Review for 10.1186/1471-230X-14-42 (2014)

Reviewer's report
Title:Patient-centered barriers impede serologic screening for celiac disease in
clinically high prevalence populations
Version:3Date:27 December 2013
Reviewer: Jeremy Woodward
Reviewer's report:
This study is an attempt to identify why patients at risk of Coeliac Disease are not
undergoing serological testing. The main outcome - that there is a lack of
knowledge of Coeliac Disease in this community - is not unexpected. Worryingly,
a large number of participants claimed not to have undergone testing because
they had no faith that their doctor would know what test to request or they had no
access to healthcare resources.
Such a study is difficult to perform as the process of enrolment significantly
skews the dataset - particularly when related to reasons for lack of engagement
with healthcare - and it is therefore puzzling that so many patients described lack
of motivation and yet were sufficiently motivated to participate in the study. There
were no questions in the questionnaire specifically to address the issue of why
the individuals engaged in the study. Indeed, the process of development of the
questionnaire - which is highly critical for a study of this nature and on which so
much depends - is not clearly described in the methods section.
Major compulsory revisions:
1. Title. 'Patient centred barriers' in the title implies active patient resistance to
testing . The study actually showed that lack of knowledge and lack of access to
healthcare resources were the predominant factors, and one could argue that
these are not really patient-centred at all. The title is therefore misleading and
needs careful rewording.
2. Methods.
a) In the methods sections, the methodology of developing the questions in the
questionnaire need to be fully explained including the process of refinement, the
level of involvement of patient groups and their make-up and background.
b) Three different at risk groups are represented - first degree relatives, those
with compatible symptoms and those with associated autoimmune conditions.
Different factors will be responsible in each of these groups - particularly those
with symptoms compared to those without symptoms as the primary reason for
participation. Whilst the majority of patients admitted to symptoms on questioning
(which is not unusual for the general population), it would be useful to know the
relative representations of those participating primarily for each of the three
reasons, and analysis of the data accordingly.
c) Demonstrating the graph of 'agree/strongly disagree' (figure 1) is misleading
as it does not include the 'disagree and strongly disagree' elements that are
included in the statistical analysis and could be omitted.
3. Results.
a) The question 'did not know where to get tested' scored most highly in the
strongly agree/agree answers, whereas the second highest scoring answer was 'I
did not know anything about Coeliac Disease'. The first question implies that the
participant knew about Coeliac Disease and wanted to be tested but simply could
not get the test. This is incongruous with the second answer - that the patient did
not know about Coeliac Disease. How do the authors explain this discrepancy?
How many patients agreed both questions?
Discretionary Revisions:
1. It would be useful to know whether or not patients had attended their physician
previously because of the GI symptoms they were experiencing - and it would be
worth showing the data on the duration of symptoms. The opportunity for
participating with as little as 4 weeks of symptoms might have encouraged
patients to participate for diagnostic reasons.
2. Where patients heard about the study would be useful data to include - as this
could influence the results - for instance if they saw a flyer at the health centre
(and were therefore attending for medical reasons) or at the grocer's store -
which might be considered more of a screening approach.
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests