Predictive accuracy of physicians’ estimates of outcome after severe stroke

<div><p>Introduction</p><p>End-of-life decisions after stroke should be guided by accurate estimates of the patient’s prognosis. We assessed the accuracy of physicians’ estimates regarding mortality, functional outcome, and quality of life in patients with severe stroke.</p><p>Methods</p><p>Treating physicians predicted mortality, functional outcome (modified Rankin scale (mRS)), and quality of life (visual analogue scale (VAS)) at six months in patients with major disabling stroke who had a Barthel Index ≤6 (of 20) at day four. Unfavorable functional outcome was defined as mRS >3, non-satisfactory quality of life as VAS <60. Patients were followed-up at six months after stroke. We compared physicians’ estimates with actual outcomes.</p><p>Results</p><p>Sixty patients were included, with a mean age of 72 years. Of fifteen patients who were predicted to die, one actually survived at six months (positive predictive value (PPV), 0.93; 95% CI, 0.66–0.99). Of thirty patients who survived, one was predicted to die (false positive rate (FPR), 0.03; 95%CI 0.00–0.20). Of forty-six patients who were predicted to have an unfavorable outcome, four had a favorable outcome (PPV, 0.93; 95% CI, 0.81–0.98; FPR, 0.30; 95% CI; 0.08–0.65). Prediction of non-satisfactory quality of life was less accurate (PPV, 0.63; 95% CI, 0.26–0.90; FPR, 0.18; 95% CI 0.05–0.44).</p><p>Conclusions</p><p>In patients with severe stroke, treating physicians’ estimation of the risk of mortality or unfavorable functional outcome at six months is relatively inaccurate. Prediction of quality of life is even more imprecise.</p></div

Odds ratios for the relation between body temperature on admission and recanalization.

<p>Odds ratios for the relation between body temperature on admission and recanalization.</p

Patient characteristics.

<p>Data are n (%), median (range), median (interquartile range (IQR)) or mean (standard deviation (SD)) where appropriate. NIHSS, National Institutes of Health Stroke Scale; TOAST, Trial of Org 10172 in Acute Stroke Treatment classification</p><p>Patient characteristics.</p

Accuracy of prognostic estimates.

<p>Accuracy of prognostic estimates.</p

Outcomes at six months.

<p>Outcomes at six months.</p

Predicted and observed 6 month functional outcome (mRS score, range 0–6) per patient (n = 59).

<p>Predicted and observed 6 month functional outcome (mRS score, range 0–6) per patient (n = 59).</p

Demographic characteristics of included patients.

<p>Demographic characteristics of included patients.</p

Distribution of predicted and actual modified Rankin Scale (mRS) grades at 6 months.

<p>Distribution of predicted and actual modified Rankin Scale (mRS) grades at 6 months.</p

Randomisation, blinded outcome assessment, and sample size calculation in systematic reviews of animal studies.

a<p>Summarises the data of six systematic reviews of treatment strategies for acute ischemic stroke. There is an overlap of 18 publications between references <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000245#pmed.1000245-Sena1" target="_blank">[16]</a> and <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000245#pmed.1000245-VanderWorp2" target="_blank">[19]</a>.</p><p>ALS, amyotrophic lateral sclerosis; N/A, data not available; RDS, respiratory distress syndrome.</p

Four types of bias threatening internal validity.

<p>Adapted from <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000245#pmed.1000245-Juni1" target="_blank">[12]</a>,<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000245#pmed.1000245-Altman1" target="_blank">[13]</a>.</p