L10 - DIAGNOSIS TO PROGNOSIS PROFILING

Question 1

Definitions of prognosis

Answer 1

Predictions based on current evidence in current situation
Definition
= Risk of future health outcomes in people with given disease or health condition

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Question 2

Clinical decision making: diagnosis vs prognosis

Answer 2

Identification of nature & cause of certain phenomenon, experience to determine cause & effect:
- Based on pathoanatomical model
- Focusing on deficits of body structures
- Using clinical examination / tests
- Imaging techniques to support clinical decision making

Prognosis goes beyond diagnosis, because it predicts patient’ trajectory &
outcomes (poor / good outcome)
Diagnosis = description aggregated from disease characteristics at single point in
time

Question 3

Rational for prognostic perspective

Answer 3

• Current approaches often encourage passivity
• Dependence on PT
• Diagnosis adds no further information
• Multifactorial nature of MSK conditions
• Consider cost-effective treatment for patients

Question 4

Process framework: description & aims to improve prognosis (4 themes) + description

Answer 4

PROGNOSTIC PROFILING: PROGRESS FRAMEWORK
- Identify standards & good practice
- Improve coherence
- Application in practice

Aims to improve prognosis research through 4 themes:
1. Fundamental prognosis research
2. Prognosis factor research
3. Prognosis model research
4. Stratified medicine research
From population level (1) to individual level (4)

Fundamental prognosis research: average risk of outcome or expected value of outcome among people
with health condition of interest in particular healthcare setting
→ Prognostic factor research: identify factors whose values (levels) associated with changes in outcome’s risk or expected value
→ Prognostic model research: develop, validate or assess impact of prognostic model to
predict individual’s outcome risk of expected outcome value using combinations of prognostic factors
→ Predictors of treatment effect research: tailor treatment decisions for individual patients according to whether they are likely to benefit from treatments

Question 5

Progress framework 1: name, description, focus, key questions & applications

Answer 5

Progress framework 1: fundamental prognosis research
“Prognosis of disease or condition is somewhat misleading expression: what is observed is prognosis of
people in particular clinical contexts, defined by current clinical approaches in diagnosing, characterizing
and managing patients with symptom or disease”
Focus: clarify how specific patterns of care (treatments, support) & variability influence future outcomes
Key questions:
- How long should recovery take?
- What is prognosis of patients with condition?
- How do current care patterns influence outcomes?
Applications:
- Understand care variability
- Study natural disease history
- Generate baseline risk for other research themes
- Helps compare outcomes from standard care to new interventions

Question 6

Progress framework 2: name, description, non modifiable factors, modifiable factors, applications, relevance for PT

Answer 6

Progress framework 2: prognostic factors
- Prognostic factor = any measure that, among people with given start point (such as stage of
disease) is associated with subsequent endpoint
o Behaviors & exposures that can raise or lower person’s risk
o Characteristics of individual that can potentially influence course of disease
- Prognostic factors associated with subsequent clinical outcomes, and if they are modifiable,
might be targeted by intervention to optimize patient outcomes
Non-modifiable: characteristics or conditions that cannot be changed but help predict course or outcome
of condition
- Demographic factors: age, sex, race…
- Anatomical changes: degenerative disc disease
- Biological markers: genes, proteins, metabolites
- Clinical variables: tumor size, nodal status…
- Comorbidities: chronic health conditions like diabetes…

Modifiable: aspects of individual’s lifestyle, behavior or environment that can be changed or managed to
reduce risk
- Lifestyle: prolonged sitting, especially with poor posture, excess body weight, smoking
- Psychological & behavioral: depression, distress, fear-avoidance beliefs coping strategies,
individual’s expectations
Applications
- Defining disease: staging cancer by tumor grade & metastasis
- Treatment decisions: drug-eluting stents recommended for high-risk coronary lesions `
- Monitoring progress : HbA1c levels in diabetes for glucose control
- Developing interventions: target modifiable prognostic factors
- Enhancing trials: stratify randomization by prognostic factors for balanced groups. Adjust for
confounders in statistical analysis
Relevance for PT:
Guides personalized care: which patients are higher risk for delayed recovery?

Question 7

Progress framework 3: name, description, benefits, selecting a prognostic tool

Answer 7

Progress framework 3: prognostic model/tools
- Mathematical models relating person’s characteristics now to risk of future outcome
- Combines multiple factors to predict individual outcomes more accurately
- Prognostic tools provide accurate estimates of probability of future outcomes for patient in
clinical practice
Benefits:
- Allows for personalized prevention & care
- Essential for setting baselines for clinical audience & benchmarking
- Informing patients & families about recovery expectations & supporting clinicians in making
informed treatment decisions
- For resource allocation
- In PT, numerous prognostic models have been designed to predict outcomes following MSK
conditions, such as neck pain
- Define rehabilitation prognostic tool as tool that operationalizes prognostic models in pragmatic
way, by giving course of action to guide clinical decision-making processes & personalize
rehabilitation approaches
- Serve practical purposes
Selecting a prognostic tool/model
Ease of use:
- Easily understandable by users
- Statistical analysis measures
- Determine what could bias results & interpretation
- Require information readily available by clinicians
Performance: acceptable performance measures
- External validity
- Reliability
- Discriminative ability
Classifications
- Sensitivity
- Specificity
- Predictive value

Question 8

Progress framework 4: name, description, relevant to PT, steps, benefits, limitations, understanding importance

Answer 8

Progress framework 4: treatment effect research
- Uses prognostic models to tailor treatments to specific patient subgroups
Relevance to PT
- Enables stratified approaches
o Patients with higher risk profiles may require more intensive therapy
o Lower-risk patients might benefit from home-based exercises
- Stratified care
o Patients’ assignment to strata
o Targeted treatment
o Outcome monitoring
Steps
Start => Patient assessment => Identify key factors (bio, psycho, social) => Risk assessment tools =>
Clinical history review => Classify risk (high, moderate, low) => Prognostic profiling completed
Benefits
- Screening inclusivity & treatment selection
- Simplicity (patients complete brief nine-item, self-report tool)
- Steered away (low risk, with good prognosis) from over investigation & treatment
- Fast track: 1st contact care decision making
- Prognosis-related findings can be used to determine person’s specific treatment needs
Limitations
- Prognostic models: high risk of bias
- Overfitting: results cannot be validated in underlying or related populations
- Poor discriminative ability: model may predict poorly, not separate low risk
from high-risk patients
- Poor calibration: may give unreliable or even misleading risk estimates
- Difficulty in selecting the most promising predictors, relatively limited
dataset
Understanding importance:
- Disease prognosis
- Prognosis factors
- Prognosis models/tools
- Prognostic stratification
 Delivering interventions