Letsinger Joshua, Rommel Casey, Hirschi Ryan, Nirula Raminder, Hawryluk Gregory W J
Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States of America.
Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah, United States of America.
PLoS One. 2017 Aug 23;12(8):e0183552. doi: 10.1371/journal.pone.0183552. eCollection 2017.
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.
已发布的指南有助于规范创伤性脑损伤患者的护理；然而，在决定是否采取积极治疗方面仍存在很大差异。国际创伤性脑损伤临床试验预后与分析任务组（IMPACT）预后计算器为研究和减少医生治疗积极性的差异提供了机会。作者希望了解IMPACT的预后计算目前如何影响患者护理，并更好地理解医生的治疗积极性。作者对为创伤性脑损伤患者提供护理的从业者进行了一项匿名的国际多学科调查。问题旨在确定IMPACT预后计算器的当前使用率以及可能导致从业者考虑不采取积极治疗的年龄和死亡或不良预后风险阈值。研究了医生治疗积极性、假定的积极性预测因素和人口统计学之间的相关性。共收到154份回复，其中一半来自熟悉IMPACT计算器的医生。该计算器最常见的用途是改善与患者及其家属的沟通。平均而言，受访者表示，对于76岁以上或死亡或不良预后几率大于85%的患者，采取非积极治疗可能是合理的。这些阈值很稳定，不受提供者或机构特征的影响。这项研究表明有必要对医生进行关于IMPACT预后计算器的教育。我们研究中确定的年龄和预后的共识值可在未来旨在减少医生治疗积极性差异的研究中进行探索，不应作为停止治疗的依据。
