Prognostic scores aid treatment conformity after ICH

By Lucy Piper

Physicians' prognosis and recommendations for patients after intracerebral haemorrhage (ICH) vary considerably, report researchers who show the potential benefits of a validated prognostic score.

The team sent written surveys presenting two ICH scenarios to practicing neurologists and neurosurgeons and asked them to estimate prognosis and treatment recommendations.

The case scenarios included combinations of older versus middle-aged patients and Glasgow Coma Scale (GCS) scores of 7T versus 11.

Among the 742 physicians who responded, their prediction of 30-day mortality varied widely across the four possible interactions between age and severity, ranging from an average of 23% to 58%.

Older versus middle-age increased the mortality estimate by 7-10 percentage points, while the effect of higher severity ranged from 18 to 29 percentage points.

Inclusion of a validated prognostic score (FUNC score) in the case presentation attenuated the prognostic variability, the researchers report in Neurology.

However, they note that this was largely due to greater consensus when scenarios depicted the most and least severe cases. The greatest effect was seen in the case of a 63-year-old patient with a GCS score of 11; inclusion of the best prognostic score (66% chance of functional recovery) decreased the mortality estimate by 5 percentage points.

A prognostic score also lessened the variability in treatment recommendations and as with mortality estimates, the greatest effects were seen in the most and least severe cases.

For cases where the chance of recovery was shown to be low, at 13%, inclusion of the prognostic score had no effect on treatment recommendations, but when the prognostic score suggested a 0% chance of functional recovery in a 76-year-old patient with a GCS score of 7T, the likelihood of recommending treatment limitations increased by 61%.

Conversely, if the score suggested a 66% chance of recovery in a 63-year-old patient with a GCS score of 11, the likelihood of recommending treatment limitations decreased by 38%.

The researchers, led by Darin Zahuranec (University of Michigan Medical School, Ann Arbor, USA), assessed physician characteristics, including recent experience of ICH cases, geographical location, practice setting and empathy, looking for possible explanations for prognosis variability.

But these characteristics explained only a small amount of the variance in mortality estimates; race also had no effect on physician prognosis or treatment recommendations, leaving the variance largely unexplained.

The findings therefore suggest that prognostic information provided to a family about an ICH patient may vary depending on the particular physician involved and "[i]ncreasing use of an accurate formal prognostic score may be one way to standardize physician prognostic estimates", says the team.

In a related editorial, Alejandro Rabinstein (Mayo Clinic Rochester, Minnesota, USA) agrees that the use of prognostic scores can be useful and is advisable, but notes that many are subject to bias, due to being supported by prognostic factors that are influenced by self-fulfilling prophecy in the case of both pessimistic and optimistic prognoses.

"The self-fulfilling prophecy cannot be proven or disproven in any practice that allows withdrawal of life-sustaining treatments", he points out, adding: "Only studies from countries where restrictions of therapy are not culturally accepted even when prognosis is considered extremely poor could help clarify this issue."

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