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

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): “Would you be surprised if this patient died in the next 2 years?” Measurements 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 high-risk 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.