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Mortality prediction using the 'surprise' question

A living systematic review

Short url: http://openmetaanalysis.github.io/surprise_question

Clinical summary: This meta-analysis suggests that the 'suprise question' is more accurate than chance in predicting mortality within one year. The heterogeneity is low.

Regarding overall accuracy, the area under the ROC curve for predicting death at one year was 0.823 which is higher than the multivariable predtice indices reviewed by Yourman (citation below).

The assessment of diagnostic accuracy was limited by not being well studied in primary care.

Since our review, the surprise question has been operationalized in an EHR (Musser et al, 2024. DOI: 10.1055/a-2247-9355; PMID: 38232748.)

Time-frame Sensitivity Specificity Area under the ROC curve Positive predictive value(at prevalence of 15%) 1- Negative predictive value(at prevalence of 50%)
One month (Hamano) 96 37
One year (6 studies) 74 79 0.84 40 5
Two years (Cohen) 38 91

Keep current with this topic

Methods overview: This repository is an openMetaAnalysis that updates a previously published narrative review.(1) Newer studies included are listed in the references below. Rationale for newer trials excluded may be listed at the end of the references.

Results: Details of the studies included are in the:

The forest plot for the primary outcomes are below. Additional forest plots of secondary analyses may be available.

Principle results for diagnostic accuracy

References:

Systematic review(s)

Most recent review(s) at time of last revision of this repository

  1. (did not include the 'surpirse question') Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012 Jan 11;307(2):182-92. doi: 10.1001/jama.2011.1966. PMID: 22235089; PMCID: PMC3792853.

Diagnostic tests assessments

  1. Hamano J, Morita T, Inoue S, Ikenaga M, Matsumoto Y, Sekine R, Yamaguchi T, Hirohashi T, Tajima T, Tatara R, Watanabe H, Otani H, Takigawa C, Matsuda Y, Nagaoka H, Mori M, Yamamoto N, Shimizu M, Sasara T, Kinoshita H. Surprise Questions for Survival Prediction in Patients With Advanced Cancer: A Multicenter Prospective Cohort Study. Oncologist. 2015 Jul;20(7):839-44. doi: 10.1634/theoncologist.2015-0015. PMID: 26054631
  2. Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, Salera M, Dall'Olio FG, Galli G, Biasco G; on behalf of the SUQ-P group. The 'surprise' question in advanced cancer patients: A prospective study among general practitioners. Palliat Med. 2014 Mar 24;28(7):959-964. PMID: 24662237.
  3. Da Silva Gane M, Braun A, Stott D, Wellsted D, Farrington K. How robust is the 'surprise question' in predicting short-term mortality risk in haemodialysis patients? Nephron Clin Pract. 2013;123(3-4):185-93. doi: 10.1159/000353735. Epub 2013 Aug 6. PMID: 23921223.
  4. Moss AH, Lunney JR, Culp S, Auber M, Kurian S, Rogers J, Dower J, Abraham J. Prognostic significance of the "surprise" question in cancer patients. J Palliat Med. 2010 Jul;13(7):837-40. doi: 10.1089/jpm.2010.0018. PMID: 20636154.
  5. Cohen LM, Ruthazer R, Moss AH, Germain MJ. Predicting six-month mortality for patients who are on maintenance hemodialysis. Clin J Am Soc Nephrol. 2010 Jan;5(1):72-9. doi: 10.2215/CJN.03860609. Epub 2009 Dec 3. PMID: 19965531
  6. Moss AH, Ganjoo J, Sharma S, Gansor J, Senft S, Weaner B, Dalton C, MacKay K, Pellegrino B, Anantharaman P, Schmidt R. Utility of the "surprise" question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008 Sep;3(5):1379-84. doi: 10.2215/CJN.00940208. PMID: 18596118
  7. Barnes S, Gott M, Payne S, Parker C, Seamark D, Gariballa S, Small N. Predicting mortality among a general practice-based sample of older people with heart failure. Chronic Illn. 2008 Mar;4(1):5-12. doi: 10.1177/1742395307083783. PubMed PMID: 18322025 First quantitative assessment of the surprise question

New study(s) undergoing review

  1. Feyi K, Klinger S, Pharro G, Mcnally L, James A, Gretton K, Almond MK. Predicting palliative care needs and mortality in end stage renal disease: use of an at-risk register. BMJ Support Palliat Care. 2015 Mar;5(1):19-25. doi: 10.1136/bmjspcare-2011-000165. Epub 2013 Mar 12. Erratum in: BMJ Support Palliat Care. 2015 Jun;5(2):206. PMID: 24644161.
  2. Pang WF, Kwan BC, Chow KM, Leung CB, Li PK, Szeto CC. Predicting 12-month mortality for peritoneal dialysis patients using the "surprise" question. Perit Dial Int. 2013 Jan-Feb;33(1):60-6. doi: 10.3747/pdi.2011.00204. Epub 2012 Aug 1. PMID: 22855890
  3. Javier AD, Figueroa R, Siew ED, Salat H, Morse J, Stewart TG, et al. Reliability and Utility of the Surprise Question in CKD Stages 4 to 5. Am J Kidney Dis. 2017 Feb 15. pii: S0272-6386(17)30006-9. doi: 10.1053/j.ajkd.2016.11.025. PMID: 28215946
  4. Hernández Quiles C, Bernabeu Wittel M, Praena Segovia J, Ternero Vega J, Díez Manglano J, Jarava Rol G, Ollero Baturone M. Comparison surprise question against a target index (PALIAR Index) for identifying terminal status in patients with advanced chronic disease. Rev Clin Esp. 2017 Mar;217(2):123-124. doi: 10.1016/j.rce.2016.10.014. English, Spanish. PMID: 27919418
  5. Tripp D, Janis J, Jarrett B, Lucas FL, Strout TD, Han PKJ, Stumpf I, Hutchinson RN. How Well Does the Surprise Question Predict 1-year Mortality for Patients Admitted with COPD? J Gen Intern Med. 2021 Sep;36(9):2656-2662. doi: 10.1007/s11606-020-06512-8. Epub 2021 Jan 6. PMID: 33409886.

New study(s) excluded

  1. Elliott M, Nicholson C. A qualitative study exploring use of the surprise question in the care of older people: perceptions of general practitioners and challenges for practice. BMJ Support Palliat Care. 2014 Aug 28. pii: bmjspcare-2014-000679. doi: 10.1136/bmjspcare-2014-000679. PMID: 25168076.
  2. Small N, Gardiner C, Barnes S, Gott M, Payne S, Seamark D, Halpin D. Using a prediction of death in the next 12 months as a prompt for referral to palliative care acts to the detriment of patients with heart failure and chronic obstructive pulmonary disease. Palliat Med. 2010 Oct;24(7):740-1. doi: 10.1177/0269216310375861. PMID: 20921093.
  3. Rhee J, Clayton JM. The 'surprise' question may improve the accuracy of GPs in identifying death in patients with advanced stage IV solid-cell cancer. Evid Based Med. 2015 Apr;20(2):71. doi: 10.1136/ebmed-2014-110114. PMID: 25732563.
  4. Hubbard G. The 'surprise question' in end-of-life care. Br J Community Nurs. 2011 Mar;16(3):109. PMID: 21378648.
  5. Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ. 2002 Oct 26;325(7370):929. PMID: 12399341 Early conceptualization of the surpirse question, but no data provided
  6. Pattison M, Romer AL. Improving Care Through the End of Life: launching a primary care clinic-based program. J Palliat Med. 2001 Summer;4(2):249-54. PubMed PMID: 11441634 Initial conceptualization of the surpirse question, but no data provided
  7. Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J. Evaluation of prognostic criteria for determining ice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA. 1999 PMID: 10553790

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