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“Prognostic pessimism” in asthma and COPD
  1. S McCarthy
  1. Dr S McCarthy, Foundation Year 2, Queen’s Hospital, Romford, Essex RM7 0AG, UK; smccarthy{at}doctors.org.uk

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Doctors can be pessimistic—especially when making a prognosis—and this in turn may influence clinical decisions. This study looked at the accuracy of the predicted outcome in patients with chronic obstructive pulmonary disease (COPD) and asthma with regard to admission to the intensive care unit (ITU).

Data were collected over 18 months from nearly half the ITUs involved in the UK Case Mix Program and three high dependency units. Patients aged <45 years and those admitted from other hospitals or within 10 days of surgery were excluded. In the 832 patients who were recruited, the primary outcome analysed was the comparison between the prediction for survival on admission and the actual outcome at 180 days. It was found that, overall, the admitting doctor underestimated the survival potential, especially in patients already in poor health. In fact, 40% of patients with the worst prognosis survived when only 10% had been predicted to do so.

The authors concluded that bias associated with “prognostic pessimism” may deny some patients the benefits of intubation, yet provided no evidence for this. One limitation of this study was that they only looked at patients who had already been admitted into intensive care and high dependency units and not ward-based patients. Also, there were no data as to the seniority or experience level of the clinician admitting to the ITU. However, with increasing pressure for ITU beds and the incidence of COPD increasing, this study provides evidence that this is an important area for further investigation.

▸ Wildman M, Sanderson C, Groves J, et al. Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and Asthma Outcome Study (CAOS): multicenter observational cohort study. BMJ 2007;335:1132–4.

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