound of 1:29,000. The same study found an overall death

3
rate for the PWS population (from the age of 3.4 to 56 years) of around 3% per year, which is higher
than the standard death rate of about 0.3% each year for people up to the age of 55 years in England
and Wales.23 Mean final height for people with PWS is approximately 154cm in males and 145-
149cm in females.2 Treatment with GH is currently recommended by NICE to help increase the
growth of children with PWS, and to help improve body composition.1

3.1.5 Chronic renal insufficiency

Chronic renal insufficiency (also known as chronic renal failure) is defined as a persistent elevation
of serum creatinine and/or urea level. It can be caused by a variety of conditions, including
congenital disorders, glomerular disorders and infections. Patients undergoing haemodialysis or
peritoneal dialysis can be considered for GH treatment, as well as those who have received kidney
transplantations. Growth failure associated with CRI can be caused by acidosis, rickets, GH
resistance, inadequate nutrition and anorexia.24 Children with CRI experience impaired growth once
their glomerular filtration rate (GFR) falls to 50% of normal, with increasing problems once the GFR
falls below 25%.25 Following kidney transplantation, chronic graft rejection and treatment with
steroids can restrict growth and development.26

The UK Renal Registry reported that there were 748 patients under the age of 18 years who were on
renal replacement therapy in the UK’s 13 paediatric renal centres.27 An Italian study of the
epidemiology of chronic renal failure in children found a mean incidence of 12.1 cases per million
(range: 8.8–13.9), with a point prevalence of 74.7 per million of the age-related population.28 Disney
and colleagues give a prevalence of 32 per million children under the age of 15 in Australia and New
Zealand having chronic kidney disease, defined by the need for dialysis or kidney transplant.29

Children with congenital disorders (approximately 60% of children with CRI)26 are usually of normal
length at birth, but are below the 3rd percentile for height within their first year and remain parallel to
normal percentiles throughout childhood.26 One study reported a mean height from birth to age ten
which was -2.37 SD ± 1.6.26 Similarly, final height is reported to be reduced to below the third
percentile in patients who developed end-stage renal failure in childhood.26 Adult final height was
more than two standard deviations below the mean for approximately 60% of boys and 41% of girls
who started renal replacement therapy before they were 15 years old.30

Treatment with GH is currently recommended by NICE to help increase the growth of prepubertal
children with CRI, when nutritional status.1 GH treatment should be stopped after a renal
transplantation, and only re-established after one year if it has been ascertained that catch-up growth
has not occurred.1

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3.1.6 SHOX deficiency
The short stature homeobox-containing gene (SHOX) is located on the distal ends of the X and Y
chromosomes. This gene plays a significant role in long bone growth, and normal growth requires
two functional copies.31;32 Growth impairment can result from having only a single functional copy of
the SHOX gene, with the other inactivated by mutation (haploinsufficiency), or deletion.31 SHOX
deficiency can cause short stature in a range of medical conditions. Clinical features associated with
SHOX deficiency include disproportionate shortening of the middle sections of the limbs, bowing of
the forearms and lower legs and arm-bone abnormality31 SHOX deficiency can cause short stature in
people with concurrent diagnoses such as Turner syndrome or idiopathic short stature. One study
estimated a prevalence of SHOX deficiency of at least 1 in 2000 children.33

3.2 Definition of the intervention

Recombinant human GH (somatropin) has been available since 1985, following the withdrawal of
cadaveric human pituitary GH due to possible transmission of Creutzfeldt-Jakob disease.2
Somatropin is a synthetic form of human growth hormone produced by recombinant DNA
technology, having a sequence identical to that of pituitary-derived human growth hormone.
Licensed dosages vary for the different indications (Table 1), depending on whether the treatment is
aiming to replace growth hormone to normal levels (for children with growth hormone deficiency),
or being used in supraphysiological doses where there is no hormone deficiency but some lack of
sensitivity to the hormone. It is given as a subcutaneous injection, usually at night (to mimic the
child’s natural fluctuations in growth hormone).2 Seven pharmaceutical companies have UK
marketing authorisations for various indications, as shown in Table 1.

Table 1 Indications for the use of somatropin in children

Indication Dose* Licensed drugs (manufacturers)
Growth hormone deficiency 23-39 Humatrope (Eli Lilly & Co. Ltd)
micrograms/kg Zomacton (Ferring Pharmaceuticals UK)
daily, or 0.7-1.0 NutropinAq (Ipsen Ltd)
mg/m2 daily Norditropin Simple Xx (Novo Nordisk Ltd)
Genotropin (Pfizer Ltd)
Omnitrope (Sandoz Ltd)
Saizen (Merck Serono)
Turner’s syndrome 45-50 Humatrope (Eli Lilly & Co. Ltd)
micrograms/kg Zomacton (Ferring Pharmaceuticals UK)
daily, or 1.4 NutropinAq (Ipsen Ltd)
mg/m2 daily Norditropin Simple Xx (Novo Nordisk Ltd)
Genotropin (Pfizer Ltd)
Omnitrope (Sandoz Ltd)
Saizen (Merck Serono)
Growth disturbance (current height 35 Humatrope (Eli Lilly & Co. Ltd)
SDS -2.5 and parental adjusted micrograms/kg Norditropin Simple Xx (Novo Nordisk Ltd)
height SDS, -1) in short children daily, or 1.0 Genotropin (Pfizer Ltd)

5
 born SGA, with a birth weight and mg/m2 daily Omnitrope (Sandoz Ltd)
/or length below -2SD, who failed Saizen (Merck Serono)
to show catch up growth (HV
SDS<0 during the last year) by 4
years of age or later
Prader-Willi syndrome, with 35 Genotropin (Pfizer Ltd)
growth velocity > 1cm/year (in micrograms/kg Omnitrope (Sandoz Ltd)
combination with energy-restricted daily, or 1.0
diet) mg/m2 daily;
max 2.7 mg
daily.
Chronic renal insufficiency in 45-50 Humatrope (Eli Lilly & Co. Ltd)
children (renal function decreased micrograms/kg NutropinAq (Ipsen Ltd)
to < 50%) daily, or 1.4 Norditropin Simple Xx (Novo Nordisk Ltd)
mg/m2 daily Genotropin (Pfizer Ltd)
Omnitrope (Sandoz Ltd)
Saizen (Merck Serono)
SHOX deficiency 0.045- Humatrope (Eli Lilly & Co. Ltd)
0.050mg/kg
daily
*Dosing information from the Electronic Medicines Compendium (http://emc.medicines.org.uk/), accessed
30 April 2008.

3.3 Place of the intervention in the treatment pathway

Growth hormone’s place in the treatment pathway depends on the child’s particular condition or
syndrome, and age at diagnosis. Appropriate timing of treatment with growth hormone will depend
on the underlying pathology.
• For children with congenital GHD, GH therapy is not generally started before the child is four
years old.2 However, if there is profound growth failure or evidence of recurrent hypoglycaemia,
which may occur in infants under the age of one, treatment may be started earlier. For children
who acquire GHD at an older age, treatment can start at a time appropriate to their condition and
stage of growth. GH therapy is contraindicated in cases of progressive tumour activity and should
not be used for growth promotion in children with closed epiphyses.
• Treatment would be discontinued after the first year if there is a poor response, i.e. <50%
increase in growth rate, or if compliance or growth rate remains poor thereafter. Otherwise
treatment could continue until height velocity was <2cm/year, assessed over 6-12 months, or
once final height was achieved. Other clinical advice suggests that treatment is necessary for the
patient to attain peak bone mass, which may not be until the age of 25 or 26 in some people.
Standard practice would be to transfer the patient to the care of adult endocrinologists, to stop
growth hormone treatment and perform dynamic function tests so see if the patient is still growth
hormone deficient.
• Current NICE guidance recommends that GH treatment for girls with TS should begin at the
earliest age possible.1 Since height velocity generally reduces from 3-4 years of age, patients

6
 diagnosed early will commence treatment around that age. Some patients with profound growth
retardation and failure to thrive may commence treatment earlier. Clinical expert advice suggests
that the mean age for starting treatment is 8-9 years of age as many girls are not diagnosed until
later in childhood.
• The place of GH in the treatment pathway for children with CRF will depend on age at diagnosis,
and on clinical factors related to management of the child’s condition. GH treatment can take
place either before or after renal transplant, although allograft rejection can be a concern if GH
treatment is given post-transplant. GH therapy should not be used after renal transplant in
seriously ill children.
• For children with PWS, treatment with GH is primarily intended to improve body composition
and metabolism, but also to increase final height. Its place in the treatment pathway will depend
on age at diagnosis, and a GH provocation test would be used to confirm whether the child is
deficient in GH. Children with PWS are assessed for obesity, potential for obstructive sleep
apnoea and ongoing respiratory illness before treatment is considered. Low muscle tone and its
impact on the child’s development are also considered.
• GH’s place in the treatment pathway for children with SHOX deficiency will depend on age at
diagnosis. Clinical evaluation would be used to assess growth failure, but there would be no need
for GH provocation tests as SHOX deficiency would have been established.
• Children born SGA but with no comorbidities may not be diagnosed until they fail to achieve
catch-up height within -2.5 SD by the age of two to four years,12 or when they start school. The
European license for HGH is for children aged 4 years and over.

3.4 Relevant comparators

The standard comparator for this review will be management strategies without somatropin.

3.5 Population and relevant sub-groups

The rationale for the initiation of growth hormone treatment in children is to maximise height
potential and body composition. The relevant populations for this review are children with the
following conditions:
• GHD;
• TS;
• CRI;
• PWS;
• SGA;
• SHOX deficiency.

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Possible subgroups would be children with different causes of GHD, and children with CRI who are
either pre- or post-transplant. However, analysis of the effectiveness of GH treatment for any of these
subgroups of patients will be limited by the available data and the statistical power of any identified
trials.

Transition of care from paediatric to adult endocrine services of young people whose linear growth is
not complete requires patients to have repeat testing of their growth hormone axis to be sure that they
need to continue treatment. This transition period will only be considered within this appraisal where
evidence from the included studies allows.

3.6 Outcomes
Clinical outcomes will include: final height gained; height standard deviation score; growth velocity;
growth velocity standard deviation score; body composition, and biochemical/metabolic markers as
appropriate; adverse effects of treatment; health-related quality of life. Direct costs will include
estimates of all health care resources consumed in the provision of the intervention, including
diagnostic tests, administration and monitoring costs – as well as consequences of those
interventions, such as treatment of adverse effects.

The scope for this project requires assessment of body composition for all indications, rather than
only for PWS as in the previous review. Consequently, searches carried out for the previous review
may not be extensive enough, and there will be an element of duplicating work in this area rather
than a simple update for these conditions. Assessment of the clinical effectiveness of growth
hormone will therefore be restricted to evidence from RCTs.

4. Report methods for synthesis of evidence of clinical and cost effectiveness

A review of the evidence for the clinical and cost effectiveness of somatropin will be undertaken
systematically following standard guidelines from the NHS Centre for Reviews and Dissemination
(CRD).34 An expert advisory group of clinical experts and service users where appropriate will
support the review team at key stages of the project.

4.1 Search strategy

• A search strategy will be developed and tested by an experienced information scientist. The
strategy will be designed to identify studies reporting clinical-effectiveness, cost-effectiveness,
health-related quality of life, resource use and costs, epidemiology and natural history.
• The draft clinical effectiveness search strategy for Medline is shown in Appendix 1. This will be
adapted for other databases.

8
• A number of electronic databases will be searched including: The Cochrane Database of
Systematic Reviews (CDSR); The Cochrane Central Register of Controlled Trials; NHS CRD
(University of York) Database of Abstracts of Reviews of Effectiveness (DARE) and the NHS
Economic Evaluation Database (NHS EED); Medline (Ovid); Embase (Ovid); National Research
Register; Current Controlled Trials; ISI Proceedings; Web of Science; and BIOSIS.
Bibliographies of related papers will be assessed for relevant studies where possible.
• The manufacturers’ submissions to NICE will be assessed for any additional studies which meet
the inclusion criteria.
• Experts will be contacted to identify additional published and unpublished references.
• Searches will be carried out from the inception date of the database. Although this will involve
duplication of searches carried out for the previous review, it will be necessary to identify trials
reporting body composition as an outcome measure, as these may not have been identified for all
conditions in the previous review. For databases of abstracts and conference presentations
searches will only be carried out for the past two years to capture any research that has not yet
been fully published. All searches will be limited to the English language, and will be updated
around February 2009.

4.2 Inclusion and exclusion criteria

4.2.1 Patients
Children with growth disturbance, as per licensed indication for each preparation available.

4.2.2 Interventions
Recombinant human growth hormone (somatropin)

4.2.3 Comparators
Treatment strategies without somatropin

4.2.4 Outcomes
The following outcomes will be included, where data are available:
• Final height gained
• Height standard deviation score
• Growth velocity
• Growth velocity standard deviation score
• Body composition, and biochemical/metabolic markers as appropriate
• Adverse effects of treatment
• Health-related quality of life

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4.2.5 Types of studies
• Fully published randomised controlled trials (RCTs) or systematic reviews of RCTs will be
included. Indicators of a systematic review include: explicit search strategy, inclusion criteria,
data extraction and assessment of quality. Where we judge it necessary and appropriate, we will
consider the inclusion of evidence from other non-randomised studies. Full economic evaluations
(cost-effectiveness studies, cost-utility studies, cost-benefit studies) and reviews of economic
evaluations will be included in the review of cost effectiveness.
• Studies published only as abstracts or conference presentations will only be included in the
primary analysis of clinical and cost-effectiveness if sufficient details are presented to allow an
appraisal of the methodology and assessment of results.
• Non-English language studies will be excluded.

4.3 Inclusion and data extraction process

• Two reviewers will assess the titles and abstracts of studies identified by the search strategy for
potential eligibility.
• The full text of relevant papers will be requested for further assessment, and these will be
screened independently by two reviewers.
• Data will be extracted by one reviewer using a standard data extraction form (Appendix 2) and
checked by a second reviewer.
• At each stage, any discrepancy will be resolved by discussion, with involvement of a third
reviewer where necessary.

4.4 Quality assessment

• The quality of included clinical effectiveness studies will be assessed using NHS CRD
(University of York) criteria. The methodological quality of the economic evaluations will be
assessed using accepted frameworks such as the International consensus-developed list of criteria
developed by Evers and colleagues,35 and Drummond and colleagues.36 For any studies based on
decision models we will also make use of the checklist for assessing good practice in decision
analytic modelling (Philips and colleagues).37
• Quality criteria will be applied by one reviewer and checked by a second reviewer, with
differences in opinion resolved by discussion and involvement of a third reviewer where
necessary.

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4.5 Methods of analysis/synthesis
• Clinical- and cost-effectiveness studies will be synthesised through a narrative review with
tabulation of results of included studies.
• Where data are of sufficient quality and homogeneity, a meta-analysis of the clinical-
effectiveness studies will be performed, using appropriate software.
• Quality of life studies will be synthesised using the same methods as above, i.e. narrative review
and meta-analysis as appropriate.

5. SHTAC economic model

5.1. Evidence to support economic model
Additional searches for other evidence to inform cost effective modelling will be conducted where
necessary. Evidence may be drawn from a range of sources, including non-randomised controlled
trials. Studies may be required which:
• assess HRQoL and the relationship between final height and mortality and morbidity rates in
the different conditions;
• estimate utility based on HRQoL measures; or
• show a relationship between height and utility in adults.

5.2 Economic Modelling

Where appropriate, evidence from a variety of sources will be synthesised within an economic
model. This will build upon earlier work (Bryant et al, 2002)2 and also upon any relevant models
found in the literature. This previous work adopted a cost per cm of final height approach and the
duration of the model was until this final height was obtained. For the current analysis we will adopt
a cost per QALY approach where feasible. This will entail constructing lifetime models for
individuals and will require data on the relationship between the effects of successful treatment (to
include but not necessary to be limited to increases in final height) and utility scores. If no data can
be found to enable this approach we will adopt a cost per cm of final height approach as for the
previous work (Bryant et al, 2002). For conditions not included in previous work, new models will be
built if appropriate data is found. For conditions where the principle driver of quality of life is
expected to be changes in final height we will use a common modelling framework. However, data
values for various parameters would be expected to differ between these models. The process will be
dependent on the identification of sufficient data to derive these models. The perspective will be that
of the NHS and Personal Social Services. Both cost and outcomes (QALYs) will be discounted at
3.5%.

11
Model structure will be determined on the basis of research evidence and clinical expert opinion of:
• The biological disease process (i.e. knowledge of the natural history of the disease);
• The main care pathways for patients in the UK NHS context (both with and without the
intervention(s) of interest); and
• The disease states or events which are most important in determining patients’ clinical outcomes,
quality of life and consumption of NHS or PSS resources.
• Mortality / life expectancy for different conditions

A decision analytic model is most likely to be constructed in EXCEL. Parameter values will be
obtained from relevant research literature, including our own systematic review of clinical and cost
effectiveness. Where required parameters are not available from good quality published studies in the
relevant patient group we may use data from lower quality evidence sources, sponsor submissions to
NICE or expert clinical opinion. Sources for parameters will be stated clearly.

Resource use will be specified and valued from the perspective of the NHS and PSS. Cost data will
be derived from local sources, extracted from published sources, or from sponsor submissions to
NICE, as appropriate.

Outcomes, in terms of final height, will be obtained from our own systematic reviews of clinical
outcomes, or extrapolated from intermediary evidence. To capture health-related quality of life
effects, utility values will be sought from the relevant research literature and from the manufacturers
(via NICE). If a cost-utility approach is possible then the time frame used will be the patient’s
lifetime to reflect the chronic nature of these conditions and the fact that many potential gains from
successful therapy could last for the entire duration of an individual’s life. Alternatively, if a cost
utility approach is not possible, the reasons for choosing an alternative (cost-effectiveness) approach
will be clearly specified and justified, and the implications of this discussed.

Uncertainty will be explored through one-way sensitivity analysis and scenario analysis. Sensitivity
analysis will also be used to test any assumptions used to derive cost and outcomes data. If the data
and modelling approach permit we will explore uncertainty by the use of a probabilistic sensitivity
analysis (PSA). The outputs of any PSA will be presented using plots of the cost-effectiveness plane
and cost-effectiveness acceptability curves.

6. Handling the company submission(s)

All data submitted by the manufacturers/sponsors will be considered if received by the TAR team no
later than 2nd March 2009. Data arriving after this date will not be considered. If the data meet the

12
inclusion criteria for the review they will be extracted and quality assessed in accordance with the
procedures outlined in this protocol. Any economic evaluations included in the company submission,
provided they comply with NICE’s advice on presentation, will be assessed for clinical validity,
reasonableness of assumptions and appropriateness of the data used in the economic model.

Any ‘commercial in confidence’ data taken from a company submission will be underlined in the
assessment report, and highlighted in blue (followed by an indication of the relevant company name
in brackets unless it is obvious from the context).

7. Competing interests of authors

None

8. Appendices
9.1. Draft search strategy
9.2. Data extraction form

Appendix 1 Draft search strategy for MEDLINE

1 growth disorders/
2 growth failure.ti,ab.
3 growth deficien*.ti,ab.
4 Prader-Willi Syndrome/
5 prader-willi.ti,ab.
6 turner syndrome/
7 (Turner*2 adj syndrome).ti,ab.
8 growth hormone deficien*.ti,ab.
9 GH deficien*.ti,ab.
10 GHD.ti,ab.
11 exp renal insufficiency chronic/
12 (chronic adj2 (renal or kidney*) adj2 (failure or insufficien*)).ti,ab.
13 (CRI or CRF).ti,ab.
14 "small for gestational age".ti,ab.
15 "short for gestational age".ti,ab.
16 infant small for gestational age/
17 "short stature homeobox-containing gene".ti,ab.
18 "short stature homeobox".ti,ab.
19 SGA.ti,ab.
20 SHOX.ti,ab.
21 PHOG.ti,ab.
22 "Pseudoautosomal homeobox-containing osteogenic gene".ti,ab.
23 or/1-22
24 human growth hormone/
25 (somatropin* or somatotropin* or somatotrophin* or genotropin* or saizen* or zomacton* or
nutropin* or norditropin* or omnitrope* or humatrope*).ti,ab.
26 24 or 25
27 exp child/ or exp adolescent/ or exp infant/

13
28 child preschool/
29 (child* or infant* or adolescen* or girl* or boy* or prepubert* or pre-pubert*).ti,ab.
30 or/27-29
31 23 and 26 and 30
32 randomized controlled trial.pt.
33 controlled clinical trial.pt.
34 exp Randomized Controlled Trial/
35 exp Randomized Controlled Trials as Topic/
36 exp random allocation/
37 Double-Blind Method/
38 Single-Blind Method/
39 ((singl* or doubl* or trebl*) adj9 (blind* or mask*)).ti,ab.
40 placebo*.ti,ab,sh.
41 random*.ti,ab.
42 (medline or medlars or embase or scisearch or cinahl).ti,ab,sh.
43 (systematic* adj5 review*).mp.
44 (systematic adj5 overview*).mp.
45 (methodolog* adj5 review).mp.
46 (methodolog* adj5 overview).mp.
47 (methodolog* adj5 research*).mp.
48 meta analysis.pt.
49 meta-analysis.sh.
50 (meta-analys* or meta analys* or metaanalys*).mp.
51 ((hand adj5 search*) or (manual* adj5 search)).mp.
52 (electronic* database* or bibliographic* database* or computer* database* or online
database*).mp.
53 (Health Technology Assessment* or Medical Technlogy Assessment*).ti,ab,in.
54 or/32-53
55 31 and 54
56 limit 55 to (english language and humans)
57 from 56 keep 1-331

Appendix 2 Data extraction forms

Data extraction form for primary studies

Reviewer: Date: Version:

Reference and Intervention Participants Outcome measures
Design
Author et al., (including, dose etc) Target population: Primary outcomes:
year (id) 1.
Number of Participants: Secondary outcomes:
Country 2. Total:
1. Method of assessing
Study design 2. outcomes:

Number of Duration of treatment: Sample attrition/dropout: Length of follow-up:

centres
Other interventions Inclusion/exclusion criteria for
Funding: used: study entry:

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Characteristics of participants:
Treatment X (specify) (n=) Treatment Y (specify) (n=) P Value
Age, years
Sex

Results
Outcomes Treatment X (specify) (n=) Treatment Y (specify) (n=) P Value
Final height
Comments
Growth Velocity
Comments
Body composition
Comments
Other (specify)
Comments
QoL
Comments

Comments
Adverse Effects

Comments

Note: If reviewer calculates a summary measure or confidence interval PLEASE INDICATE

Methodological comments
• Allocation to treatment groups:
• Blinding:
• Comparability of treatment groups:
• Method of data analysis:
• Sample size/power calculation:
• Attrition/drop-out:

Quality criteria for assessment of experimental studies

1. Was the assignment to the treatment groups really random?
2. Was the treatment allocation concealed?
3. Were the groups similar at baseline in terms of prognostic factors?
4. Were the eligibility criteria specified?
5. Were outcome assessors blinded to the treatment allocation?
6. Was the care provider blinded?
7. Was the patient blinded?
8. Were the point estimates and measure of variability presented for the primary outcome
measure?
9. Did the analyses include an intention to treat analysis?
10. Were withdrawals and dropouts completely described?

Quality criteria for assessment of observational studies

Cohort studies
Is there sufficient description of the groups and the distribution of prognostic factors?
Are the groups assembled at a similar point in their disease progression?
Is the intervention/treatment reliably ascertained?
Were the groups comparable on all important confounding factors?

15
Was there adequate adjustment for the effects of these confounding variables?
Was a dose-response relationship between intervention and outcome demonstrated?
Was outcome assessment blind to exposure status?
Was follow-up long enough for the outcomes to occur?
What proportion of the cohort was followed-up?
Were drop-out rates and reasons for drop-out similar across intervention and unexposed
groups?
Case-control studies
Is the case definition explicit?
Has the disease state of the cases been reliably assessed and validated?
Were the controls randomly selected from the source of population of the cases?
How comparable are the cases and controls with respect to potential confounding factors?
Were interventions and other exposures assessed in the same way for cases and controls?
How was the response rate defined?
Were the non-response rates and reasons for non-response the same in both groups?
Is it possible that over-matching has occurred in that cases and controls were matched on
factors related to exposure?
Was an appropriate statistical analysis used (matched or unmatched)?
Case series
Is the study based on a representative sample selected from a relevant population?
Are the criteria for inclusion explicit?
Did all individuals enter the survey at a similar point in their disease progression?
Was follow-up long enough for important events to occur?
Were outcomes assessed using objective criteria or was blinding used?
If comparisons of sub-series are being made, was there sufficient description of the series
and the distribution of prognostic factors?

Data extraction form for Systematic Reviews

Reviewer: Date: Version:
Reference Methods
Study Ref: Aim/Objective:

Author: Search strategy: databases searched

Year:
Country: Inclusion criteria.
Interventions:
Funding: Participants:
Outcome measures:
Study design:

Quality criteria:

Application of methods:

Methods for analysis

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Reviewer: Date: Version:
Reference Methods
Results
Quantity and quality of included studies

Treatment effect

Assessment of heterogeneity

Economic evaluation

Conclusions

Implications of the review

Methodological comments
• Search strategy
• Participants
• Inclusion/exclusion criteria
• Quality assessment of studies
• Method of synthesis

General comments
• Generalisability
• Funding

Quality Assessment for Systematic Reviews

1. Are any inclusion/exclusion criteria reported relating to the primary studies which
address the review question?
2. Is there evidence of a substantial effort to search for all relevant research?
3. Is the validity of included studies adequately assessed?
4. Is sufficient detail of the individual studies presented?
5. Are the primary studies summarised appropriately?

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