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Certainty and mortality prediction in critically ill children
J P Marcin1, R K Pretzlaff, M M Pollack
1Department of Pediatrics, Section of Critical Care Medicine, University of California-Davis, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA. jpmarcin@ucdavis.edu
Insights
Physician confidence in mortality predictions influences their stated prognosis. Less confident prognoses often fall in the intermediate range, impacting patient care decisions.
Area of Science:
- Pediatric Critical Care Medicine
- Clinical Decision-Making
- Medical Prognostication
Background:
- Physician's subjective mortality predictions are crucial for patient management in pediatric intensive care.
- Understanding the interplay between prediction accuracy and confidence is vital for refining prognostic assessments.
Purpose of the Study:
- To investigate the relationship between physician's subjective mortality predictions and their confidence levels in pediatric intensive care unit (ICU) patients.
- To determine if confidence in prognostication varies with the predicted mortality risk.
Main Methods:
- Prospective cohort study of pediatric ICU patients (<18 years).
- Physicians provided mortality risk predictions and confidence levels within 24 hours of admission.
- Median confidence levels were compared across different mortality risk prediction ranges.
Main Results:
- Physicians expressed significantly less confidence in mortality predictions between 5% and 95%.
- Predictions <5% and >95% were associated with higher confidence levels.
- Physician experience correlated positively with increased confidence in prognostication.
Conclusions:
- Physician confidence significantly impacts subjective mortality predictions, with lower confidence leading to intermediate risk assessments.
- Assessing physician confidence alongside mortality predictions is essential for understanding potential biases in therapeutic planning.
- Confidence levels in prognostic assessments may influence clinical decision-making and future patient outlooks.
Objectives:
The objective of this study is to investigate the relationship between a physician's subjective mortality prediction and the level of confidence with which that mortality prediction is made.
Design And Participants:
The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit (ICU) at a University Children's Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions.
Results:
Data were collected on 642 of 713 eligible patients (36 deaths, 5.6%). Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions <5% and >95%. Experience was associated with greater confidence in prognostication.
Conclusions:
We conclude that a physician's subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions (or any prognostic assessment) may therefore be important because different levels of confidence may translate into differences in a physician's therapeutic plans and their assessment of the patient's future.