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Certainty and mortality prediction in critically ill children

¹ Department of Pediatrics, Section of Critical Care Medicine, University of California, Davis, Sacramento, CA 95817, USA
² Professor of Pediatrics, George Washington University School of Medicine, Chairman, Critical Care Medicine, Children’s National Medical Center, USA
³ Professor of Pediatrics, George Washington University School of Medicine, Senior Statistician, Center for Health Services and Clinical Research, Children’s Research Institute, Children’s National Medical Center, USA
⁴ Research Professor of Pediatrics, George Washington University School of Medicine, Research Scientist, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, USA

Correspondence to:
James P Marcin
MD, MPH, Department of Pediatrics, Section of Critical Care Medicine, UC Davis Children’s Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA; jpmarcin{at}ucdavis.edu 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.

Keywords: prognosis; certainty; critical care; mortality; paediatrics