Adherence to Recommended Inpatient Hepatic Encephalopathy Workup
Hepatic encephalopathy (HE) is characterized by altered sensorium and is the most common indication for hospitalization among patients with cirrhosis. Liver societal guidelines for inpatient HE revolve around identification of potential precipitants. In this retrospective study, we aimed to determine adherence to societal guidelines for evaluation of HE in 78 inpatients. The adherence rate to societal recommended guidelines for workup of HE was low, with only 17 (22%) patients having complete diagnostic workup within 24 hours of admission. Notably, 23 (30%) patients were not subjected to blood culture analysis, 16 (21%) were missing urinalysis, and 15 (20%) were missing chest radiograph. In patients with ascites (N = 34), 26 (77%) did not have a diagnostic paracentesis to exclude spontaneous bacterial peritonitis. In contrast, serum ammonia determination, a laboratory test not endorsed by societal guidelines for workup of HE, was ordered in 74 (95%) patients. These findings underscore the limited adherence to societal guidelines in hospitalized patients with HE.
© 2019 Society of Hospital Medicine
Although serum ammonia testing is not endorsed by the AASLD/EASL guidelines for HE,5 it is ordered nearly universally. The cost of an individual test is relatively low, but the cumulative cost of serum ammonia testing can be substantial because HE is the most common indication for hospitalization among patients with cirrhosis.4 Initiatives, such as the Choosing Wisely® campaign, encourage high-value and evidence-based care by limiting excessive and unnecessary diagnostic testing.10 The Canadian Choosing Wisely campaign specifically includes avoidance of serum ammonia testing for diagnosis of HE to provide high-value care in hepatology.11
Although the exact reasons for nonadherence to recommended HE evaluations are unclear, a potential method to mitigate excessive testing is to utilize the EMR and ordering system.3 EMR-based strategies can curb unnecessary testing in inpatient settings.12 The use of HE order sets, the inclusion of clinical decision support systems, and the restriction of access to specialized testing can be readily incorporated into the EMR to encourage adherence to guideline-based care while limiting unnecessary testing.
This study should be interpreted in the context of study limitations. Given the retrospective design of the study, salient factors in decisions behind diagnostic testing cannot be assessed. Future studies should utilize mixed-model methodology to elucidate reasons behind these decisions. The present study used a strict definition of complete workup including all the mentioned elements of the diagnostic workup for HE; however, in clinical practice, providers could be justified in not ordering certain tests if the specific clinical scenario does not lead to its use (eg, chest X-ray deferred in a patient with clear lung exam, no symptoms, or hypoxia). Similarly, UDS was included as a required element for a complete workup. While it may be ordered in a case-by-case basis to screen for illicit drug abuse, UDS is also a critical element of the workup to screen for opioid use as a precipitant of HE. Finally, considering the strict study entry criteria, we excluded repeated admissions for HE during the study period and therefore likely underestimate the cost burden of serum ammonia testing.
In conclusion, valuable guideline-based diagnostic testing is often missing in patients admitted for HE while serum ammonia testing is nearly universally ordered. These findings underscore the importance of implementing educational strategies, such as the Choosing Wisely® campaign, and EMR-based clinical decision support systems to improve health resource utilization in patients with cirrhosis and HE.
Disclosures
The authors have nothing to disclose.
