title: 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.
  
  
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Lebwohl
authors.forename: Robert M
authors.initials: RM
authors.lastname: Genta
authors.forename: Robert C
authors.initials: RC
authors.lastname: Kapel
authors.forename: Daniel
authors.initials: D
authors.lastname: Sheehan
authors.forename: Nina S
authors.initials: NS
authors.lastname: Lerner
authors.forename: Peter H
authors.initials: PH
authors.lastname: Green
authors.forename: Alfred I
authors.initials: AI
authors.lastname: Neugut
authors.forename: Andrew
authors.initials: A
authors.lastname: Rundle
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy / Q000592:standards / Q000706:statistics & numerical data; D002446:Celiac Disease / Q000473:pathology*; D016208:Databases, Factual; D004386:Duodenum / Q000473:pathology; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009518:New York; D017410:Practice Guidelines as Topic; D011647:Puerto Rico; D011787:Quality of Health Care; D016526:Workload / Q000706:statistics & numerical data