title: Variability in physician prognosis and recommendations after intracerebral hemorrhage.
abstract: To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score.
  
  
  
  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).
  
  
  
  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).
  
  
  
  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.
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI. zdarin@umich.edu.
authors.forename: Darin B
authors.initials: DB
authors.lastname: Zahuranec
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Angela
authors.initials: A
authors.lastname: Fagerlin
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Brisa N
authors.initials: BN
authors.lastname: Sánchez
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Meghan E
authors.initials: ME
authors.lastname: Roney
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Bradford B
authors.initials: BB
authors.lastname: Thompson
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Andrea
authors.initials: A
authors.lastname: Fuhrel-Forbis
authors.affiliation: From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
authors.forename: Lewis B
authors.initials: LB
authors.lastname: Morgenstern
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D015999:Multivariate Analysis; D009462:Neurology; D009493:Neurosurgery; D015588:Observer Variation; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D011795:Surveys and Questionnaires