Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America.
Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, United States of America.
PLoS One. 2020 Mar 2;15(3):e0228947. doi: 10.1371/journal.pone.0228947. eCollection 2020.
Surgical decision-making in severe traumatic brain injury (TBI) is complex. Neurosurgeons weigh risks and benefits of interventions that have the potential to both maximize the chance of recovery and prolong suffering. Inaccurate prognostication can lead to over- or under-estimation of outcomes and influence treatment recommendations.
To evaluate the impact of evidence-based risk estimates on neurosurgeon treatment recommendations and prognostic beliefs in severe TBI.
In a survey-based randomized experiment, a total of 139 neurosurgeons were presented with two hypothetical patient with severe TBI and subdural hematoma; the intervention group received additional evidence-based risk estimates for each patient. The main outcome was neurosurgeon treatment recommendation of non-surgical management. Secondary outcomes included prediction of functional recovery at six months.
In the first patient scenario, 22% of neurosurgeons recommended non-surgical management and provision of evidence-based risk estimates increased the propensity to recommend non-surgical treatment (odds ratio [OR]: 2.81, 95% CI: 1.21-6.98; p = 0.02). Neurosurgeon prognostic beliefs of 6-month functional recovery were variable in both control (median 20%, IQR: 10%-40%) and intervention (30% IQR: 10%-50%) groups and neurosurgeons were less likely to recommend non-surgical management when they believed prognosis was favorable (odds ratio [OR] per percentage point increase in 6-month functional recovery: 0.97, 95% confidence interval [CI]: 0.95-0.99). The results for the second patient scenario were qualitatively similar.
Our findings show that the provision of evidence-based risk predictions can influence neurosurgeon treatment recommendations and prognostication, but the effect is modest and there remains large variability in neurosurgeon prognostication.
严重创伤性脑损伤 (TBI) 的手术决策非常复杂。神经外科医生需要权衡干预措施的风险和获益，这些干预措施有可能最大限度地提高恢复机会并延长患者的痛苦。不准确的预后评估可能导致对结果的高估或低估，并影响治疗建议。
评估基于证据的风险估计对神经外科医生治疗建议和严重 TBI 预后判断的影响。
在一项基于调查的随机实验中，共有 139 名神经外科医生对两名患有严重 TBI 和硬膜下血肿的假设患者进行了评估；干预组为每位患者提供了额外的基于证据的风险估计。主要结局是神经外科医生对非手术治疗的治疗建议。次要结局包括对 6 个月时功能恢复的预测。
在第一个患者场景中，22%的神经外科医生建议采用非手术治疗，而提供基于证据的风险估计则增加了推荐非手术治疗的可能性（优势比 [OR]：2.81，95%置信区间 [CI]：1.21-6.98；p = 0.02）。在对照（中位数 20%，IQR：10%-40%）和干预组（30% IQR：10%-50%）中，神经外科医生对 6 个月功能恢复的预后判断均存在差异，当他们认为预后较好时，他们不太可能建议采用非手术治疗（6 个月功能恢复每增加一个百分点的优势比 [OR]：0.97，95%置信区间 [CI]：0.95-0.99）。第二个患者场景的结果定性相似。
我们的研究结果表明，提供基于证据的风险预测可以影响神经外科医生的治疗建议和预后判断，但效果有限，神经外科医生的预后判断仍然存在很大差异。
