The accuracy of diagnostic tests for GH deficiency in adults: a systematic review and meta-analysis

Context: The diagnostic accuracy of tests used to diagnose GH deficiency (GHD) in adults is unclear. Objective: We conducted a systematic review and meta-analysis of studies that provided data on the available diagnostic tests. Data sources: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Sciences, and Scopus) through April 2011. Study selection: Review of reference lists and contact with experts identified additional candidate studies. Reviewers, working independently and in duplicate, determined study eligibility. Data extraction: Reviewers, working independently and in duplicate, determined the methodological quality of studies and collected descriptive, quality, and outcome data. Data synthesis: Twenty-three studies provided diagnostic accuracy data; none provided patient outcome data. Studies had fair methodological quality, used several reference standards, and included over 1100 patients. Several tests based on direct or indirect stimulation of GH release were associated with good diagnostic accuracy, although most were assessed in one or two studies decreasing the strength of inference due to small sample size. Serum levels of GH or IGF1 had low diagnostic accuracy. Pooled sensitivity and specificity of the two most commonly used stimulation tests were found to be 95 and 89% for the insulin tolerance test and 73 and 81% for the GHRH+arginine test respectively. Meta-analytic estimates for accuracy were associated with substantial heterogeneity. Conclusion: Several tests with reasonable diagnostic accuracy are available for the diagnosis of GHD in adults. The supporting evidence, however, is at high risk of bias (due to heterogeneity, methodological limitations, and imprecision).