Author information
1
Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA.
2
University of Washington, Seattle, WA, USA.
3
C.H.U.M, and McGill University Medical Centers, Montreal, QC, Canada.
4
Mayo Clinic, Rochester, MN, USA.
5
University of California, San Francisco, CA, USA.
6
University of Alberta, Edmonton, AB, Canada.
Abstract
Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However its severity assessment is often subjective, which needs to be studied systematically.
AIM:
To determine how accurately trainee and non-trainee practitioners grade and manage HE patients throughout its severity.
METHODS:
We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and non-trainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades<2 or ≥2 HE and trainees/non-trainees Results: 108 respondents (62 trainees, 46 non-trainees) were included. Grades≤2 vs.≥2 HE: A higher percentage of respondents were better at correctly diagnosing grades≥2 compared to grades<2 (91 vs 64%, p<0.001). Specialized cognitive testing was checked significantly more often in grades<2, while more aggressive investigation for precipitating factors was ordered in HE grades>2. Serum ammonia levels were ordered in almost a third of ≥2 grade patients. Trainees/non-trainees: HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and perform a more thorough work-up for precipitating factors compared to non-trainee respondents.
CONCLUSIONS:
There was excellent concordance in the classification of grade ≥2 HE between non-trainees vs. trainees but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing and nutritional management between trainees and non-trainees. These results have important implications at the patient level, interpreting multi-center clinical trials and, in the education of practitioners.