Coeliac disease in primary care: evaluation of a case-finding strategy.

BACKGROUND: Coeliac disease is still under-diagnosed as a consequence of poor physician awareness of the clinical spectrum of the disease. We evaluated the feasibility and the cost-effectiveness of a case-finding approach for early identification of cases, carried out by primary care practitioners. METHODS: We developed a case-finding strategy based on testing for anti-tissue transglutaminase IgA antibodies in subjects showing predefined signs and symptoms or belonging to at-risk groups. RESULTS: Sixty-nine primary care doctors and 60 primary care paediatricians agreed to participate. One thousand forty-one adults and 447 children were selected for anti-tissue transglutaminase testing during the year of the study (2001). Thirty-one (2.08%, 19 adults and 12 children) were ultimately diagnosed as coeliac patients. While no cases of coeliac disease had been diagnosed by the participating doctors in the previous year, 29 subjects were diagnosed as coeliacs in the year after the completion of the study (2002). The prevalence of confirmed coeliac disease in the population under study increased from 1:1,506 to 1:1,073 in adults and from 1:827 to 1:687 in children from year 2000 to 2001. When cases diagnosed in 2002 are included, the prevalence is 1:832 and 1:602, respectively. We calculated a cost of 923.25 euros for each new case diagnosed. CONCLUSIONS: Case-finding is a feasible and successful strategy for detecting undiagnosed coeliac patients and has the important added value of increasing the awareness of the disease among primary care physicians; it represents a cost-effective alternative to population screening for reducing the burden of undiagnosed coeliac disease.

The relationship between physicians' self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes. The QuED Study Group--quality of care and outcomes in type 2 diabetes.

OBJECTIVE: To investigate the relationship between beliefs of physicians relative to intensive metabolic control in type 2 diabetes and levels of HbA1c obtained in a sample of their patients. RESEARCH DESIGN AND METHODS: Physicians' beliefs were investigated through a questionnaire sent to a sample of self-selected clinicians participating in a nationwide initiative aimed at assessing the relationship between the quality of care delivered to patients with type 2 diabetes and their outcomes. At the same time, physicians were asked to collect clinical data on a random sample of their patients, stratified by age (<65 vs. > or = 65 years). Mean HbA1c levels in the study population were thus evaluated according to target fasting blood glucose (FBG) used by their physicians. RESULTS: Of 456 physicians, 342 (75%) returned the questionnaire. Among the responders, 200 diabetologists and 99 general practitioners (GPs) recruited 3,297 patients; 2,003 of whom were always followed by the same physician and 1,294 of whom were seen by different physicians in the same structure on different occasions. Only 14% of the respondents used target FBG levels < or = 6.1 mmol/l, whereas 38% pursued values >7.8 mmol/l, with no statistically significant difference between diabetologists and GPs. The analysis of the relationship between FBG targets and metabolic control, restricted to those patients always seen by the same physician, showed a strong linear association, with mean HbA1c values of 7.0 +/- 1.6 for patients in the charge of physicians pursuing FBG levels < or = 6.1 mmol/l and 7.8 +/- 1.8 for those followed by physicians who used target values >7.8 mmol/l. After adjusting for patients' and physicians' characteristics, the risk of having HbA1c values > 7.0% was highly correlated with physicians' beliefs. Patients followed by different physicians in the same unit showed a risk of inadequate metabolic control similar to that of patients followed by physicians adopting a nonaggressive policy. CONCLUSIONS: Doctors adopt extremely heterogeneous target FBG levels in patients with type 2 diabetes, which in turn represent an important independent predictor of metabolic control. To improve patient outcomes, physicians-centered educational activities aimed at increasing the awareness of the potential benefits of a tight metabolic control in patients with type 2 diabetes are urgently needed.