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Procedure volume influences adherence to celiac disease guidelines

Lebwohl, Benjamina,b; Genta, Robert M.d; Kapel, Robert C.e; Sheehan, Danielc; Lerner, Nina S.c; Green, Peter H.a; Neugut, Alfred I.b; Rundle, Andrewb

European Journal of Gastroenterology & Hepatology: November 2013 - Volume 25 - Issue 11 - p 1273–1278
doi: 10.1097/MEG.0b013e3283643542
Original Articles: Small Bowel 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.

aDepartment 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

Correspondence to Benjamin Lebwohl, MD, MS, Department of Medicine, Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Avenue, Suite 936, New York, NY 10032, USA Tel: +1 212 305 5990; fax: +1 212 305 3738; e-mail:

Received May 1, 2013

Accepted June 13, 2013

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins