The most common number of specimens submitted in this dataset was 2 (Fig. 1). Two specimens usually can be collected by using one pass of the biopsy forceps. A second pass of the forceps, done for the purpose of collecting additional specimens, increases the length of the procedure. Although the amount of time for an additional pass of the biopsy forceps for additional biopsies is low (approximately 1 minute), the incremental yield of this additional time taken

was heretofore Nivolumab clinical trial unknown. Given the high incremental yield in the present analysis (resulting in a doubling of the proportion of patients with a pathological diagnosis of CD), the proposed standard of submitting ≥4 specimens appears to be justified. We observed a marked variability between individual endoscopists with regard to the proportion of examinations in which the recommended number of specimens was submitted. Although the mean adherence rate among providers was 38.3%, the most common percentage adherence per individual was between 0% and 10%. The wide variability in adherence to this recommendation is reminiscent of the variability of a familiar quality indicator in gastroenterology, check details the adenoma detection

rate in screening colonoscopy.22 The discovery of that variability and associated predictive factors such as colonoscope withdrawal time23 has led to a focus on high-quality colonoscopy as a priority for the profession of gastroenterology.24 The findings in the present study, of low adherence to a recommendation in the face of a high diagnostic yield of submitting ≥4 specimens, should spur efforts to increase adherence to this standard. This study has several limitations. This was a retrospective analysis of a pathology tissue database, which

has nevertheless yielded high-quality analyses of GI epidemiology and quality measures.25 and 26 In this database, we did not have access in all patients to key variables that influence the likelihood of CD, such as data regarding family history of CD or serology results. Those with positive CD serology results (ie, noted in the clinical indication field) were classified Farnesyltransferase in the “suspected CD” indication category; this variable was included in the multivariate analysis. Information regarding the type of sedation used during the procedure and degree of sedation, which may have impacted the ability to obtain ≥4 specimens, was not available. The diagnosis of CD in this study was based strictly on histopathologic findings, and reliance on histology alone has been criticized for its lack of specificity.27 For this reason, we considered only the most severe histopathologic changes (Marsh III lesions) as CD, excluding the increasingly common report of increased intraepithelial lymphocytosis, so as to maximize the specificity of the outcome in this analysis. Certain providers may have a particular interest or expertise in CD and thus are more likely to submit ≥4 specimens.