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

<div><p>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.</p></div

Characteristics of survey respondents.

<p>Characteristics of survey respondents.</p

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator - Fig 3

<p><b>Responses to survey questions 18, 19, 17, and 16 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0183552#pone.0183552.s001" target="_blank">S1 Survey</a>, Supplemental Digital Content 1) are presented in A, B, C, and D, respectively.</b> In our survey, we posed a series of questions that assumed the calculator produced results that were 100% accurate. <b>A)</b> Reported extent to which age influences aggressive care among different specialties, by specialty. Just over 10% of all respondents said that age had no influence on their decision making. <b>B)</b> Reported age threshold at which one might consider withholding aggressive care, by specialty. <b>C)</b> Reported chance of poor outcome that prompts comfort care considerations, by specialty. <b>D)</b> Reported chance of mortality that prompts comfort care considerations, by specialty. Error bars represent standard error.</p

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator - Fig 2

<p><b>Responses to survey questions 12, 13, 14, and 15 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0183552#pone.0183552.s001" target="_blank">S1 Survey</a>, Supplemental Digital Content 1) are presented in A, B, C, and D, respectively.</b> General surgeons returned a larger number of survey responses (109), neurosurgeons returned 37 responses; the remaining practitioners (neither GS nor NS) returned 7 surveys. <b>A)</b> The proportion of respondents that reported awareness of the IMPACT prognostic calculator by specialty. <b>B)</b> Reported frequency of use of the IMPACT prognostic calculator in patient management by specialty (p = 0.236). Over 45% of all respondents that were aware of the calculator “Never” use it in practice. <b>C)</b> Influence of IMPACT prognostic calculations on patient care by specialty. <b>D)</b> Reported uses of the IMPACT prognostic calculator by specialty. Respondents could select more than one option.</p

Effect of variables on physician aggressiveness.

<p><b>A)</b> Chance of mortality that prompts withholding aggressive care by years in practice. <b>B)</b> Chance of mortality that prompts withholding aggressive care by trauma center level. <b>C)</b> Chance of mortality that prompts withholding aggressive care by trauma volume per year. <b>D)</b> Chance of mortality that prompts withholding aggressive care by frequency of TBI care provided.</p