Variability in physician prognosis and recommendations after intracerebral hemorrhage

Abstract

Objective: To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score.

Methods: A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment).

Results: A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88).

Conclusions: Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.

Figure 1. Randomization of case vignettes

Demonstration of the format of the different survey versions resulting from randomization of prognostic score, patient age, clinical severity, and race. Note that case order (whether the moderate or severe case was shown first) was also randomized, but this is not shown in the figure for clarity.

Figure 2. Distribution of 30-day mortality estimates by case characteristics

(A–D) Presented patient ages and Glasgow Coma Scale (GCS) scores.

Figure 3. Effect of providing a model prognostic estimate on physician treatment recommendations

Physicians indicated their recommended initial intensity of treatment on a 6-point ordinal scale with anchors of 1 = comfort measures and 6 = full intensive treatment. Numbers inside each bar represent the percentage of cases where each level of treatment intensity was selected. In each panel (A–D), the top bar represents the responses where no prognostic score was provided, and the bottom bar is the responses when physicians were provided a prognostic score that gave the probability of functional independence at 90 days (with options of 0%, 13%, or 66%, depending on the case characteristics). Note that the largest differences in recommendations are observed in panels A and D. GCS = Glasgow Coma Scale.