Abstract
BackgroundHealthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles. A comparable set of forces may play out at the national and international levels as demonstrated in significant differences in the diagnostic management of pediatric Celiac Disease (CD) between European and North American practitioners.MethodsWe use retrospective clinical cohorts of 27,868 serum tissue transglutaminase (tTG) immunoglobulin A levels and 7907 upper gastrointestinal endoscopy pathology reports to create a dataset of 793 pathology reports with matching tTG results between July 1 of 2014 and July 1 of 2018. We use this dataset to characterize histopathological findings in the duodenum, stomach and esophagus of patients as a function of serum tTG levels. In addition, we use the dataset to estimate the local and national cost of endoscopies performed in patients with serum tTG levels greater than 10 times the upper limit of normal.ResultsUsing evidence from a US tertiary care center, we show that in the cohort of pediatric patients with high pre-test probability of CD as determined by serum tTG levels, biopsy provides no additional diagnostic value for CD, and that it counter-intuitively introduces diagnostic uncertainty in a number of patients. We estimate that using the European diagnostic algorithms could avoid between 4891 and 7738 pediatric endoscopies per year in the US for evaluation of CD.ConclusionsThis study considers the North American and European management guidelines for the diagnosis of pediatric CD and highlights the slow adoption in North America of evidence-based algorithms developed and applied in Europe for triage of endoscopy and biopsy. We suggest that system dynamics influences that help maintain the status quo in North America include a variety of social and economic factors in addition to medical evidence. This work contributes to the growing body of evidence that the dynamics that largely favor maintaining status quo management policies in a variety of systems extend to clinical medicine and potentially influence clinical decisions at the level of individual patients and the population.
Highlights
Healthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles
Contributions to literature This study adds to a growing body of evidence suggesting that in children with a high pre-test probability of Celiac Disease, invasive endoscopy with biopsy adds little to no additional diagnostic information with respect to Celiac Disease, and its system-wide costs may exceed any benefits
This study provides a system dynamics framework for understanding the roots of policy differences between European and North American practitioners with respect to clinical practice guidelines
Summary
Healthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles. A comparable set of forces may play out at the national and international levels as demonstrated in significant differences in the diagnostic management of pediatric Celiac Disease (CD) between European and North American practitioners. The adoption of novel practices or performance improvements may face a comparable set of resistance forces at the national or international levels. These forces accelerate the adoption of processes deemed favorable to individual providers or healthcare systems (e.g., safer medications or higher reimbursements), and decelerate the adoption of disruptive processes deemed unfavorable (e.g., elimination of revenue-generating procedures or adoption of standardized protocols). One notable example of delayed clinical implementation at the international level is the diagnostic management of pediatric Celiac Disease (CD)
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