Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients

Carneiro, Bárbara Vieira; Crozatti, Lucas Lonardoni; Mendes, Pedro Vitale; Nassar Júnior, Antonio Paulo; Taniguchi, Leandro Utino

doi:10.5935/0103-507X.20220019-en

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Revista Brasileira de Terapia Intensiva

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ORIGINAL ARTICLE • Rev. bras. ter. intensiva 34 (2) • Apr-Jun 2022 • https://doi.org/10.5935/0103-507X.20220019-en copy

Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance.

Methods:

We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient’s probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians’ categories. We also stratified the results according to randomized question framing.

Results:

We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians’ experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians.

Conclusion:

Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals’ prediction. Question framing affected the predictive performance of surrogates but not of physicians.

Keywords:
Prognosis; Internship and residency; Critical illness; Decision-making; Delivery of health care; Hospitalization; Intensive care units; Mortality

	Surrogate	Resident		ICU fellow		ICU senior
	Survive Die	Survive	Die	Survive	Die	Survive	Die
AUC	0.69^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization. 0.56	0.80^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.	0.82†^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.	0.80^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.	0.80†^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.	0.85‡^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.	0.79†^* * p < 0.001 for AUC significantly higher than 0.50; † p < 0.01 compared to surrogate’s prediction of dying in the hospitalization; ‡ p = 0.01 compared to surrogate’s prediction of surviving in the hospitalization.
95%CI	0.56 - 0.80 0.42 - 0.69	0.68 - 0.89	0.70 - 0.91	0.68 - 0.89	0.67 - 0.89	0.74 - 0.93	0.66 - 0.89

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - Vila Olímpia, CEP 04545-100 - São Paulo - SP - Brasil, Tel.: (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: rbti.artigos@amib.com.br

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[1] Conflicts of interest: None

Age (years)	54 (38.75 - 65.25)
Male	60 (50.8)
SAPS III	53 (42.75 - 63)
Admission type
Medical	77 (65.3)
Emergency surgery	39 (33.1)
Elective surgery	2 (1.7)
Length of hospital stay before ICU admission (days)	1 (1 - 4)
Charlson comorbidity index	2 (0 - 3.5)
Eastern Cooperative Oncology Group
0 - 1	85 (72.1)
2	23 (19.5)
3 - 4	7 (5.9)
Type of advanced disease
Chronic heart failure (NYHA IV)	19 (16.1)
Cirrhosis	4 (3.4)
Metastatic cancer or hematologic malignancy	7 (5.9)
Sepsis at ICU admission^*	29 (24.6)
Mechanical ventilation at interview†	55 (46.6)
Vasopressors at interview†	60 (50.8)
Renal replacement therapy at interview†	14 (11.9)
Decisions regarding limitation of treatment‡
None	98 (83.1)
Any decision	12 (10.2)
Hospital mortality	45 (38.1)

Age (years)	44.5 (34 - 54)
Male	44 (37.6)
Relationship to patient
Spouse	37 (31.4)
Child	42 (35.6)
Parent	14 (11.9)
Other relative	25 (21.2)
Level of education
Did not attend school	4 (3.4)
Attended but did not complete school	38 (32.3)
Completed high school	45 (38.2)
Undergraduate degree	31 (26.3)
Religious preference
Catholic	45 (38.1)
Evangelical	37 (31.4)
None, agnostic, or atheist	8 (6.8)
Spiritist	9 (7.6)
Other christian	2 (1.7)
Other	4 (3.4)
Declined response	4 (3.3)