Accuracy of the Surprise Question on Patients with Advanced Chronic Disease in the Primary Care Setting: Preliminary Results

Dear Editor:

The need to identify patients with palliative care needs has resulted in the development of many tools. The surprise question (SQ) “Would you be surprised if this patient were to die in the next year?” was tested in several contexts with good results. ¹ However, a systematic review and meta-analyses ² takes a less enthusiast conclusion. It states that the SQ performs poor to modestly and that other tools are warranted.

Portugal's reform and expansion of its palliative care network increase the need of simple and effective referral instruments. There are no studies in Portugal regarding the accuracy of the SQ and its Portuguese translation and validation have been reported elsewhere. ³

General practitioners (GPs) provide first line longitudinal care for both acute and chronic health conditions. They remain with the same group of patients through many years, giving them a profound knowledge of their patients. The Portuguese General Practitioner Sentinel Network (PGPSN) is an organization composed of GPs nationwide, who gather systematic data for epidemiological surveillance and research.

We designed a pragmatic follow-up study, aimed to measure the accuracy of the SQ at 6 and 12 months of follow-up, when applied by GPs to patients with (1) solid cancer, stage IV; (2) congestive heart failure (CHF) NYHA stages III/IV; (3) chronic kidney disease (CKD), stages IV/V; and (4) chronic obstructive pulmonary disease (COPD), stages III/IV. This study was approved by the Ethics Committee of the Faculty of Medicine of the University of Lisbon and by the Ethics Committee of the National Health Institute Dr. Ricardo Jorge.

We invited all members of the PGPSN to participate. To increase our sample, we also invited several GPs from our contacts list. All participant GPs were asked to select patients from their patient's list that fulfilled the inclusion criteria, from January to April 2017.

At the beginning of the study, participant GPs answered the SQ at 6 and 12 months for every patient, along with reporting their demographics and chronic conditions. This letter is the interim analysis after six months of follow-up. Our sample is composed of 22 GPs, 4 of whom are male, with an average age of 43 years (standard deviation [SD] = 13) and 59% have had some form of palliative care training. A total of 209 patients were included, 54% of whom were male, with an average age 72.6 years (SD = 12.7); 34% suffered from cancer, 33% from CHF, 20% from CKD, and 16% from COPD. Of these, 37% had a “not surprised” response to the SQ at six months. We obtained follow-up information from 96% (n = 201) of patients. Results regarding the accuracy of the SQ are listed in Table 1.

The positive predictive value 29.9% and negative predictive value 89.5% highlight the fact that the SQ at six months is not an accurate tool. Despite some methodologic limitations and small sample, this study adds important preliminary results to the body of literature regarding referral tools to identify patients with palliative care needs. Our group will continue this research to publish the final results after the 12-month follow-up completion.