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Prognosis Predictions by Families, Physicians, and Nurses of Patients with Severe Acute Brain Injury: Agreement and Accuracy

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An Invited Commentary to this article was published on 26 April 2022

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Abstract

Background

Effective shared decision-making relies on some degree of alignment between families and the medical team regarding a patient’s likelihood of recovery. Patients with severe acute brain injury (SABI) are often unable to participate in decisions, and therefore family members make decisions on their behalf. The goal of this study was to evaluate agreement between prognostic predictions by families, physicians, and nurses of patients with SABI regarding their likelihood of regaining independence and to measure each group’s prediction accuracy.

Methods

This observational cohort study, conducted from 01/2018 to 07/2020, was based in the neuroscience and medical/cardiac intensive care units of a single center. Patient eligibility included a diagnosis of SABI—specifically stroke, traumatic brain injury, or hypoxic ischemic encephalopathy—and a Glasgow Coma Scale ≤ 12 after hospital day 2. At enrollment, families, physicians, and nurses were asked separately to predict a patient’s likelihood of recovering to independence within 6 months on a 0–100 scale, regardless of whether a formal family meeting had occurred. True outcome was based on modified Rankin Scale assessment through a family report or medical chart review. Prognostic agreement was measured by (1) intraclass correlation coefficient; (2) mean group prediction comparisons using paired Student’s t-tests; and (3) prevalence of concordance, defined as an absolute difference of less than 20 percentage points between predictions. Accuracy for each group was measured by calculating the area under a receiver operating characteristic curve (C statistic) and compared by using DeLong’s test.

Results

Data were collected from 222 patients and families, 45 physicians, and 103 nurses. Complete data on agreement and accuracy were available for 187 and 177 patients, respectively. The intraclass correlation coefficient, in which 1 indicates perfect correlation and 0 indicates no correlation, was 0.49 for physician-family pairs, 0.40 for family-nurse pairs, and 0.66 for physician-nurse pairs. The difference in mean predictions between families and physicians was 23.5 percentage points (p < 0.001), 25.4 between families and nurses (p < 0.001), and 1.9 between physicians and nurses (p = 0.38). Prevalence of concordance was 39.6% for family-physician pairs, 30.0% for family-nurse pairs, and 56.2% for physician-nurse pairs. The C statistic for prediction accuracy was 0.65 for families, 0.82 for physicians, and 0.76 for nurses. The p values for differences in C statistics were < 0.05 for family-physician and family-nurse groups and 0.18 for physician-nurse groups.

Conclusions

For patients with SABI, agreement in predictions between families, physicians, and nurses regarding likelihood of recovery is poor. Accuracy appears higher for physicians and nurses compared with families, with no significant difference between physicians and nurses.

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Change history

  • 20 September 2023

    Article was updated to correct the abbreviated name spelling of Dr. Rachel Rutz Voumard.

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Acknowledgements

We would like to thank Kaley Dugger, Allison Kunze, Nathan McLaughlin, Erik Risa, and Dr. Kim Matsumoto and for assistance with data collection.

Funding

National Institute of Neurological Disorders and Stroke, K23 NS099421, for Claire J Creutzfeldt, MD; National Institutes of Health, National Heart Lung, and Blood Institute, 5 T32 HL125195-02, for Whitney Kiker (Funding obtained by Curtis JR, Kross EK, Rosenberg AR).

Author information

Authors and Affiliations

  1. Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA

    Whitney A. Kiker & J. Randall Curtis

  2. Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA

    Whitney A. Kiker, J. Randall Curtis & Claire J. Creutzfeldt

  3. Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA

    Rachel Rutz Voumard, W. T. Longstreth Jr. & Claire J. Creutzfeldt

  4. Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

    Rachel Rutz Voumard

  5. Oregon Health and Sciences University School of Medicine, Portland, OR, USA

    Wesley Plinke

Authors
  1. Whitney A. Kiker
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  2. Rachel Rutz Voumard
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  3. Wesley Plinke
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  4. W. T. Longstreth Jr.
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  5. J. Randall Curtis
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  6. Claire J. Creutzfeldt
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Contributions

Dr. Kiker and Dr. Creutzfeldt had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kiker, Longstreth, Curtis, and Creutzfeldt. Acquisition, analysis, or interpretation of data: Kiker, Rutz Voumard, Plinke, Curtis, and Creutzfeldt. Drafting of the article: Kiker and Creutzfeldt. Critical revision of the article for important intellectual content: all authors. Statistical analysis: Kiker and Creutzfeldt. Obtained funding: Kiker, Rutz Voumard, Creutzfeldt, and Curtis. Supervision: Curtis and Creutzfeldt. All authors have approved of the final manuscript.

Corresponding author

Correspondence to Whitney A. Kiker.

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Conflicts of interest

There are no conflicts of interest to report.

Ethical approval/informed consent

The University of Washington Institutional Review Board approved this study (study 00003393).

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Supplementary Information

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12028_2022_1501_MOESM1_ESM.docx

Supplemental Fig. 1 ROC curves for each group, stratified by GCS. n = 44 for GCS 3–5; n = 71 for GCS 6–8; n = 72 for GCS 9–12. GCS, Glasgow Coma Scale, ROC, receiver operating characteristic. (DOCX 4642 kb)

12028_2022_1501_MOESM2_ESM.tiff

Supplemental Fig. 2 ROC Curves by participant group with CMO patients (n = 61) removed. n = 116. CMO, comfort measures only, ROC, receiver operating characteristic. (TIFF 1428 kb)

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Kiker, W.A., Rutz Voumard, R., Plinke, W. et al. Prognosis Predictions by Families, Physicians, and Nurses of Patients with Severe Acute Brain Injury: Agreement and Accuracy. Neurocrit Care 37, 38–46 (2022). https://doi.org/10.1007/s12028-022-01501-7

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