Performance of the Surprise Question Compared to Prediction Models in Hemodialysis Patients: A Prospective Study

Abstract

Background: The surprise question (SQ) (“Would you be surprised if this patient were still alive in 6 or 12 months?”) is used as a mortality prognostication tool in hemodialysis (HD) patients. We compared the performance of the SQ with that of prediction models (PMs) for 6- and 12-month mortality prediction. Methods: Demographic, clinical, laboratory, and dialysis treatment indicators were used to model 6- and 12-month mortality probability in a HD patients training cohort (n = 6,633) using generalized linear models (GLMs). A total of 10 nephrologists from 5 HD clinics responded to the SQ in 215 patients followed prospectively for 12 months. The performance of PM was evaluated in the validation (n = 6,634) and SQ cohorts (n = 215) using the areas under receiver operating characteristics curves. We compared sensitivities and specificities of PM and SQ. Results: The PM and SQ cohorts comprised 13,267 (mean age 61 years, 55% men, 54% whites) and 215 (mean age 62 years, 59% men, 50% whites) patients, respectively. During the 12-month follow-up, 1,313 patients died in the prediction model cohort and 22 in the SQ cohort. For 6-month mortality prediction, the GLM had areas under the curve of 0.77 in the validation cohort and 0.77 in the SQ cohort. As for 12-month mortality, areas under the curve were 0.77 and 0.80 in the validation and SQ cohorts, respectively. The 6- and 12-month PMs had sensitivities of 0.62 (95% CI 0.35–0.88) and 0.75 (95% CI 0.56–0.94), respectively. The 6- and 12-month SQ sensitivities were 0.23 (95% CI 0.002–0.46) and 0.35 (95% CI 0.14–0.56), respectively. Conclusion: PMs exhibit superior sensitivity compared to the SQ for mortality prognostication in HD patients.

Predicting one‐year mortality in heart failure using the ‘Surprise Question’: a prospective pilot study

“…The Surprise Question has been validated in patients with cancer and in those with and without dialysis‐dependent chronic kidney disease in whom it reliably and accurately predicts survival . Although decompensation of heart failure requiring hospitalisation is a poor prognostic sign, many patients subsequently have long periods of relative stability, and it is this characteristic non‐linear trajectory of heart failure which casts doubt as to whether the Surprise Question is an appropriate tool.…”

Usability of the Surprise Question by Nurses and Patients’ Families for Risk Stratification in Emergency Patients: A Prospective Cohort Study

“…The discrimination in our study (area under the curve: 0.62) is generally weaker than in other studies. 12 , 20 , 35 , 36 However, a previous study also found lower discriminatory values for endpoints other than mortality. 30 Another study about the Surprise Question conducted at the emergency department measured acute morbidity as the endpoint and also resulted in a lower area under the curve for nurses (0.68) and patients (0.54), similar to our results.…”

The EPICTER score: a bedside and easy tool to predict mortality at 6 months in acute heart failure

“…Our study also included a survival rate of fewer than 6 months estimated by the doctor treating the patient. In spite of the fact that it is a subjective variable, its usefulness as a screening tool to identify patients at the end of life has been proven in cancer 28 and chronic kidney disease 29 . Recent studies 30,31 have also shown the validity of the Surprise Question (‘Would you be surprised if your patient died within 1 year?’) in predicting mortality in HF.…”

“…In spite of the fact that it is a subjective variable, its usefulness as a screening tool to identify patients at the end of life has been proven in cancer 28 and chronic kidney disease. 29 Recent studies 30 , 31 have also shown the validity of the Surprise Question (‘Would you be surprised if your patient died within 1 year?’) in predicting mortality in HF. Surprisingly, the intuitive prediction of physicians in our score turned out to be the strongest predictor along with the age over 85 years.…”