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Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital

IMPORTANCE: The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. OBJECTIVE: To determine the association of the question, “Would you be surprised if your patient died in the next one month?” (known as the surprise question) asked...

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Autores principales: Ouchi, Kei, Strout, Tania, Haydar, Samir, Baker, Olesya, Wang, Wei, Bernacki, Rachelle, Sudore, Rebecca, Schuur, Jeremiah D., Schonberg, Mara A., Block, Susan D., Tulsky, James A.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745053/
https://www.ncbi.nlm.nih.gov/pubmed/31517962
http://dx.doi.org/10.1001/jamanetworkopen.2019.11139
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author Ouchi, Kei
Strout, Tania
Haydar, Samir
Baker, Olesya
Wang, Wei
Bernacki, Rachelle
Sudore, Rebecca
Schuur, Jeremiah D.
Schonberg, Mara A.
Block, Susan D.
Tulsky, James A.
author_facet Ouchi, Kei
Strout, Tania
Haydar, Samir
Baker, Olesya
Wang, Wei
Bernacki, Rachelle
Sudore, Rebecca
Schuur, Jeremiah D.
Schonberg, Mara A.
Block, Susan D.
Tulsky, James A.
author_sort Ouchi, Kei
collection PubMed
description IMPORTANCE: The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. OBJECTIVE: To determine the association of the question, “Would you be surprised if your patient died in the next one month?” (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. EXPOSURES: Treating emergency clinicians were required to answer the surprise question, “Would you be surprised if your patient died in the next one month?” in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. MAIN OUTCOMES AND MEASURES: The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. RESULTS: The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). CONCLUSIONS AND RELEVANCE: This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.
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spelling pubmed-67450532019-09-27 Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital Ouchi, Kei Strout, Tania Haydar, Samir Baker, Olesya Wang, Wei Bernacki, Rachelle Sudore, Rebecca Schuur, Jeremiah D. Schonberg, Mara A. Block, Susan D. Tulsky, James A. JAMA Netw Open Original Investigation IMPORTANCE: The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. OBJECTIVE: To determine the association of the question, “Would you be surprised if your patient died in the next one month?” (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. EXPOSURES: Treating emergency clinicians were required to answer the surprise question, “Would you be surprised if your patient died in the next one month?” in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. MAIN OUTCOMES AND MEASURES: The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. RESULTS: The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). CONCLUSIONS AND RELEVANCE: This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen. American Medical Association 2019-09-13 /pmc/articles/PMC6745053/ /pubmed/31517962 http://dx.doi.org/10.1001/jamanetworkopen.2019.11139 Text en Copyright 2019 Ouchi K et al. JAMA Network Open. http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Ouchi, Kei
Strout, Tania
Haydar, Samir
Baker, Olesya
Wang, Wei
Bernacki, Rachelle
Sudore, Rebecca
Schuur, Jeremiah D.
Schonberg, Mara A.
Block, Susan D.
Tulsky, James A.
Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title_full Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title_fullStr Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title_full_unstemmed Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title_short Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital
title_sort association of emergency clinicians' assessment of mortality risk with actual 1-month mortality among older adults admitted to the hospital
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745053/
https://www.ncbi.nlm.nih.gov/pubmed/31517962
http://dx.doi.org/10.1001/jamanetworkopen.2019.11139
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