Prioritizing Primary Care Patients for a Communication Intervention Using the “Surprise Question”: a Prospective Cohort Study

Abstract

BACKGROUND: Communication about priorities and goals improves the value of care for patients with serious illnesses. Resource constraints necessitate targeting interventions to patients who need them most. OBJECTIVE: To evaluate the effectiveness of a clinician screening tool to identify patients for a communication intervention. DESIGN: Prospective cohort study. SETTING: Primary care clinics in Boston, MA. PARTICIPANTS: Primary care physicians (PCPs) and nurse care coordinators (RNCCs) identified patients at high risk of dying by answering the Surprise Question (SQ): BWould you be surprised if this patient died in the next 2 years?M EASUREMENTS: Performance of the SQ for predicting mortality, measured by the area under receiver operating curve (AUC), sensitivity, specificity, and likelihood ratios. RESULTS: Sensitivity of PCP response to the SQ at 2 years was 79.4% and specificity 68.6%; for RNCCs, sensitivity was 52.6% and specificity 80.6%. In univariate regression, the odds of 2-year mortality for patients identified as high risk by PCPs were 8.4 times higher than those predicted to be at low risk (95% CI 5.7-12.4, AUC 0.74) and 4.6 for RNCCs (3.4-6.2, AUC 0.67). In multivariate analysis, both PCP and RNCC prediction of high risk of death remained associated with the odds of 2-year mortality. LIMITATIONS: This study was conducted in the context of a high-risk care management program, including an initial screening process and training, both of which affect the generalizability of the results. CONCLUSION: When used in combination with a highrisk algorithm, the 2-year version of the SQ captured the majority of patients who died, demonstrating better than expected performance as a screening tool for a serious illness communication intervention in a heterogeneous primary care population.

Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study

“…Clinicians described 3 approaches to selecting patients for conversations. The first involved use of the "surprise question" [27][28][29] (e.g. would you be surprised if the patient died in the next year?)…”

Patient Identification for Serious Illness Conversations: A Scoping Review

“…Potential facilitators were described as including simple and structured screening systems [ 37 ], EHR/EMR support and reminders [ 45 ], and clinician education [ 5 , 29 ]. Tools such as the SQ were said to improve clinician buy-in and contemplation surrounding recruitment for, and conduction of, serious illness conversations [ 26 ]. With regards to barriers, several studies outlined potential discrepancies in the interpretation of identification criteria.…”

Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial

“…Poor prognosis will be defined as less than a 1 year prognosis as determined by the treating nephrologists answering ‘No’ to the Surprise Question (‘Would you be surprised if this patient died in the next 12 months?’). A ‘No’ answer to the Surprise Question has been demonstrated to be an accurate predictor of 1 year mortality in older patients with advanced CKD not on dialysis and patients with multiple comorbidities 63 68–70. Subjects aged 65–69 will require both advanced CKD and a poor prognosis while those aged 70 and older will require either advanced CKD or a poor prognosis.…”