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This slide shows an analytic framework for a CER on the use of recombinant human growth hormone in patients with cystic fibrosis. The population with cystic fibrosis, including subgroups (age, gender, baseline clinical status, prior treatment) receives recombinant human growth hormone. The intermediate outcomes include IGF factors, protein turnover, nutritional status, growth measures, bone measures, lung function, pulmonary exacerbations, antibiotic use, exercise tolerance, sex hormones, and pubertal development. The final health outcomes include mortality, hospitalization, bone fracture, and health-related quality of life. The adverse events include altered glucose, diabetes mellitus, lymphoid overgrowth, and malignancy.

Devise an Analytic Framework

Topic Refinement Process: UCONN/HH EPC Example (IV). This slide shows an analytic framework for a CER on the use of recombinant human growth hormone in patients with cystic fibrosis. The population with cystic fibrosis, including subgroups receiving recombinant human growth hormone. The intermediate outcomes include IGF factors, protein turnover, nutritional status, growth measures, bone measures, lung function, pulmonary exacerbations, antibiotic use, exercise tolerance, sex hormones, and pubertal development. The final health outcomes include mortality, hospitalization, bone fracture, and health-related quality of life. The adverse events include altered glucose, diabetes mellitus, lymphoid overgrowth, and malignancy.

Topic Refinement Process: UCONN/HH EPC Example (IV)

Key Questions (I). KQ 1: In patients with cystic fibrosis, does treatment with rhGH as an adjuvant to usual care improve intermediate outcomes, including pulmonary function (FEV percent and FEV1 absolute value), growth (height, weight, lean body mass, protein turnover), exercise tolerance, and bone mineralization, compared with usual care alone? KQ 2: In patients with cystic fibrosis, does treatment with rhGH as an adjuvant to usual care improve health outcomes, including frequency of required intravenous antibiotic treatments, frequency of hospitalization, quality of life, bone fracture or development of osteoporosis/osteopenia, or mortality, compared with usual care alone? KQ 3: In patients with cystic fibrosis, what is the strength of evidence that intermediate outcomes of pulmonary function, growth, and bone mineralization are associated with improvements in health outcomes of quality of life, bone fracture or development of osteoporosis/osteopenia, or mortality? KQ 4: In patients with cystic fibrosis, what is the frequency of nonmalignant serious adverse effects resulting from treatment with rhGH? Adverse effects of interest include, but are not limited to: glucose intolerance, diabetes, and hypoglycemia.

Key Questions (I)

Key Questions (II). KQ 5: nWhat is the risk of malignancy associated with rhGH use as determined by (a) markers of cancer risk with rhGH (IGF-I increases over 100 ng/ml or IGFBP-3 decreases over 1,000 ng/ml) from studies of rhGH in people with CF [cystic fibrosis], and (b) assessment of evidence on cancer incidence from non-CF patients receiving modest doses of rhGH (0.2 mg/kg per week to 0.6 mg/kg per week) for disorders such as growth hormone deficiency and idiopathic short stature? KQ 6: In patients with CF, how are efficacy, effectiveness, safety, or adverse events impacted by rhGH dose, therapy duration, baseline nutritional status, and concurrent medical therapies? KQ 7: In patients with CF, how do the efficacy, effectiveness, safety, or adverse events of treatment with rhGH differ between subgroups of patients? Subgroup characteristics of interest include, but are not limited to, age (prepubertal, pubertal, postpubertal); gender; baseline clinical status (height, weight, lean body mass, pulmonary function, exercise tolerance, nutritional status); and/or the nature, extent, and effectiveness of prior treatment.

Key Questions (II)