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Procedure volume influences adherence to celiac disease guidelines
Benjamin Lebwohl1, Robert M Genta, Robert C Kapel
1aDepartment of Medicine, Celiac Disease Center, Columbia University Medical Center bDepartment of Epidemiology, Mailman School of Public Health cInstitute for Social and Economic Research and Policy, Columbia University, New York, New York dMiraca Life Sciences, Irving, Texas eDepartment of Medicine, Danbury Hospital, Danbury, Connecticut, USA.
Insights
Physician adherence to celiac disease biopsy guidelines is lower for high-volume doctors but higher in group endoscopy suites. This impacts undiagnosed celiac disease rates, highlighting practice patterns affecting diagnostic accuracy.
Area of Science:
- Gastroenterology
- Medical Diagnostics
- Public Health
Background:
- Celiac disease affects nearly 1% of the US population, yet most cases remain undiagnosed.
- Low adherence to submitting at least four duodenal biopsy specimens is a key factor in underdiagnosis.
- Understanding physician and practice characteristics influencing adherence is crucial for improving diagnosis.
Purpose of the Study:
- To investigate the association between physician and practice characteristics and adherence to duodenal biopsy guidelines.
- To identify factors that may improve or hinder the submission of adequate specimens for celiac disease diagnosis.
Main Methods:
- Utilized a national pathology database of adult duodenal biopsies from 2006-2009.
- Employed hierarchical modeling to analyze the impact of procedure volume, gastroenterologists per suite, and per capita density on adherence.
- Included 92,580 patient cases from 669 gastroenterologists across 191 zip codes.
Main Results:
- Higher procedure volume correlated with decreased adherence to biopsy guidelines (OR 0.92 per 100 procedures).
- Increased adherence was observed in suites with more gastroenterologists (OR 1.08 per additional gastroenterologist).
- Gastroenterologist density per capita in a practice's zip code did not significantly impact adherence.
Conclusions:
- High-volume physicians show lower adherence, potentially due to time constraints for submitting multiple specimens.
- Collaborative practice environments (more endoscopists per suite) may foster better adherence, possibly through peer education.
- Optimizing practice structures could enhance diagnostic rates for celiac disease.
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.
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