Stroke Outcomes Research Unit, Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
Neurology. 2013 Jul 30;81(5):448-55. doi: 10.1212/WNL.0b013e31829d874e. Epub 2013 Jun 28.
We compared the accuracy of clinicians and a risk score (iScore) to predict observed outcomes following an acute ischemic stroke.
The JURaSSiC (Clinician JUdgment vs Risk Score to predict Stroke outComes) study assigned 111 clinicians with expertise in acute stroke care to predict the probability of outcomes of 5 ischemic stroke case scenarios. Cases (n = 1,415) were selected as being representative of the 10 most common clinical presentations from a pool of more than 12,000 stroke patients admitted to 12 stroke centers. The primary outcome was prediction of death or disability (modified Rankin Scale [mRS] ≥3) at discharge within the 95% confidence interval (CI) of observed outcomes. Secondary outcomes included 30-day mortality and death or institutionalization at discharge.
Clinicians made 1,661 predictions with overall accuracy of 16.9% for death or disability at discharge, 46.9% for 30-day mortality, and 33.1% for death or institutionalization at discharge. In contrast, 90% of the iScore-based estimates were within the 95% CI of observed outcomes. Nearly half (n = 53 of 111; 48%) of participants were unable to accurately predict the probability of the primary outcome in any of the 5 rated cases. Less than 1% (n = 1) provided accurate predictions in 4 of the 5 cases and none accurately predicted all 5 case outcomes. In multivariable analyses, the presence of patient characteristics associated with poor outcomes (mRS ≥3 or death) in previous studies (older age, high NIH Stroke Scale score, and nonlacunar subtype) were associated with more accurate clinician predictions of death at 30 days (odds ratio [OR] 2.40, 95% CI 1.57-3.67) and with a trend for more accurate predictions of death or disability at discharge (OR 1.85, 95% CI 0.99-3.46).
Clinicians with expertise in stroke performed poorly compared to a validated tool in predicting the outcomes of patients with an acute ischemic stroke. Use of the risk stroke outcome tool may be superior for decision-making following an acute ischemic stroke.
我们比较了临床医生和风险评分（iScore）预测急性缺血性卒中患者预后的准确性。
JURaSSiC（临床医生判断与风险评分预测卒中结局）研究将 111 名具有急性卒中护理专业知识的临床医生分配，以预测 5 个缺血性卒中病例场景的结局概率。从 12 个卒中中心收治的 12000 多名卒中患者中，选择了最常见的 10 种临床表现作为病例池的代表。主要结局为在观察结局的 95%置信区间（CI）内预测出院时的死亡或残疾（改良 Rankin 量表[mRS]≥3）。次要结局包括 30 天死亡率和出院时的死亡或住院。
临床医生共进行了 1661 次预测，出院时死亡或残疾的总体准确率为 16.9%，30 天死亡率为 46.9%，出院时死亡或住院的准确率为 33.1%。相比之下，90%的 iScore 基于估计值在观察结果的 95%CI 内。近一半（n=111；48%）的参与者无法准确预测 5 个评分病例中任何一个的主要结局概率。不到 1%（n=1）在 4 个病例中提供了准确的预测，没有人准确预测了所有 5 个病例的结局。在多变量分析中，先前研究中与不良结局（mRS≥3 或死亡）相关的患者特征（年龄较大、NIH 卒中量表评分较高和非腔隙性亚型）的存在与临床医生对 30 天死亡的更准确预测相关（比值比[OR]2.40，95%CI 1.57-3.67），并与出院时死亡或残疾的更准确预测呈趋势相关（OR 1.85，95%CI 0.99-3.46）。
与经过验证的工具相比，具有卒中专业知识的临床医生在预测急性缺血性卒中患者的结局方面表现不佳。在急性缺血性卒中后，使用卒中风险预测工具可能更有利于决策。
