Physician Intuition Versus Model Predicted Prognosis in Heart Failure

Heart failure (HF) is a large and growing medical and economic problem, with over 26 million people suffering worldwide. The prognosis associated with HF is poor. Optimal management of patients with HF, crucial to improve outcomes and minimize costs, depends on adequate assessment of prognosis to decide on appropriate testing and intervention.

There are predictive models, with satisfactory discrimination and calibration, that can accurately estimate mortality in HF patients. Despite their availability, physicians seldom use these models, instead relying on their informed intuition, which has proven to be limited. No studies have compared physician intuition (standard practice) and model predicted survival in patients with HF. The investigators therefore propose a Canadian multicentre study comparing physician intuition and model prediction to estimate one-year survival in ambulatory HF patients and secondly to assess the possible impact of intuition versus model prediction on the use of resources. Evaluating whether predictive models are more accurate than physician intuition will inform the best strategy to assess patient prognosis in HF. More accurate prognostic estimates will facilitate patient management by matching the need for further therapy or testing to patient risk thus offering greater clinical benefit and improving utilization of resources.

This study will evaluate the accuracy and impact of physician intuition and predictive models in the assessment of prognosis in ambulatory HF patients by: i. comparing the accuracy of 1-year physician predicted survival and 1-year model predicted survival to the true (observed) 1-year survival; ii. evaluating the accuracy of physician intuition according to physician's level of confidence in their intuition (very low, low, moderate, high or very high); iii. evaluating whether physician expertise impacts accuracy of physician intuition; iv. evaluating whether physician gender, patient gender and physician-patient gender concordance impact accuracy of physician intuition; and v. studying the association between physician estimated survival and resource use and related cost.

The investigators hypothesize that predictive models will more accurately predict mortality than physicians, with more marked differences in less experienced physicians or when physician confidence in estimate is low. Physicians will use more resources when they consider patients to be high risk. If these hypotheses prove correct, incorporation of user-friendly systems to estimate prognosis into clinical practice can offer clinical benefit, facilitate patient management and improve utilization of resources.

This is a Canadian multicentre prospective cohort study of consecutive consenting ambulatory adult heart failure (HF) patients followed in a HF clinic. Participating centers include tertiary care hospitals with dedicated HF clinics in British Columbia (St. Paul's Hospital, Providence Health Care Centre); Manitoba (St. Boniface General Hospital); Ontario (Toronto General Hospital, St. Michael's Hospital, Ottawa Heart Institute, Sunnybrook Hospital, Mount Sinai Hospital, Hamilton Health Science, Southlake Regional Health Centre); Quebec (McGill University Health Centre); and Nova Scotia (Nova Scotia Health Authority). These clinics attend to different HF populations permitting a wide representation of patient profiles.