Variability in physician prognosis and recommendations after intracerebral hemorrhage

Abstract

Objective: To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score. Methods: 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). Results: 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). Conclusions: 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.