QUESTION RELATED TO PROGNOSIS IN QUESTION RELATED TO PROGNOSIS IN THE PRACTICE OF MEDICINE:THE PRACTICE OF MEDICINE:

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What are the What are the consequences consequences of having the of having the disease?disease?

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Biologic onset

ClinicalDiagnosis

OutcomeRecoveryDisabilityDeathetc

Natural history of diseases

Clinical courses

(no medical intervention)

(medical intervention)

QUESTIONS ABOUT HOW PATIENTS’ QUESTIONS ABOUT HOW PATIENTS’ ILLNESS WILL AFFECT THEM:ILLNESS WILL AFFECT THEM:

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Is it dangerous?Is it dangerous?

Could I die of it?Could I die of it?

Will there be pain?Will there be pain?

How long will I be able to How long will I be able to continue my present activities?continue my present activities?

Will it ever go away altogether?Will it ever go away altogether?

DESCRIBING OUTCOMES OF DISEASE:DESCRIBING OUTCOMES OF DISEASE:

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Should include the full range of manifestations that would be considered important to patients (5Ds):

DeathDeath

DiseaseDisease

DisabilityDisability

DiscomfortDiscomfort

DissatisfactionDissatisfaction

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Onset of acute myocardial infarction

1. Age >>2. Male3. LDL>/ HDL<4. Cigarette smoking5. Hypertension6. Inactivity

1. Age >>2. Male3. Anterior infarction4. Hypotension5. Congestive heart failure6. Ventricular arrythmia

PROGNOSIS RISK

Outcome:Death, reinfarctionWell

Differences between risk and prognostic factors for acute myocardial infarction

RATES COMMONLY USED TO DESCRIBE RATES COMMONLY USED TO DESCRIBE PROGNOSIS:PROGNOSIS:

RateRate Definition*Definition*5-year survival5-year survival Percent of patients surviving 5 years from some Percent of patients surviving 5 years from some

point in the course of their diseasepoint in the course of their diseaseCase fatalityCase fatality Percent of patients with a disease who die of itPercent of patients with a disease who die of itDisease-specific Disease-specific mortalitymortality

Number of people per 10,000 (or 100,000) Number of people per 10,000 (or 100,000) population dying of a specific diseasepopulation dying of a specific disease

ResponseResponse Percent of patients showing some evidence of Percent of patients showing some evidence of improvement following an interventionimprovement following an intervention

RemissionRemission Percent of patients entering a phase in which Percent of patients entering a phase in which disease is no longer detectabledisease is no longer detectable

RecurrenceRecurrence Percent of patients who have return of disease Percent of patients who have return of disease after a disease-free intervalafter a disease-free interval

7*Time under observation is either stated or assumed to be sufficiently long so that all events that will occur have been

observed

Critical Appraisal : Prognosis

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a) Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease?

b) Was the follow-up of the study patients sufficiently long and complete?

c) Were objective outcome criteria applied in a ‘blind’ fashion?

d) If subgroups with different prognoses are identified, was there adjustment for important prognostic factors and validation in an independent “test set” patients?

1. 1. Are the results of the study valid? Are the results of the study valid?

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a) How likely are the outcomes over time?b) How precise is this prognostic estimate?

2. Are the results of this study 2. Are the results of this study important?important?

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..:: 5 years curve for three different diseases ::..

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a) Is my patient so different from those in the study that its results cannot apply?

b) Will this evidence make a clinically important impact on my conclusions about what to offer or tell my patient?

3. Can I apply this valid, important 3. Can I apply this valid, important evidence about prognosis to my evidence about prognosis to my

patient?patient?

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