Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists.
OBJECTIVE
Physician prediction of outcome in critically ill neurologic patients impacts treatment decisions and goals of care. In this observational study, we prospectively compared predictions by neurointensivists to patient outcomes at 6 months.


METHODS
Consecutive neurologic patients requiring mechanical ventilation for 72 hours or more were enrolled. The attending neurointensivist was asked to predict 6-month 1) functional outcome (modified Rankin scale [mRS]), 2) quality of life (QOL), and 3) whether supportive care should be withdrawn. Six-month functional outcome was determined by telephone interviews and dichotomized to good (mRS 0-3) and poor outcome (mRS 4-6).


RESULTS
Of 187 eligible patients, 144 were enrolled. Neurointensivists correctly predicted 6-month functional outcome in 80% (95% confidence interval [CI], 72%-86%) of patients. Accuracy for a predicted good outcome was 63% (95% CI, 50%-74%) and for poor outcome 94% (95% CI, 85%-98%). Excluding patients who had life support withdrawn, accuracy for good outcome was 73% (95% CI, 60%-84%) and for poor outcome 87% (95% CI, 74%-94%). Accuracy for exact agreement between neurointensivists' mRS predictions and actual 6-month mRS was only 43% (95% CI, 35%-52%). Predicted accuracy for QOL was 58% (95% CI, 39%-74%) for good/excellent and 67% (95% CI, 46%-83%) for poor/fair. Of 27 patients for whom withdrawal of care was recommended, 1 patient survived in a vegetative state.


CONCLUSIONS
Prediction of long-term functional outcomes in critically ill neurologic patients is challenging. Our neurointensivists were more accurate in predicting poor outcome than good outcome in patients requiring mechanical ventilation >or=72 hours.
Finley Caulfield
A
A
Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA, USA. afinley@stanford.edu
Gabler
L
L
Lansberg
M G
MG
Eyngorn
I
I
Mlynash
M
M
Buckwalter
M S
MS
Venkatasubramanian
C
C
Wijman
C A C
CA
D000203:Activities of Daily Living; D000208:Acute Disease / Q000628:therapy*; D001927:Brain Diseases / Q000175:diagnosis* / Q000628:therapy; D002985:Clinical Protocols / Q000592:standards; D016638:Critical Illness / Q000628:therapy*; D003661:Decision Support Techniques; D003951:Diagnostic Errors / Q000517:prevention & control*; D004185:Disability Evaluation; D023261:Glasgow Outcome Scale; D020445:Hospitalists / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000592:standards / Q000706:statistics & numerical data; D007407:Interviews as Topic; D009462:Neurology / Q000379:methods / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011788:Quality of Life; D015203:Reproducibility of Results; D012121:Respiration, Artificial / Q000401:mortality*; D012720:Severity of Illness Index; D028761:Withholding Treatment / Q000592:standards