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Meta-Analysis
. 2022 Jul;36(7):1023-1046.
doi: 10.1177/02692163221099116.

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

Eline Vtj van Lummel  1   2 , Larissa Ietswaard  2 , Nicolaas Pa Zuithoff  2 , Dave Ht Tjan  1 , Johannes Jm van Delden  2
Affiliations
Meta-Analysis

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

Eline Vtj van Lummel et al. Palliat Med. 2022 Jul.

Erratum in

  • Corrigendum.
    [No authors listed] [No authors listed] Palliat Med. 2022 Jul;36(7):NP1. doi: 10.1177/02692163221121217. Epub 2022 Sep 6. Palliat Med. 2022. PMID: 36068701 Free PMC article. No abstract available.

Abstract

Background: The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights.

Aim: To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional.

Design: Systematic review and meta-analysis.

Data sources: Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated.

Results: Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question.

Conclusion: We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.

Keywords: Surprise question; advance care planning; meta-analysis; palliative care; systematic review.

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Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
PRISMA flow diagram of screening process.
Figure 2.
Figure 2.
Forest plots for sensitivity.
Figure 3.
Figure 3.
Forest plots for specificity.
Figure 4.
Figure 4.
Forest plots showing PPV for various mortality rates (5%, 10% and 25%).
Figure 5.
Figure 5.
Forest plots showing NPV for various mortality rates (5%, 10% and 25%).
Appendix 5.
Appendix 5.
Forest plot of the sensitivity of individual studies.
Appendix 6.
Appendix 6.
Forest plot of the specificity of individual studies.
See this image and copyright information in PMC

References

    1. WHO. Palliative care, https://www.who.int/health-topics/palliative-care (accessed 18 May 2021).
    1. Lynn J, Schall MW, Milne C, et al. Quality improvements in end of life care: insights from two collaboratives. Jt Comm J Qual Improv 2000; 26: 254–267. - PubMed
    1. Downar J, Goldman R, Pinto R, et al. The ‘surprise question’ for predicting death in seriously ill patients: a systematic review and meta-analysis. CMAJ 2017; 189: E484–E493. - PMC - PubMed
    1. White N, Kupeli N, Vickerstaff V, et al. How accurate is the ‘Surprise Question’ at identifying patients at the end of life? A systematic review and meta-analysis. BMC Med 2017; 15(1): 139. - PMC - PubMed
    1. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6(7): e1000097. - PMC - PubMed