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. 2020 Mar 2;15(3):e0228947.
doi: 10.1371/journal.pone.0228947. eCollection 2020.

Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons

Theresa Williamson  1 , Marc D Ryser  2   3   4 , Jihad Abdelgadir  1 , Monica Lemmon  5   6 , Mary Carol Barks  7 , Rasheedat Zakare  3 , Peter A Ubel  3   7
Affiliations

Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons

Theresa Williamson et al. PLoS One. .

Abstract

Background: Surgical decision-making in severe traumatic brain injury (TBI) is complex. Neurosurgeons weigh risks and benefits of interventions that have the potential to both maximize the chance of recovery and prolong suffering. Inaccurate prognostication can lead to over- or under-estimation of outcomes and influence treatment recommendations.

Objective: To evaluate the impact of evidence-based risk estimates on neurosurgeon treatment recommendations and prognostic beliefs in severe TBI.

Methods: In a survey-based randomized experiment, a total of 139 neurosurgeons were presented with two hypothetical patient with severe TBI and subdural hematoma; the intervention group received additional evidence-based risk estimates for each patient. The main outcome was neurosurgeon treatment recommendation of non-surgical management. Secondary outcomes included prediction of functional recovery at six months.

Results: In the first patient scenario, 22% of neurosurgeons recommended non-surgical management and provision of evidence-based risk estimates increased the propensity to recommend non-surgical treatment (odds ratio [OR]: 2.81, 95% CI: 1.21-6.98; p = 0.02). Neurosurgeon prognostic beliefs of 6-month functional recovery were variable in both control (median 20%, IQR: 10%-40%) and intervention (30% IQR: 10%-50%) groups and neurosurgeons were less likely to recommend non-surgical management when they believed prognosis was favorable (odds ratio [OR] per percentage point increase in 6-month functional recovery: 0.97, 95% confidence interval [CI]: 0.95-0.99). The results for the second patient scenario were qualitatively similar.

Conclusions: Our findings show that the provision of evidence-based risk predictions can influence neurosurgeon treatment recommendations and prognostication, but the effect is modest and there remains large variability in neurosurgeon prognostication.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Neurosurgeon prognostic beliefs.
Neurosurgeon prognostic beliefs about 30-day survival and 6-month ADL are shown for the hypothetical scenarios 1 (A) and 2 (B). Each dot represents an individual neurosurgeon prognostic estimate. Red dots represent neurosurgeons who recommended a craniotomy for the hypothetical patient and black dots represent neurosurgeons who did not recommend a craniotomy. Horizontal lines represent the median (middle line) and interquartile range (top and bottom lines) of the predictions, respectively.
Fig 2
Fig 2. Exploratory mediation analysis.
Relationship between receipt of evidence-based risk estimates, prognostic beliefs and treatment recommendation. When including prognostic estimates in the model, the relationship between receipt of evidence-based risk estimates and treatment recommendation loses statistical significance.
See this image and copyright information in PMC

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