Validation of the "surprise question" in gynecologic oncology: Comparing physicians, advanced practice providers and nurses.

Abstract

151 Background: The “surprise question” – “Would you be surprised if this patient died in the next year?” has been validated in non-gynecologic cancer as highly predictive of 12-month mortality. It has been used as a major inclusion criterion in studies showing benefit to specialized palliative care. It has not been studied in the gynecologic oncology (GO) population or with non-physician providers. Our objectives were to (1) evaluate the prognostic significance of the surprise question in GO patients and (2) compare the performance of the surprise question among different provider groups. Methods: The surprise question was asked of a group of 18 GO providers from a single academic institution (7 physicians, 7 advanced practice providers (APP) and 4 chemotherapy nurses (RN)) regarding their patients currently receiving radiation or chemotherapy. Demographic and clinical data were abstracted from chart review and mortality data was collected 12 months later. Results: The 263 patients included had a median age of 64 and the majority were white (94%). The most common cancer was ovary (50%), 58% had stage III/IV disease and 46% had recurrent disease. There were 54 deaths (20.5% one-year mortality). Risk of mortality was significantly higher for patients with a response of “No” to the surprise question from the MD (40% vs 10.6%, p < 0.01), APP (43.2% vs 7.6%, p < 0.01) and RN (50.8% vs 13.1%, p < 0.01). The unadjusted odds ratio for death within a year associated with a “No” answer to the surprise question by provider were as follows: MD OR 5.6 (p < 0.001), APP 9.21 (p < 0.001), RN 6.86 (p < 0.001). The APP group had the highest sensitivity (79.5%), while the RN group had the best specificity (75.6%). Conclusions: The surprise question is a simple, feasible and effective tool to identify patients with gynecologic cancer who have a greatly increased risk of 12-month morality when administered by physicians, advanced practice providers or chemotherapy nurses. This one question screen could be used to identify patients appropriate for early referral to specialized palliative care or patients in whom to consider initiating conversations about goals of care and advanced care planning.