How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD?

Abstract

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP. OBJECTIVE: To assess how well the SQ predicts mortality and prompts ACP for COPD patients. DESIGN: Retrospective cohort study. SUBJECTS: Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018. MAIN MEASURES: Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-ofcare conversation, change in code status, or completion of ACP document). KEY RESULTS: The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67,. CONCLUSIONS: The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

“…In five other studies multiple healthcare professionals answered the surprise question, however, no separate data was reported. 40,51,54,67,73…”

“…57 Four studies used two variants of the surprise question with varying timeframes. 31,44,64,74 In general, patients included were adults (>18 years), except for one study performed in children. 44 Eighteen studies included patients with kidney disease, 12 patients with cancer, seven with cardiac disease, seven included a diverse group of patients in general practice/primary care, six studies included patients with pulmonary disease and five studies included patients from the emergency department.…”

The ‘Surprise question’ in heart failure: a prospective cohort study

“…The SQ's performance has been evaluated for patients with both oncological [4][5][6][7] and non-oncological diseases, including chronic kidney disease 8 and chronic obstructive pulmonary disease. 9 For patients with oncological diseases, the sensitivity of the 1-year SQ has varied from 58% to 85%. [4][5][6][7] For patients with non-oncological diseases, the performance also varies even within the same disease.…”

“…[4][5][6][7] For patients with non-oncological diseases, the performance also varies even within the same disease. [8][9][10] Despite the heterogeneity among performance measures, two systematic reviews suggest that, in general, the performance of the SQ predicting 1-year mortality is better for patients with oncological disease than for patients with nononcological disease. 10 11 Recently, the SQ's performance was assessed for an inpatient population with HF 12 and for a population with HF in an emergency setting.…”

Comparison of characteristics and management of emergency department presentations between patients with met and unmet palliative care needs

“…As such, numerous studies have assessed the ability of screening tools to help ED healthcare providers identify ED patients with unmet palliative care needs who may benefit from timely referral to palliative services [ 4 ]. The proportion of patients identified as having unmet palliative care needs across various EDs have ranged considerably, from 5% [ 5 ] to 83% [ 6 ], which is likely due to differences in the criteria for palliative needs among the available screening tools, clinical heterogeneity among the study populations, and variability in healthcare systems. While various studies have identified ED patients with unmet palliative care needs, only a handful of studies have conducted an assessment of whether there are any potential differences in the characteristics and ED management of patients identified as having met or unmet palliative care needs [ 6 , 7 ].…”