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Gupta A, Burgess R, Drozd M, Gierula J, Witte K, Straw S. The Surprise Question and clinician-predicted prognosis: systematic review and meta-analysis. BMJ Support Palliat Care 2024:spcare-2024-004879. [PMID: 38925876 DOI: 10.1136/spcare-2024-004879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The Surprise Question, 'Would you be surprised if this person died within the next year?' is a simple tool that can be used by clinicians to identify people within the last year of life. This review aimed to determine the accuracy of this assessment, across different healthcare settings, specialties, follow-up periods and respondents. METHODS Searches were conducted of Medline, Embase, AMED, PubMed and the Cochrane Central Register of Controlled Trials, from inception until 01 January 2024. Studies were included if they reported original data on the ability of the Surprise Question to predict survival. For each study (including subgroups), sensitivity, specificity, positive and negative predictive values and accuracy were determined. RESULTS Our dataset comprised 56 distinct cohorts, including 68 829 patients. In a pooled analysis, the sensitivity of the Surprise Question was 0.69 ((0.64 to 0.74) I2=97.2%), specificity 0.69 ((0.63 to 0.74) I2=99.7%), positive predictive value 0.40 ((0.35 to 0.45) I2=99.4%), negative predictive value 0.89 ((0.87 to 0.91) I2=99.7%) and accuracy 0.71 ((0.68 to 0.75) I2=99.3%). The prompt performed best in populations with high event rates, shorter timeframes and when posed to more experienced respondents. CONCLUSIONS The Surprise Question demonstrated modest accuracy with considerable heterogeneity across the population to which it was applied and to whom it was posed. Prospective studies should test whether the prompt can facilitate timely access to palliative care services, as originally envisioned. PROSPERO REGISTRATION NUMBER CRD32022298236.
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Affiliation(s)
- Ankit Gupta
- Leeds Institute of Medical Education, University of Leeds, Leeds, UK
| | | | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Wallin JM, Jacobson SH, Axelsson L, Lindberg J, Persson CI, Stenberg J, Wennman-Larsen A. Discrepancy in responses to the surprise question between hemodialysis nurses and physicians, with focus on patient clinical characteristics: A comparative study. Hemodial Int 2023; 27:454-464. [PMID: 37318069 DOI: 10.1111/hdi.13103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The surprise question (SQ) "Would I be surprised if this patient died within the next xx months" can be used by different professions to foresee the need of serious illness conversations in patients approaching end of life. However, little is known about the different perspectives of nurses and physicians in responses to the SQ and factors influencing their appraisals. The aim was to explore nurses' and physicians' responses to the SQ regarding patients on hemodialysis, and to investigate how these answers were associated with patient clinical characteristics. METHODS This comparative cross-sectional study included 361 patients for whom 112 nurses and 15 physicians responded to the SQ regarding 6 and 12 months. Patient characteristics, performance status, and comorbidities were obtained. Cohen's kappa was used to analyze the interrater agreement between nurses and physicians in their responses to the SQ and multivariable logistic regression was applied to reveal the independent association to patient clinical characteristics. FINDINGS Proportions of nurses and physicians responding to the SQ with "no, not surprised" was similar regarding 6 and 12 months. However, there was a substantial difference concerning which specific patient the nurses and physicians responded "no, not surprised", within 6 (κ = 0.366, p < 0.001, 95% CI = 0.288-0.474) and 12 months (κ = 0.379, p < 0.001, 95% CI = 0.281-0.477). There were also differences in the patient clinical characteristics associated with nurses' and physicians' responses to the SQ. DISCUSSION Nurses and physicians have different perspectives in their appraisal when responding to the SQ for patients on hemodialysis. This may reinforce the need for communication and discussion between nurses and physicians to identify the need of serious illness conversations in patients approaching the end of life, in order to adapt hemodialysis care to patient preferences and needs.
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Affiliation(s)
- Jeanette M Wallin
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lena Axelsson
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
| | - Jenny Lindberg
- Department of Clinical Sciences, Unit of Medical Ethics, Lund University, Lund, Sweden
| | - Carina I Persson
- Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
| | - Jenny Stenberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Agneta Wennman-Larsen
- Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Romero‐Correa M, Salamanca‐Bautista P, Bilbao‐González A, Quirós‐López R, Nieto‐Martín MD, Martín‐Jiménez ML, Morales‐Rull JL, Quiles‐García D, Gómez‐Gigirey A, Formiga F, Aramburu‐Bodas Ó, Arias‐Jiménez JL, Choucino‐Fernández T, Porto‐Pérez A, Piñeiro‐Parga P, Pedrosa‐Fraga C, Suárez‐Gil R, González‐Soler J, López‐Mato P, Latorre‐Díez A, Ferreira‐González L, Sánchez‐Cembellin M, Gallego‐Villalobos M, Rugeles‐Niño J, Rodríguez‐Avila E, González‐Franco A, Guerra‐Acebal C, Sebastián‐Leza A, Monte‐Armenteros J, Frutos‐Muñoyerro G, Clemente‐Sarasa C, Díez‐Manglano J, Josa‐Laorden C, Torres‐Courchoud I, Gómez‐Aguirre N, Jordana‐Camajuncosa R, Cajamarca‐Calva L, Torrente‐Jiménez I, Serrado‐Iglesias A, Ceresuela L, Salas‐Campos R, Delás‐Amat J, Brasé‐Arnau A, Petit‐Salas I, Romaní‐Costa V, Expósito‐López A, Sabbagh‐Fajardo C, Recio‐Iglesias J, Alemán‐Llansó C, Suriñach‐Caralt J, Trullás‐Vila J, Armengou‐Arxe A, García‐Torras S, Solé‐Felip C, Lacal‐Martínez A, Otero‐Soler M, Muela‐Molinero A, Carrera‐Izquierdo M, Arribas‐Arribas P, Inglada‐Galiana L, Ruiz ‐de Temiño Á, Silva‐Vázquez Á, Fuentes‐Pardo L, García‐García M, Piniella‐Ruiz E, Pérez‐Alves B, Gonzalo‐Pascua S, Marrero‐Francés J, Méndez‐Bailón M, Martín‐Sánchez F, Varas‐Mayoral M, Asenjo‐Martínez M, Yebra‐Yebra M, Sánchez‐Sauce B, Herreros B, Quesada‐Simón A, Vives‐Beltrán I, Álvarez‐Troncoso J, Martínez‐Marín L, Martínez PG, Mayorga ED, Moreno‐Palanco M, Soler‐Rangel L, Abellán‐Martínez J, Colás‐Herrera A, López‐Castellanos G, Ruíz‐Ortega R, Ruiz‐Barraza E, Montero‐Hernández E, Arévalo‐Lorido J, Carretero‐Gómez J, Calderón‐Jiménez P, Herrero‐Domingo A, Martín‐Barba S, Blázquez‐Encinar J, Jiménez‐Guardiola C, Cepeda‐Rodrigo J, Carrascosa‐García S, Llacer‐Iborra P, Moreno‐García M, Díez‐García L, Sánchez‐López P, Martínez‐Soriano M, Menor E, Montero‐Pérez‐Barquero M, Anguita‐Sánchez M, Sánchez‐Moruno M, Fuentes‐Espínola M, Zambrana‐García J, Guisado‐Espartero E, Mejías‐Real I, Alcalá‐Pedrajas J, Carrasco‐Sánchez F, Díaz‐Pérez C, Guzmán‐García M, Domingo‐Roa S, Cortés‐Rodríguez B, García‐Redecillas C, Martín‐Navarro R, Macías‐Ávila P, Antequera‐Martín‐Portugués I, Blanco‐Soto M, Flores‐Álvarez F, Aparicio‐Santos R, García‐Serrano R, Jiménez‐de‐Juan C, Ternero‐Vega J, Villalonga‐Comas M, Díaz‐Cañestro M, Asensio‐Rodríguez J, Gil‐Díaz A, Marrero‐Medina I, Puente‐Fernández A, Gudiño‐Aguirre D, Dávila‐Ramos M, Calderón E, Fernández‐Martínez J, Vázquez‐Rodríguez P, Conde‐Martel A, García‐García J, Páez‐Rubio I, López‐Reboiro M, Sánchez‐Sánchez C. The EPICTER score: a bedside and easy tool to predict mortality at 6 months in acute heart failure. ESC Heart Fail 2022. [PMCID: PMC9288794 DOI: 10.1002/ehf2.13924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims Estimating the prognosis in heart failure (HF) is important to decide when to refer to palliative care (PC). Our objective was to develop a tool to identify the probability of death within 6 months in patients admitted with acute HF. Methods and results A total of 2848 patients admitted with HF in 74 Spanish hospitals were prospectively included and followed for 6 months. Each factor independently associated with death in the derivation cohort (60% of the sample) was assigned a prognostic weight, and a risk score was calculated. The accuracy of the score was verified in the validation cohort. The characteristics of the population were as follows: advanced age (mean 78 years), equal representation of men and women, significant comorbidity, and predominance of HF with preserved ejection fraction. During follow‐up, 753 patients (26%) died. Seven independent predictors of mortality were identified: age, chronic obstructive pulmonary disease, cognitive impairment, New York Heart Association class III–IV, chronic kidney disease, estimated survival of the patient less than 6 months, and acceptance of a palliative approach by the family or the patient. The area under the ROC curve for 6 month death was 0.74 for the derivation and 0.68 for the validation cohort. The model showed good calibration (Hosmer and Lemeshow test, P value 0.11). The 6 month death rates in the score groups ranged from 6% (low risk) to 54% (very high risk). Conclusions The EPICTER score, developed from a prospective and unselected cohort, is a bedside and easy‐to‐use tool that could help to identify high‐risk patients requiring PC.
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Affiliation(s)
| | - Prado Salamanca‐Bautista
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
| | - Amaia Bilbao‐González
- Osakidetza Basque Health Service, Research Unit Basurto University Hospital Bilbao Spain
- Health Service Research Network on Chronic Diseases (REDISSEC) Barakaldo Spain
- Kronikgune Institute for Health Services Research Barakaldo Spain
| | | | | | | | | | - Dolores Quiles‐García
- Internal Medicine Department Hospital Universitario General de Valencia Valencia Spain
| | | | - Francesc Formiga
- Internal Medicine Department Hospital Universitari de Bellvitge Barcelona Spain
| | - Óscar Aramburu‐Bodas
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
| | - José Luis Arias‐Jiménez
- Internal Medicine Department Hospital Universitario Virgen Macarena Seville Spain
- University of Seville Seville Spain
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Maes H, Van Den Noortgate N, De Brauwer I, Velghe A, Desmedt M, De Saint-Hubert M, Piers R. Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units. Acta Clin Belg 2022; 77:286-294. [PMID: 33044915 DOI: 10.1080/17843286.2020.1829869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the prognostic value of the Surprise Question (SQ) in older persons. METHODS A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model. RESULTS The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward. CONCLUSION The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.
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Affiliation(s)
- Hanne Maes
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Isabelle De Brauwer
- Geriatric Medicine, Saint Luc UCLouvain, Bruxelles, Belgium
- Geriatric Medicine, CHU-UCL Namur, Belgium
| | - Anja Velghe
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Ruth Piers
- Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Lai CF, Cheng CI, Chang CH, Chen YT, Hwang HC, Lin SL, Huang JW, Huang SJ. Integrating the Surprise Question, Palliative Care Screening Tool, and Clinical Risk Models to Identify Peritoneal Dialysis Patients With High One-Year Mortality. J Pain Symptom Manage 2020; 60:613-621.e6. [PMID: 32278098 DOI: 10.1016/j.jpainsymman.2020.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
CONTEXT Universal screening to identify vulnerable patients who may receive limited benefits from life-sustaining treatments can facilitate palliative care in dialysis populations. OBJECTIVES We aimed to develop prediction models for one-year mortality in peritoneal dialysis (PD) patients. METHODS This prospective cohort study included 401 adult Taiwanese prevalent PD patients (average age 56.2 ± 14 years). In addition to obtaining clinical characteristics and laboratory data, the primary care nurses evaluated the surprise question (SQ) and palliative care screening tool (PCST) for each patient in March 2015. Multivariate logistic regression models were conducted to predict the primary outcome of one-year all-cause mortality. RESULTS There were 34 (8.5%) patients who died during the first year of follow-up. Patients allocated to the not surprised group according to the SQ and those who received a score of ≥4 on the PCST had increased odds of death (odds ratio 24.68 [95% CI 10.66-57.13] and 12.18 [95% CI 5.66-26.21], respectively). We also developed a clinical risk model for one-year mortality that included sex, dialysis vintage, coronary artery disease, malignancy, normalized protein nitrogen appearance, white blood cell count, and serum albumin and sodium levels. Integrating the SQ, PCST, and clinical risk model exhibited good discrimination with an area under the receiver operating characteristic curve of 0.95. Kaplan-Meier analysis showed worse survival in high-risk patients predicted by the integrated model (log-rank P < 0.001). CONCLUSION Screening with the use of the integrated measurement can identify high-risk PD patients. This approach may facilitate palliative care interventions for at-risk subpopulations.
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Affiliation(s)
- Chun-Fu Lai
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-I Cheng
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ting Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiau-Chien Hwang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuei-Liong Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jenq-Wen Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Sheng-Jean Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Taipei City Hospital, Taipei, Taiwan
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Straw S, Byrom R, Gierula J, Paton MF, Koshy A, Cubbon R, Drozd M, Kearney M, Witte KK. Predicting one-year mortality in heart failure using the 'Surprise Question': a prospective pilot study. Eur J Heart Fail 2018; 21:227-234. [PMID: 30548129 DOI: 10.1002/ejhf.1353] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/19/2018] [Accepted: 10/05/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Surprise Question: 'would you be surprised if this patient were to die within the next year?' has been shown to predict mortality in patients with chronic kidney disease and cancer. This prospective study aimed to determine whether the Surprise Question could identify heart failure patients with a prognosis of less than 1 year, and whether the Surprise Question can be used by different healthcare professionals. METHODS AND RESULTS Overall, 129 consecutive patients admitted with decompensated heart failure were included. Doctors and nurses were asked to provide a 'surprised' or 'not surprised' response to the Surprise Question for each patient. Patients were followed up until death or 1 year following study inclusion. The sensitivity, specificity, positive predictive value and negative predictive value of the Surprise Question were assessed. Cox regression was used to determine covariates significantly associated with survival. The Surprise Question showed excellent sensitivity (0.85) and negative predictive value (0.88) but only fair specificity (0.59) and positive predictive value (0.52) when asked of cardiologists. There were similar levels of accuracy between doctors and specialist nurses. The Surprise Question was significantly associated with all-cause mortality in multivariate regression analysis (hazard ratio 2.8, 95% confidence interval 1.0-7.9, P = 0.046). CONCLUSION This study demonstrates that the Surprise Question can identify heart failure patients within the last year of life. Despite over-classification of patients into the 'not surprised' category, the Surprise Question identified nearly all patients who were within the last year of life, whilst also accurately identifying those unlikely to die.
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Affiliation(s)
- Sam Straw
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Aaron Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Ebke M, Koch A, Dillen K, Becker I, Voltz R, Golla H. The "Surprise Question" in Neurorehabilitation-Prognosis Estimation by Neurologist and Palliative Care Physician; a Longitudinal, Prospective, Observational Study. Front Neurol 2018; 9:792. [PMID: 30319526 PMCID: PMC6165871 DOI: 10.3389/fneur.2018.00792] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022] Open
Abstract
Background: The 12-months “surprise” question (12-SQ) for estimating prognosis and the need for integrating palliative care (PC) services has not yet been investigated for neurological patients. Objective: Test the value of the 12-SQ on a sample of neurorehabilitation patients. Methods: All patients newly registered in the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic (8/2016-03/2017) were asked to participate. The treating neurorehabilitation physicians (NP) and an external consulting PC physician (PCP) independently estimated patients' prognosis using the 12-SQ; while symptom burden was independently assessed using the standardized palliative outcome measurement HOPE-SP-CL, a set of additional neurological issues, and ECOG. Follow-up with consenting patients 12 months later was via telephone. Descriptive and inferential statistics were utilized in data analysis. Results: Of 634 patients, 279 (44%) patients (male: 57.7%, female: 42.3%; mean age: 63 ± 14) (or, alternatively, their legal representative) consented and were assessed at baseline. Per patient NP and PCP both answered the 12-SQ with “Yes” (164), with “No” (42), or had different opinions (73). The “No” group displayed the highest symptom burden on all three measures for both disciplines. Overall, PCP scored higher (i.e., worse) than NP on all measures used. Follow-up was possible for 236 (drop-out: 15.4%) patients (deceased: 34 (14.4%), alive: 202 (85.6%)). Baseline scores on all measures were higher for deceased patients compared to those still living. Prognostic characteristics were: sensitivity: NP 50%, PCP 67.6%; specificity: NP 86.1%, PCP 70.3%, p < 0.001; positive predictive value: NP 37.8%, PCP 27.7%; negative predictive value: NP 91.1%, PCP 92.8%; area under the curve: NP 0.68, PCP 0.69; success rate: NP 80.9%, PCP 69.9%, p = 0.002. Regression analysis indicated that age, dysphagia and overburdening of family (NP answering the 12-SQ), dysphagia and rehabilitation phase (PCP answering the 12-SQ) were associated with increased likelihood of dying within 12 months. Without the 12-SQ as relevant predictor, age, dysphagia and ECOG were significant predictors (NP and PCP). Conclusion: Combining the 12-SQ with a measurement assessing PC and neurological issues could potentially improve the 12-SQ's predictive performance of 12-month survival and help to identify when to initiate the PC approach. Clinical experiences influence assessment and prognosis estimation.
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Affiliation(s)
- Markus Ebke
- Neurological Centre for Rehabilitation-MEDIAN-Clinics, Bad Salzuflen, Germany.,Dr. Becker Rhein Sieg Clinic, Nümbrecht, Germany
| | - Andreas Koch
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Kim Dillen
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany.,Center for Integrated Oncology Cologne/Bonn, Cologne, Germany.,Center for Clinical Trials, University of Cologne, Cologne, Germany.,Medical Faculty, Center for Health Services Research (ZVFK), University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany.,Center for Integrated Oncology Cologne/Bonn, Cologne, Germany
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