Do Gastroenterologists Adhere to Diagnostic and Treatment Guidelines for Celiac Disease?

Abstract

AIM: Our group hypothesized that significant variation exists between suggested clinical guidelines, the clinical practices of practicing gastroenterologists and academic experts in celiac disease (CD). METHOD: We designed 4 CD vignettes comparing experts and practicing gastroenterologists. Practicing gastroenterologists (n=169) were surveyed during Digestive Disease Week 2009 and experts (n=22) answered e-mail surveys. Ratings for answers in each vignette was done using a 9-point RAND Appropriateness Scale (RAS) with endorsement defined as RAS score of 7 to 9. We also calculated the RAND "Disagreement Index" (DI) was calculated, with DI>1.0 indicated extreme variation. RESULTS: A total of 169 practicing gastroenterologists and 22 experts were included. Differences in all vignette answers were present. Differences were seen for use of IgA anti-endomysial antibodies (P=0.0241), human leukocyte antigen DQ2/8 testing (P=0.0325), gluten challenge (P<0.0001), and oat consumption (P<0.0001). There were differences in recommendations for biopsy review (P=0.0479) and management of dermatitis herpetiformis (P=0.0025). Experts consistently endorsed CD screening in patients with type 1 diabetes, Down and Turner syndromes, and relatives of CD patients compared with practicing physicians (P=0.0054, 0.0003, <0.0001, 0.0304). Experts endorsed CD screening for atypical presentations (delayed puberty, elevated transaminases, primary biliary cirrhosis, autoimmune hepatitis, and infertility). CONCLUSION: There is significant disagreement between nonexperts and experts in diagnosis and management of CD. Promotion of existing guidelines and further research is advised.