Awareness and Practice Patterns of Celiac Disease Among Family Physicians: A Questionnaire-Based Study in Relation to Years in Practice and Awareness of Local Guidelines

Abstract

Objective: To evaluate awareness and practice patterns of family physiciansregarding celiac disease (CD), in relation to years in practice and awareness of local guidelines
Methods: A total of 147 family physicians (mean age 39.4 years, range, 24 to 64 years and 52.4% were female) working in primary care clinics across Gaziantep province were included on a voluntary basis in this cross-sectional questionnaire-survey. The questionnaire form elicited items on sociodemographic characteristics of physicians (age, gender, years in practice), their awareness of CD (serological tests, screening indications, types of the disease) and practice patterns in CD including frequency of suspected diagnosis, serological tests, intestinal biopsy, risk of malignancy, gluten-free diet strictness and criteria, IgA screening and awareness of local guidelines. The questionnaire form was applied via face-to-face interview method.
Results: Presence of chronic diarrhea (33.7%) was reported to be the most indication for serological analysis and typical form of the disease (49.8%) was reported to be more commonly recognized. Only 17.7% of physicians reported that they frequently suspect CD in adult patients, 38.1% reported that they frequently refer patients for serological tests for CD and 36.1% reported that they always recommend intestinal biopsy for serology positive patients. Overall, 63.5% of physicians considered strict the gluten-free diet to always be applied by patients with CD, 51% reported that they recommend a gluten-free diet to serology negative patient with symptoms similar to CD and 19.7% reported that they recommend IgA screening for patients with CD. No significant difference was noted in practice pattern variables with respect to years in practice, while the likelihood of a physician to always recommend intestinal biopsy for serology positive patients (42.7% vs. 27.7%, p=0.028) significantly increased with the awareness of guidelines.
Conclusion: In conclusion, our findings indicate low level of awareness about CD in terms of adult-onset and atypical presentations and poor knowledge regarding the diagnosis and practice patterns in CD among family physicians, regardless of the years in practice. Accordingly, our findings indicate a need to increase awareness of CD and improve adherence to guidelines via educational sessions and workshops among family physicians, particularly in terms of the recognition of adult onset of symptoms, the utility of serological tests combined with intestinal biopsy and proper recommendation of gluten-free diet in individuals with CD.

Keywords

• Celiac disease
• family care physicians
• Awareness

Aile Hekimleri Arasında Çölyak Hastalığı Farkındalığı ve Pratik Modelleri: Meslek Yıllarına ve Yerel Kılavuzların Farkındalığına İlişkin Anket Tabanlı Bir Çalışma

Abstract

Amaç: Aile hekimlerinin çölyak hastalığı (ÇH) ile ilgili farkındalık ve klinik pratikleri, mesleki yıllara ve yerel klavuzların farkındalığına göre değerlendirmek. Yöntemler: Gaziantep’teki birinci basamak kliniklerinde çalışan toplam 147 aile hekimi bu kesitsel ankete gönüllü olarak dahil edildi. Anket formunda hekimlerin sosyodemografik özellikleri, ÇH farkındalıkları (serolojik testler, tarama endikasyonları, hastalık tipleri) ve ÇH’dan şüphelenme sıklığı, bağırsak biyopsisi, malignite riski, glutensiz diyet katılığı ve kriterleri, IgA taraması ve yerel kılavuzlar hakkında farkındalıkları sorgulandı. Anket formu yüz yüze görüşme yöntemi ile uygulanmıştır. Bulgular: Serolojik analiz için en fazla endikasyonun kronik ishal varlığı (%33,7) ve hastalığın tipik formunun (%49,8) daha yaygın olarak tanındığı bildirilmiştir. Hekimlerin sadece %17,7’si erişkin hastalarda sıklıkla ÇH’dan şüphelendiklerini, % 38.1’i sık sık hastaları ÇH için serolojik testlere sevk ettiklerini ve % 36.1’i seroloji pozitif hastalar için her zaman bağırsak biyopsisi önerdiklerini bildirmiştir. Genel olarak, hekimlerin %63,5’i katı glutensiz diyetin ÇH’da daima uygulanması gerektiğini düşünmektedir. %51’i ÇH’na benzer semptomları olup seroloji negatif hastalarına glutensiz bir diyet önerdiklerini ve %19,7’si ÇH’da IgA taraması önerdiklerini bildirmiştir. Bir doktorun seroloji pozitif hastalar için bağırsak biyopsisini her zaman önerme olasılığı (42.7% vs. 27.7%, p=0.028) kılavuzların farkında olmasıyla önemli ölçüde artmıştır. Sonuç: Bulgularımız, erişkin başlangıçlı ve atipik semptomlar konusunda ÇH hakkında düşük düzeyde farkındalık ve mesleki yıllara bakılmaksızın aile hekimleri arasında ÇH’da tanı ve takip hakkında yetersiz bilgi olduğunu göstermektedir. Buna göre, bulgularımız, özellikle yetişkinlerde semptomların tanınması, bağırsak biyopsisi ile kombine serolojik testlerin kullanımı ve uygun öneriler açısından, aile hekimleri arasında eğitim toplantıları ve çalıştaylar yoluyla ÇH farkındalığını artırma ve kılavuzlara daha fazla uyma ihtiyacını göstermektedir.

Keywords

• Çölyak Hastalığı
• Aile Hekimi
• Farkındalık

References

1. Ludvigsson JF, Leffler DA, Bai J, Biagi F, Fasano A, Green PH, et al. The Oslo definitions for coeliac disease and related terms. Gut. 2013; 62:43–52.
2. Green P, Cellier C. Celiac disease. New England Journal of Medicine. 2007; 357:1731–1743.
3. Gasbarrini GB, Mangiola F, Gerardi V, Lanino G, Corazza GR, Gasbarrini A, et al. Coeliac disease: an old or a new disease? History of a pathology. Intern Emerg Med 2014; 9: 249–256.
4. Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA. American College of Gastroenterology. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 2013; 108: 656-76.
5. Tatar G, Elsurer R, Simsek H, Balaban YH, Hascelik G, Ozcebe OI, et al. Screening of tissue transglutaminase antibody in healthy blood donors for celiac disease screening in the Turkish population. Dig Dis Sci. 2004;49(9):1479–1484.
6. Tack GJ, Verbeek WH, Schreurs MW, Mulder CJ. The spectrum of celiac disease: epidemiology, clinical aspects and treatment. Nat Rev Gastroenterol Hepatol. 2010 Apr;7(4):204-13.
7. Green PH. Where are all those patients with celiac disease? Am J Gastroenterol 2007; 102: 1461–1463.
8. Lanzarotto F, Crimí F, Amato M, Villanacci V, Pillan NB, Lanzini A. Is under diagnosis of celiac disease compounded by mismanagement in the primary care set ting? A survey in the Italian Province of Brescia. Minerva Gastroenterol Dietol 2004; 50: 283-8.

9. Norström F, Lindholm L, Sandström O, Nordyke K, İvarsson A. Delay to celiac disease diagnosis and its implications for health-related quality of life. BMC Gastroenterol 2011; 11: 118.
10. Green PHR, Stavros SN, Panagi SG, Goldstein SL, Mcmahon DJ, Absan H, et al. Characteristics of adult celiac disease in the USA. results of a national survey Am J Gastrol. 2001;96:126–131.
11. Zipser RD, Patel S, Yahya KZ, Baisch DW, Monarch E. Presentations of adult celiac disease in a nationwide patient support group. Dig Dis Sci. 2003;48:761–764.
12. Rostami NM, Rostami K, Pourhoseingholi MA, Nazemalhosseini ME, Habibi M, Dabiri H, et al. Atypical presentation is dominant and typical for coeliac disease. J Gastro Liver Dis 2009;18:285-91.
13. Barzegar F, Rostami-Nejad M, Rostami K, Ahmadi S, Mohaghegh SH, Sadeghi A, et al. Lack of health care professional's awareness for management of celiac disease may contribute to the under diagnosis of celiac disease. Gastroenterol Hepatol Bed Bench. 2019 Summer;12(3):203-208.
14. Ludvigsson JF, Bai JC, Biagi F, Card TR, Ciacci C, Ciclitira PC, et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut. 2014;63: 1210–1228.
15. Ianiro G, Bibbò S, Bruno G, Ricci R, Arena V, Gasbarrini A,et al. Prior Misdiagnosis of Celiac Disease Is Common Among Patients Referred to a Tertiary Care Center: A Prospective Cohort Study. Clin Transl Gastroenterol. 2016 Jan 28;7:e139.
16. Zipser RD, Farid M, Baisch D, Patel B, Patel D. Physician awareness of celiac disease: a need for further education. J Gen Intern Med 2005; 20: 644-6
17. Collin P, Vilppula A, Luostarinen L, Holmes GKT, Kaukinen K. Review article: coeliac disease in later life must not be missed. Aliment Pharmacol Ther 2018;47:563-72.
18. van Gils T, Senler TG, van der Horst HE, Mulder CJJ, Bouma G, de Vries H. The daily practice of (suspected) coeliac disease management by general practitioners: A qualitative approach. Eur J Gen Pract. 2018 Dec;24(1):236-242.
19. Assiri AM, Saeed A, Saeed E, El-Mouzan MI, Alsarkhy AA, Al-Turaiki M,et al. Assessment of knowledge of celiac disease among health care professionals. Saudi Med J. 2015 Jun;36(6):751-3.
20. Cataldo F, Montalto G. Celiac disease in the developing countries: a new and challenging public health problem. World J Gastroenterol. 2007 Apr 21;13(15):2153-9.
21. Jinga M, Popp A, Balaban DV, Dima A, Jurcut C. Physicians' attitude and perception regarding celiac disease: A questionnaire-based study. Turk J Gastroenterol. 2018 Jul;29(4):419-426.
22. Roy A, Mehra S, Kelly CP, Tariq S, Pallav K, Dennis M, et al. The association between socioeconomic status and the symptoms at diagnosis of celiac disease: a retrospective cohort study. Therap Adv Gastroenterol 2016; 9: 495- 502.
23. Dickey W, McMillan SA. Changing diagnostic pathways in coeliac disease: most case now identified in primary care. Program of the 11th International Symposium on Coeliac Disease, Belfast, Northern Ireland, 2004:167.
24. McGowan KE, Lyon ME, Butzner JD. Celiac Disease and IgA Deficiency: Complications of Serological Testing Approaches Encountered in the Clinic. Clin Chem 2008; 54: 1203-9.
25. McGowan KE, Lyon ME, Loken SD, Butzner JD. Celiac disease: are endomysial antibody test results being used appropriately? Clin Chem 2007; 53: 1775-81
26. Elfström P, Granath F, Ekström Smedby K, Montgomery SM, Askling J, Ekbom A, et al. Risk of lymphoproliferative malignancy in relation to small intestinal histopathology among patients with celiac disease. J Natl Cancer Inst 2011; 103:436-44.
27. Mormile R. Non-Hodgkin lymphoma in celiac disease: causality or casuality on the scene? Int J Colorectal Dis 2016; 31: 1077.
28. Freeman HJ. Adult celiac disease and its malignant complications. Gut Liver. 2009 Dec;3(4):237-46.