Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA.
University of Washington, Seattle, WA, USA.
C.H.U.M, and McGill University Medical Centers, Montreal, QC, Canada.
Mayo Clinic, Rochester, MN, USA.
University of California, San Francisco, CA, USA.
University of Alberta, Edmonton, AB, Canada.
Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However its severity assessment is often subjective, which needs to be studied systematically.
To determine how accurately trainee and non-trainee practitioners grade and manage HE patients throughout its severity.
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.
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.