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    Original Investigation
    Emergency Medicine
    September 13, 2019

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

    Author Affiliations
    • 1Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
    • 3Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts
    • 4Department of Emergency Medicine, Maine Medical Center, Portland, Maine
    • 5Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 6Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
    • 7Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 8Department of Medicine, University of California, San Francisco
    • 9Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
    • 10Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 11Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
    JAMA Netw Open. 2019;2(9):e1911139. doi:10.1001/jamanetworkopen.2019.11139
    Key Points español 中文 (chinese)

    Question  What is the association of emergency clinicians’ assessment of mortality risk with the actual 1-month mortality among older adults who are admitted to the hospital from the emergency department?

    Findings  In this prospective cohort study including 10 737 older adults who visited the emergency department, emergency clinicians’ response of no to the question, “Would you be surprised if your patient died in the next one month?” was associated with 1-month mortality after controlling for confounders. However, the diagnostic test characteristics of the surprise question were poor.

    Meaning  Asking emergency clinicians the surprise question may be a valuable tool to identify older patients in the ED with high risk of 1-month mortality.

    Abstract

    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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