Factors Considered by Clinicians when Prognosticating Intracerebral Hemorrhage Outcomes

David Y. Hwang, Stacy Y. Chu, Cameron A. Dell, Mary J. Sparks, Tiffany D. Watson, Carl D. Langefeld, Mary E. Comeau, Jonathan Rosand, Thomas W.K. Battey, Sebastian Koch, Mario L. Perez, Michael L. James, Jessica McFarlin, Jennifer L. Osborne, Daniel Woo, Steven J. Kittner, Kevin N. Sheth

Research output: Contribution to journalArticlepeer-review

10 Scopus citations

Abstract

Background: The early subjective clinical judgment of clinicians outperforms formal prognostic scales for accurate determination of outcome after intracerebral hemorrhage (ICH), with the judgment of physicians and nurses having equivalent accuracy. This study assessed specific decisional factors that physicians and nurses incorporate into early predictions of functional outcome. Methods: This prospective observational study enrolled 121 ICH patients at five US centers. Within 24 h of each patient’s admission, one physician and one nurse on the clinical team were each surveyed to predict the patient’s modified Rankin Scale (mRS) at 3 months and to list up to 10 subjective factors used in prognostication. Factors were coded and compared between (1) physician and nurse and (2) accurate and inaccurate surveys, with accuracy defined as an exact prediction of mRS. Results: Aside from factors that are components of the ICH or FUNC scores, surveys reported pre-existing comorbidities (40.0%), other clinical or radiographic factors not in clinical scales (43.0%), and non-clinical/radiographic factors (21.9%) as important. Compared to physicians, nurses more frequently listed neurologic examination components (Glasgow Coma Scale motor, 27.3 vs. 5.8%, p < 0.0001; GCS verbal, 12.4 vs. 0.0%, p < 0.0001) and non-clinical/radiographic factors (31.4 vs. 12.4%, p = 0.0005). Physicians more frequently listed neuroimaging factors (ICH location, 33.9 vs. 7.4%, p < 0.0001; intraventricular hemorrhage, 13.2 vs. 2.5%, p = 0.003). There was no difference in listed factors between accurate versus inaccurate surveys. Conclusions: Clinicians frequently utilize factors outside of the components of clinical scales for prognostication, with physician and nurses focusing on different factors despite having similar accuracy.

Original languageEnglish
Pages (from-to)316-325
Number of pages10
JournalNeurocritical Care
Volume27
Issue number3
DOIs
StatePublished - Dec 1 2017

Bibliographical note

Funding Information:
Acknowledgements We thank Christian Ramos, Division of Neuro-critical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, for his assistance with cleaning the data. The Wake Forest School of Medicine Center for Public Health Genomics provided computational support. Supported by: American Heart Association (Clinical Research Training Award 11CRP5480009 to K.N.S.) and National Institute of Neurological Disorders and Stroke (R01NS059727 to J.R. and U01NS069763 to D.W.). The sources of funding had no role in study design, data collection, analyses, interpretations, and decision to submit the article for publication.

Funding Information:
We thank Christian Ramos, Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, for his assistance with cleaning the data. The Wake Forest School of Medicine Center for Public Health Genomics provided computational support. Supported by: American Heart Association (Clinical Research Training Award 11CRP5480009 to K.N.S.) and National Institute of Neurological Disorders and Stroke (R01NS059727 to J.R. and U01NS069763 to D.W.). The sources of funding had no role in study design, data collection, analyses, interpretations, and decision to submit the article for publication. All authors contributed to the study design and data analysis and approved the final version of the manuscript. In addition: D.Y.H. monitored data collection for all sites; cleaned, analyzed, and interpreted the data; and drafted the paper. S.Y.C. analyzed and interpreted the data and drafted the paper. C.A.D., M.J.S., and T.D.W. recruited subjects and collected data for their local site and monitored data collection for all sites. C.D.L. and M.E.C. contributed to study conception and statistical analysis. T.W.K.B., M.L.P., J.M., and J.L.O. each recruited subjects and collected data at respective sites. J.R., S.K., M.L.J., D.W., S.J.K., and K.N.S. each contributed to study conception and supervised data collection at respective sites. K.N.S., the principal investigator, initiated the study, designed data collection tools, had access to all the data, and takes responsibility for the data, accuracy of the data analysis, and the conduct of the research. D.W. and K.N.S. obtained funding for the study.

Funding Information:
Conflicts of interest This study was sponsored by the American Heart Association (Dr. Sheth) and the National Institute of Neurological Disorders and Stroke (Dr. Rosand and Dr. Woo). Dr. Hwang has received recent funding from the American Brain Foundation, the Apple Pickers Foundation (Westerly, RI), the Neurocritical Care Society, and the National Institute on Aging (for Loan Repayment). He has also received recent speaking fees from Pennsylvania State University, Mayo Clinic, and the Society of Critical Care Medicine and modest book royalties from Oxford University Press and the Neuro-critical Care Society. Dr. Chu reports no relevant disclosures. Mr. Dell reports no relevant disclosures. Ms. Sparks reports no relevant disclosures. Ms. Watson reports no relevant disclosures. Dr. Langefeld reports no relevant disclosures. Ms. Comeau reports no relevant disclosures.

Publisher Copyright:
© 2017, Springer Science+Business Media, LLC.

Keywords

  • Cohort studies
  • Critical care
  • Intracerebral hemorrhage
  • Outcome research
  • Prognosis

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Clinical Neurology

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