Tufts University School of Medicine, Boston, MA, USA.
Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.
J Gen Intern Med. 2021 Sep;36(9):2656-2662. doi: 10.1007/s11606-020-06512-8. Epub 2021 Jan 6.
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.
To assess how well the SQ predicts mortality and prompts ACP for COPD patients.
Retrospective cohort study.
Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.
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-of-care conversation, change in code status, or completion of ACP document).
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, 95% CI 1.64-4.36).
The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.
慢性阻塞性肺疾病（COPD）患者在生命末期（EOL）经常接受负担沉重的护理，并且很少完成预先护理计划（ACP）。意外问题（SQ）是一种预测工具，可以促进 ACP。
评估 SQ 预测 COPD 患者死亡率和提示 ACP 的能力。
回顾性队列研究。
2015 年 7 月至 2018 年 9 月期间因 COPD 急性加重而住院的患者。
急诊科（ED）和住院医生回答“如果这个患者在接下来的 30 天（ED）/1 年（住院）内死亡，你会感到惊讶吗？”主要结局指标是 SQ 预测 30 天和 1 年死亡率的准确性。次要结局是 SQ 与 ACP（姑息治疗咨询、记录的目标治疗对话、改变代码状态或完成 ACP 文档）之间的相关性。
30 天 SQ 对预测 30 天死亡率具有高特异性但低敏感性：敏感性 12%，特异性 95%，PPV 11%，NPV 96%。1 年 SQ 对预测 1 年死亡率的准确性更好：敏感性 47%，特异性 75%，PPV 35%，NPV 83%。在调整年龄、性别和前 6 个月入院后，1 年 SQ+应答与 1 年死亡率的更高几率相关（OR 2.38，95%CI 1.39-4.08），而 SQ-则相反。1 年 SQ+患者更有可能进行目标治疗对话（25%对 11%，p < 0.01），并完成预先指示或 POLST（46%对 23%，p < 0.01）。在多变量调整后，1 年 SQ 的 SQ+应答与 ACP 接受的更高几率相关（OR 2.67，95%CI 1.64-4.36）。
1 年意外问题可能是 COPD 患者住院期间预测和预先护理计划的有效组成部分。
