Disparities by Gender, Race and Geography Exist in Whether Patients Receive a Confirmatory Celiac Disease Endoscopy and Biopsy After Screening Positive

OBJECTIVES: Celiac disease (CD) guidelines from US-based professional associations recommend endoscopy (EGD) and biopsy to confirm the diagnosis of CD after a positive blood test. A US-based insurance claims database was analyzed to determine whether these guidelines are followed and any differences by demographics.

METHODS: The Optum Clinformatics database includes commercial and Medicare Advantage claims from all 50 states. A representative 25% sample was used with approximately 19.25 million unique patients. Patients without a previous CD ICD-9 or ICD-10 code were analyzed. Significant differences were calculated using chi square tests and post-hoc z-tests on adjusted residuals.

RESULTS: 8544 patients not previously diagnosed with CD had a positive screening test. 2557 (29.9%) did not receive the recommended EGD. Significantly more women (71.6%) and fewer men (67.3%) than expected obtained the EGD (p < .01). Significantly more non-Hispanic White patients (72.89%), and significantly fewer non-Hispanic Asian patients (59.31%) and patients with unknown/missing race data (54.43%) than expected obtained an EGD (p = .005). In an analysis of known census regions (N = 8515), there was a significant association with obtaining an EGD (p < .02). Though no significant pairwise differences were found, fewer patients in the Midwest (28.04%) and South (28.58%) obtained an EGD compared to patients in the Northeast (31.43%) and West (32.05%).

CONCLUSIONS: Almost one-third of patients with a positive screening test did not have the recommended confirmatory EGD. Many celiac disease centers are located in the Northeast, which may be why more patients in this region received appropriate follow up. It is unclear why fewer non-Hispanic Asian patients had the appropriate EGD. This study highlights some demographic disparities in who gets appropriate care after a positive CD screening test. Conclusions about whether the EGD was missed due to the patient, provider, or another cause cannot be drawn and more research is needed.