title: A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts?
abstract: BACKGROUND
  Prognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis.
  
  
  OBJECTIVE
  To examine the accuracy of clinicians' estimates of survival and to determine if any clinical profession is better at doing so than another.
  
  
  METHODS
  MEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked.
  
  
  METHODS
  
  
  
  METHODS
  patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English.
  
  
  METHODS
  if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care.
  
  
  METHODS
  A quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame).
  
  
  RESULTS
  4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74-0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear "expert" subgroup of clinicians identified.
  
  
  CONCLUSIONS
  High heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified.
  
  
  CONCLUSIONS
  Studies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians' predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other.
  
  
  CONCLUSIONS
  Further research is needed to understand how clinical predictions are formulated and how their accuracy can be improved.
authors: Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom.
authors: Nicola
authors: http://orcid.org/0000-0002-7438-0072
authors: N
authors: White
authors: Department of Primary Care & Public Health Sciences, King's College London, London, United Kingdom.
authors: Fiona
authors: http://orcid.org/0000-0002-0762-8111
authors: F
authors: Reid
authors: Department of Experimental Psychology, University College London, London, United Kingdom.
authors: Adam
authors: A
authors: Harris
authors: Department of Clinical Sciences, Brunel University London, London, United Kingdom.
authors: Priscilla
authors: P
authors: Harries
authors: Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom.
authors: Patrick
authors: http://orcid.org/0000-0002-5765-9047
authors: P
authors: Stone
mesh_terms: D000465:Algorithms; D006801:Humans; D010166:Palliative Care / Q000379:methods* / Q000458:organization & administration*; D000070659:Patient Comfort; D010820:Physicians; D011336:Probability; D011379:Prognosis; D013534:Survival; D016896:Treatment Outcome