Physician experience improves ability to predict 6-month functional outcome of severe traumatic brain injury.
Clinical experience
Clinical prediction
Functional outcome
Neuroprognostication
Traumatic brain injury
Journal
Acta neurochirurgica
ISSN: 0942-0940
Titre abrégé: Acta Neurochir (Wien)
Pays: Austria
ID NLM: 0151000
Informations de publication
Date de publication:
08 2023
08 2023
Historique:
received:
28
03
2023
accepted:
04
06
2023
medline:
9
8
2023
pubmed:
30
6
2023
entrez:
30
6
2023
Statut:
ppublish
Résumé
The functional prognosis of severe traumatic brain injury (TBI) during the acute phase is often poor and uncertain. We aimed to quantify the elements that shade the degree of uncertainty in prognostic determination of TBI and to better understand the role of clinical experience in prognostic quality. This was an observational, prospective, multicenter study. The medical records of 16 patients with moderate or severe TBI in 2020 were randomly drawn from a previous study and submitted to two groups of physicians: senior and junior. The senior physician group had graduated from a critical care fellowship, and the junior physician group had at least 3 years of anesthesia and critical care residency. They were asked for each patient, based on the reading of clinical data and CT images of the first 24 h, to determine the probability of an unfavorable outcome (Glasgow Outcome Scale < 4) at 6 months between 0 and 100, and their level of confidence. These estimations were compared with the actual evolution. Eighteen senior physicians and 18 junior physicians in 4 neuro-intensive care units were included in 2021. We observed that senior physicians performed better than junior physicians, with 73% (95% confidence interval (CI) 65-79) and 62% (95% CI 56-67) correct predictions, respectively, in the senior and junior groups (p = 0.006). The risk factors for incorrect prediction were junior group (OR 1.71, 95% CI 1.15-2.55), low confidence in the estimation (OR 1.76, 95% CI 1.18-2.63), and low level of agreement on prediction between senior physicians (OR 6.78, 95% CI 3.45-13.35). Determining functional prognosis in the acute phase of severe TBI involves uncertainty. This uncertainty should be modulated by the experience and confidence of the physician, and especially on the degree of agreement between physicians.
Sections du résumé
BACKGROUND
The functional prognosis of severe traumatic brain injury (TBI) during the acute phase is often poor and uncertain. We aimed to quantify the elements that shade the degree of uncertainty in prognostic determination of TBI and to better understand the role of clinical experience in prognostic quality.
METHODS
This was an observational, prospective, multicenter study. The medical records of 16 patients with moderate or severe TBI in 2020 were randomly drawn from a previous study and submitted to two groups of physicians: senior and junior. The senior physician group had graduated from a critical care fellowship, and the junior physician group had at least 3 years of anesthesia and critical care residency. They were asked for each patient, based on the reading of clinical data and CT images of the first 24 h, to determine the probability of an unfavorable outcome (Glasgow Outcome Scale < 4) at 6 months between 0 and 100, and their level of confidence. These estimations were compared with the actual evolution.
RESULTS
Eighteen senior physicians and 18 junior physicians in 4 neuro-intensive care units were included in 2021. We observed that senior physicians performed better than junior physicians, with 73% (95% confidence interval (CI) 65-79) and 62% (95% CI 56-67) correct predictions, respectively, in the senior and junior groups (p = 0.006). The risk factors for incorrect prediction were junior group (OR 1.71, 95% CI 1.15-2.55), low confidence in the estimation (OR 1.76, 95% CI 1.18-2.63), and low level of agreement on prediction between senior physicians (OR 6.78, 95% CI 3.45-13.35).
CONCLUSIONS
Determining functional prognosis in the acute phase of severe TBI involves uncertainty. This uncertainty should be modulated by the experience and confidence of the physician, and especially on the degree of agreement between physicians.
Identifiants
pubmed: 37389747
doi: 10.1007/s00701-023-05671-x
pii: 10.1007/s00701-023-05671-x
doi:
Types de publication
Observational Study
Multicenter Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
2249-2256Informations de copyright
© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.
Références
Amzallag J, Ropers J, Shotar E, Mathon B, Jacquens A, Degos V, Bernard R (2023) PREDICT-TBI: comparison of physician predictions with the IMPACT model to predict 6-month functional outcome in traumatic brain injury. Neurocrit Care. https://doi.org/10.1007/s12028-023-01718-0
doi: 10.1007/s12028-023-01718-0
pubmed: 37059958
Anderson WG, Cimino JW, Ernecoff NC et al (2015) A multicenter study of key stakeholders’ perspectives on communicating with surrogates about prognosis in intensive care units. Ann Am Thorac Soc 12:142–152
doi: 10.1513/AnnalsATS.201407-325OC
pubmed: 25521191
pmcid: 4342839
Barrera R, Nygard S, Sogoloff H, Groeger J, Wilson R (2001) Accuracy of predictions of survival at admission to the intensive care unit. J Crit Care 16:32–35
doi: 10.1053/jcrc.2001.21794
pubmed: 11230722
Christakis NA, Lamont EB (2000) Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ 320:469–472
doi: 10.1136/bmj.320.7233.469
pubmed: 10678857
pmcid: 27288
Cox CE, Martinu T, Sathy SJ, Clay AS, Chia J, Gray AL, Olsen MK, Govert JA, Carson SS, Tulsky JA (2009) Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 37:2888–2894; quiz 2904
Crash Trial Collaborators MRC, Perel P, Arango M et al (2008) Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:425–429
doi: 10.1136/bmj.39461.643438.25
Detsky ME, Harhay MO, Bayard DF et al (2017) Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA 317:2187–2195
doi: 10.1001/jama.2017.4078
pubmed: 28528347
pmcid: 5710341
Dijkland SA, Foks KA, Polinder S, Dippel DWJ, Maas AIR, Lingsma HF, Steyerberg EW (2020) Prognosis in moderate and severe traumatic brain injury: a systematic review of contemporary models and validation studies. J Neurotrauma 37:1–13
doi: 10.1089/neu.2019.6401
pubmed: 31099301
Fayol P, Carrière H, Habonimana D, Preux P-M, Dumond J-J (2004) French version of structured interviews for the Glasgow Outcome Scale: guidelines and first studies of validation. Ann Readaptation Med Phys Rev Sci Soc Francaise Reeducation Fonct Readaptation Med Phys 47:142–156
Finley Caulfield A, Gabler L, Lansberg MG, Eyngorn I, Mlynash M, Buckwalter MS, Venkatasubramanian C, Wijman CAC (2010) Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists. Neurology 74:1096–1101
doi: 10.1212/WNL.0b013e3181d8197f
pubmed: 20368630
pmcid: 2865775
Galton F (1907) Vox Populi Nature 75:450–451
Hautz WE, Kämmer JE, Schauber SK, Spies CD, Gaissmaier W (2015) Diagnostic performance by medical students working individually or in teams. JAMA 313:303–304
doi: 10.1001/jama.2014.15770
pubmed: 25603003
Izzy S, Compton R, Carandang R, Hall W, Muehlschlegel S (2013) Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too? Neurocrit Care 19:347–363
doi: 10.1007/s12028-013-9925-z
pubmed: 24132565
Jones K, Quinn T, Mazor KM, Muehlschlegel S (2021) Prognostic uncertainty in critically ill patients with traumatic brain injury: a multicenter qualitative study. Neurocrit Care. https://doi.org/10.1007/s12028-021-01230-3
doi: 10.1007/s12028-021-01230-3
pubmed: 34080083
Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V, Maas A (2016) Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health 1:e76–e83
doi: 10.1016/S2468-2667(16)30017-2
pubmed: 29253420
Moskowitz J, Quinn T, Khan MW, Shutter L, Goldberg R, Col N, Mazor KM, Muehlschlegel S (2018) Should we use the IMPACT-model for the outcome prognostication of TBI patients? A qualitative study assessing physicians’ perceptions. MDM Policy Pract 3:2381468318757987
pubmed: 30288437
pmcid: 6124938
Navi BB, Kamel H, McCulloch CE, Nakagawa K, Naravetla B, Moheet AM, Wong C, Johnston SC, Hemphill JC, Smith WS (2012) Accuracy of neurovascular fellows’ prognostication of outcome after subarachnoid hemorrhage. Stroke 43:702–707
doi: 10.1161/STROKEAHA.111.639161
pubmed: 22223238
Quinn T, Moskowitz J, Khan MW, Shutter L, Goldberg R, Col N, Mazor KM, Muehlschlegel S (2017) What families need and physicians deliver: contrasting communication preferences between surrogate decision-makers and physicians during outcome prognostication in critically ill TBI patients. Neurocrit Care 27:154–162
doi: 10.1007/s12028-017-0427-2
pubmed: 28685395
pmcid: 5693603
Roozenbeek B, Lingsma HF, Lecky FE et al (2012) Prediction of outcome after moderate and severe traumatic brain injury: external validation of the International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models. Crit Care Med 40:1609–1617
doi: 10.1097/CCM.0b013e31824519ce
pubmed: 22511138
pmcid: 3335746
Sinuff T, Adhikari NKJ, Cook DJ, Schünemann HJ, Griffith LE, Rocker G, Walter SD (2006) Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med 34:878–885
doi: 10.1097/01.CCM.0000201881.58644.41
pubmed: 16505667
Steyerberg EW, Wiegers E, Sewalt C et al (2019) Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet Neurol 18:923–934
doi: 10.1016/S1474-4422(19)30232-7
pubmed: 31526754
Steyerberg EW, Mushkudiani N, Perel P, et al (2008) Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e165; discussion e165
Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC, Academy A, of Critical Care Medicine, (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 36:953–963
doi: 10.1097/CCM.0B013E3181659096
pubmed: 18431285
Turgeon AF, Dorrance K, Archambault P et al (2019) Factors influencing decisions by critical care physicians to withdraw life-sustaining treatments in critically ill adult patients with severe traumatic brain injury. CMAJ Can Med Assoc J J Assoc Medicale Can 191:E652–E663
doi: 10.1503/cmaj.190154
Turgeon AF, Lauzier F, Burns KEA et al (2013) Determination of neurologic prognosis and clinical decision making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists. Crit Care Med 41:1086–1093
doi: 10.1097/CCM.0b013e318275d046
pubmed: 23385104
White DB, Ernecoff N, Buddadhumaruk P, Hong S, Weissfeld L, Curtis JR, Luce JM, Lo B (2016) Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision makers of critically ill patients. JAMA 315:2086–2094
doi: 10.1001/jama.2016.5351
pubmed: 27187301