Procedure volume influences adherence to celiac disease guidelines

Abstract

Background Although the prevalence of celiac disease in the USA approaches 1%, most cases are undiagnosed, in part, because of low adherence to the recommendation of submitting at least four specimens during duodenal biopsy. We aimed to determine whether physician and practice characteristics are associated with adherence to this recommendation. Materials and methods We used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006–2009. Hierarchical modeling was used to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence. Results We identified 92 580 patients (67% female, mean age 53.5 years) who met our inclusion/exclusion criteria. Specimens were submitted by 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite. On multivariate analysis, a higher procedure volume was associated with a decreased adherence [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88–0.97; P = 0.002]. An increased adherence was reported for gastroenterologists working at suites with higher numbers of gastroenterologists (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04–1.13; P < 0.001) but not for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99–1.03; P = 0.21). Conclusion High-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit at least four specimens. In contrast, a greater number of endoscopists working in an endoscopy suite are associated with an increased adherence, possibly because of peer education.

Rates of Duodenal Biopsy During Upper Endoscopy Differ Widely Between Providers

“…As noted above, there was one prior report suggesting decreased adherence to duodenal biopsy guidelines among higher-volume providers [14], as well as one report of increased rates of duodenal biopsy at academic centers compared to community sites [12]. In the colonoscopy literature there is evidence that provider experience and procedure volume are associated with improved cecal intubation rate [27] as well as fewer adverse events [28], although adenoma detection rate may suffer with very high or very low procedure volumes [29].…”

“…Although the rates of duodenal biopsy during upper endoscopy appear to be increasing over time [11], published series from the last 15 years suggest that the majority of patients undergoing endoscopy for symptoms consistent with CD still may not have a duodenal biopsy performed during the procedure [11,12]. To date there have been a few reports addressing potential clinical, demographic, and provider-specific factors contributing to the underperformance of duodenal biopsy in the US [11,[13][14][15]. but overall there remains a paucity of data exploring the decision to perform duodenal biopsy.…”

Diagnostics of Adult Forms of Celiac Disease: More Intensive Screening Improves Diagnosis

“…Several methods of case-finding have been proposed, including several procedures. In practice, intestinal symptoms are usually evident [11,12] although in recent years, atypical presentations of adult CD have become frequently recognized. Varying prevalence of CD occurs in both children and adults from various states in Europe and other continents.…”

Narrow band imaging combined with water immersion technique in the diagnosis of celiac disease

“…In clinical practice, however, even experienced endoscopists are often not compliant to the "multiple biopsy" guidelines [6], with lower rates of adherence particularly among physicians with high procedure volume [7]. If the site of mucosal damage could be certainly identified prior to obtaining the specimen, this would minimize the number of biopsies for histological evaluation, reduce the invasiveness of the endoscopic procedure itself and save time and resources.…”