The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator

Abstract

Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT’s prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.

Outcome Prediction after Moderate and Severe Traumatic Brain Injury: External Validation of Two Established Prognostic Models in 1742 European Patients

“…Treatment options for TBI patients are scarce, and documenting prognosis in the intensive care setting does not seem to substantially affect treatment decisions. [25][26][27] On the other hand, there is an increasing recognition that estimates of prognosis by clinicians are often unduly pessimistic for TBI patients, 28 and regular comparison of outcome predicted by these models with clinical expectations may help individual clinicians calibrate their prognostication and practice. Based on the good discriminative ability of the IMPACT and CRASH models, potential applications in research settings are risk stratification in trials and covariate adjustment in statistical analyses to increase statistical power.…”

Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons

“…In the first patient scenario, belief about the patient's prognosis was associated with the decision to offer or not offer a craniotomy. In a previous study, neurosurgeons stated they would consider not offering aggressive treatment when the chance of specific poor prognoses was 80% or greater [15]. Interestingly, in our study, although poor prognosis correlated with fewer craniotomies, many neurosurgeons were still willing to recommend craniotomy at a very low chance of functional recovery.…”

“…due to the fact that neurosurgeons are not confident in the validity of the tool, that they have fixed beliefs about prognosis, or that they primarily rely on personal experience and training to make decisions. Indeed, a recent survey of neurosurgeons found that the use of risk calculators is rare in practice, and that neurosurgeons are unlikely to rely on them for decision making [15]. Finally, it is possible that neurosurgeons depending on practice type, experience, or health system in which they practice could have different responses to evidence-based risk estimates.…”

“…Two such risk calculators are CRASH [11] and IMPACT [12], which both incorporate patient presentation data to predict multiple short and long-term outcomes [13,14]. Although validated, these calculators are not widely used in clinical practice [15]. Therefore, little is known about the effect of prognostic calculators on neurosurgeon prognostic beliefs and treatment recommendations.…”

Performance of CRASH and IMPACT Prognostic Models for Traumatic Brain Injury at 12 and 24 Months Post-Injury

“… 17–19 Previous work has demonstrated that neurosurgeons tend to be more nihilistic on long-term outcomes than general surgeons or other trauma specialists. 20 In clinical trials in TBI, the leading cause of death is attributable to withdrawal of life-sustaining therapies, often occurring early within 72 h of injury. 21 CRASH and IMPACT lack the discriminatory ability for individual patients to guide life-or-death decisions, given that they incorrectly predicted that nearly 1 in 5 patients would have an unfavorable outcome or die.…”