Rm. Poses et al., PHYSICIANS SURVIVAL PREDICTIONS FOR PATIENTS WITH ACUTE CONGESTIVE-HEART-FAILURE, Archives of internal medicine, 157(9), 1997, pp. 1001-1007
Background: Current guidelines suggest that patients with low likeliho
ods of survival may be excluded from intensive care. Patients with new
or exacerbated congestive heart failure are frequently but not inevit
ably admitted to critical care units. Objective: To assess how well ph
ysicians could predict the probability of survival for acutely ill pat
ients with congestive heart failure, and in particular how well they c
ould identify patients with small chances of survival. Methods: This w
as a prospective cohort study done in the emergency departments of a u
niversity hospital, a Veterans Affairs medical center, and a community
hospital. The study population was consecutive adults for whom new or
exacerbated congestive heart failure, diagnosed clinically, was a maj
or reason for the emergency department visit. Physicians caring for th
e study patients in the emergency departments recorded their judgments
of the numeric probability that each patient would survive for 90 day
s and for 1 year. The patients' vital status at 90 days and 1 year was
ascertained by multiple means, including interview, chart review, and
review of hospital and state databases. Results: By calibration curve
analysis, the physicians underestimated survival probability at both
90 days and 1 year, particularly for patients they judged to have the
lowest probabilities of survival. Their predictions had modest discrim
inating ability (receiver operating characteristic curve areas, 0.66 [
SE=0.020] for 90 days; 0.63 [SE=0.017] for 1 year). The physicians ide
ntified only 15 patients they judged to have a 90-day survival probabi
lity of 10% or less, whose survival rate was actually 33.3%. Conclusio
ns: Physicians have great difficulty predicting survival for patients
with acute congestive heart failure and cannot identify patients with
poor chances of survival. Current triage guidelines that suggest patie
nts with poor chances of survival may be excluded from critical care m
ay be impractical or harmful.