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Grading early hepatic encephalopathy requires additional training

Gastroenterology faculty, nurse practitioners and physician assistants had excellent concordance in classifying grade 2 or higher hepatic encephalopathy compared with gastroenterology and hepatology physicians, according to a recently published study. Lower grades, however, showed significant discordance between the two groups.

“Cirrhosis and hepatic encephalopathy (HE) is a major cause of morbidity and mortality in the United States, and the trend points towards a growing burden over time,” Bradley Reuter, MD, from the Virginia Commonwealth University, and colleagues wrote. “The current study results show that an accurate and reproducible assessment of lower grades of HE remains problematic even among trainees and practitioners of the subspecialty of gastroenterology.”

The study comprised 62 trainees (gastroenterology fellows and internal medicine residents) and 46 non-trainees (gastroenterology faculty, nurse practitioners and physician assistants) enrolled from centers in the U.S. and Canada.

To determine how accurately trainee and non-trainee practitioners could properly grade and manage hepatic encephalopathy, Reuter and colleagues showed the participants a series of standardized simulated patient videos that demonstrated patients with no hepatic encephalopathy or grade 1, 2, 3 or 4 hepatic encephalopathy.

More trainees (91.9% vs. 59.5%) and non-trainees (90.6% vs. 68.5%) were able to correctly diagnose hepatic encephalopathy grades 2 and higher compared with grade 1 or no hepatic encephalopathy.

Overall, trainees and non-trainees had similar outcomes regarding properly diagnosing and managing hepatic encephalopathy grades, with a few exceptions.

Trainees were more likely to inquire about bowel movement frequency in both cases of grade 1 or no hepatic encephalopathy (89% vs 73%; P < .001) and grades 2 and higher (95% vs. 86%; P < .001) compared with non-trainees. Trainees were significantly more likely to order Xifaxan (rifaximin, Salix; 68% vs. 30%; P < .001) and blood cultures (94% vs. 83%; P < .001) in cases of grades 2 and higher. Finally, trainees were less likely to order blood ammonia for grade 1 or no hepatic encephalopathy (7% vs. 16%; P = .03) and less likely to manage higher grades with low protein diet (8% vs. 18%; P = .006) compared with non-trainees.

“These results have important implications with respect to patient care, resource utilization, conduct of multi-center clinical trials and, most importantly, in the training and continuing education of practitioners who deal with this complex patient population,” the researchers wrote. “Given the stability of the diagnosis beyond grade 2, the definition of all other grades below that as covert HE seems to be an important option until better operative criteria are defined for grade 1 in multi-center studies. Efforts must be made to improve training in this area at every level including during medical school, residency and fellowship.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.