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): multicentre observational cohort study

doi:10.1136/bmj.39371.524271.55

BMJ 2007;335:1132 (1 December), doi:10.1136/bmj.39371.524271.55 (published 1 November 2007)

Research

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): multicentre observational cohort study

Martin J Wildman, consultant chest physician¹, Colin Sanderson, reader in health services research², Jayne Groves, research nurse³, Barnaby C Reeves, reader in epidemiology², Jon Ayres, professor⁴, David Harrison, senior statistician⁵, Duncan Young, consultant intensivist⁶, Kathy Rowan, director⁵

¹ Northern General Hospital, Sheffield, ² London School of Hygiene and Tropical Medicine, London, ³ Birmingham Heartlands Hospital, Birmingham, ⁴ Department of Occupational and Environmental Medicine, Liberty Safe Work Research Centre, Aberdeen, ⁵ Intensive Care National Audit and Research Centre, London, ⁶ Adult Intensive Care Unit, John Radcliffe Hospital, Oxford

Correspondence to: M Wildman martin.wildman{at}sth.nhs.uk

Objective To determine whether clinicians' prognoses in patientswith severe acute exacerbations of obstructive lung diseaseadmitted to intensive care match observed outcomes in termsof survival.

Design Prospective cohort study.

Setting 92 intensive care units and three respiratory high dependencyunits in the United Kingdom.

Participants 832 patients aged 45 years and older with breathlessness,respiratory failure, or change in mental status because of anexacerbation of COPD, asthma, or a combination of the two.

Main outcome measures Outcome predicted by clinicians. Observedsurvival at 180 days.

Results 517 patients (62%) survived to 180 days. Clinicians'prognoses were pessimistic, with a mean predicted survival of49% at 180 days. For the fifth of patients with the poorestprognosis according to the clinician, the predicted survivalrate was 10% and the actual rate was 40%. Information from adatabase covering 74% of intensive care units in the UK suggestedno material difference between units that participated and thosethat did not. Patients recruited were similar to those not recruitedin the same units.

Conclusions Because decisions on whether to admit patients withCOPD or asthma to intensive care for intubation depend on clinicians'prognoses, some patients who might otherwise survive are probablybeing denied admission because of unwarranted prognostic pessimism.

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