8 th World Research Congress of the European Association for Palliative Care

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1 Centro Interdipartimentale di Ricerche sul Cancro «Giorgio Prodi» Is the surprise question a useful trigger to predict those advanced cancer patients who could benefit from early palliative care? A prospective study among general practitioners. Giulia Galli 8 th World Research Congress of the European Association for Palliative Care Lleida, 5 7 June 2014 The Academy of Sciences of Palliative Medicine is coordinated by the Isabella Seràgnoli Foundation Bologna

2 WOULD YOU BE SURPRISED IF THIS PATIENT DIED WITHIN A YEAR? WOULD YOU BE THE SURPRISE SURPRISED IF THIS QUESTION PATIENT DIED WITHIN A YEAR? Della Penna R. Asking the right question, J Pall Med 2001 GSF Prognostic Indicator Guidance, Version 4, 2011

3 METHODS 2 METHODS 1 Design: Prospective cohort study Aim of the study: assessment of the reliability of the fase 1: clinical assessment of patients and answer to the SQ GP s answer to the 1 year surprise question. THE STUDY fase 2: patients status at 12 month interval Statistical Subjectsanalysis: of the study: 50 randomly selected general practitioners METHODS from the Bologna area in Comparison of variables in the two groups: Fisher s Test and t test; Italy. Sensitivity, specificity, PPV and NPV of the answer given to the SQ; MCC; Patients 1 year who survival were curves: cared Kaplan Meier by the method; GP and who had advanced stage cancer (stage IV), excluding those Determination of the prognostic factors influencing the risk of death at 1 with onco-haematological disorders. year: univariate and multivariate Cox proportional hazard regression models; Measurement of the risk of death at 1 year for the SQ s answer: odds ratio (OR).

4 Patients Mean age (years±se) All (N = 231) Yes (N = 105) No (N = 126) The Surprise Question RESULTS 1 DEMOGRAPHICS AND CANCER SITE OF PATIENTS THE STUDY P value 70.2 (0.9) 69.5 (1.3) 70.7 (1.2) 0.47 Men, n (%) 117 (50.6) 57 (54.3) 60 (47.6) 0.36 RESULTS Cancer, n (%) Lung 47 (20) 16 (15) 31 (25) Breast 46 (20) 28 (27) 18 (14) Colon 33 (14) 17 (16) 16 (13) Prostate 18 (8) 13 (12) 5 (4) Pancreas 15 (6) 2 (2) 13 (10) Ovary Uterus 15 (6) 6 (6) 9 (7) Other sites 57 (25) 23 (22) 34 (27) Moroni M et al, Palliat Med, March 2014

5 RESULTS 2 RESULTS 3 DAYS OF SURVIVAL IN 1 YEAR FOR YES AND NO GROUPS 100 SURPRISE QUESTION (231 evaluable cases) Yes SURVIVAL % Group Alive Deceased Yes Mean (+SE) Days Alive No Yes = No = Sensitivity = 69.3% (C.I ) Specificity = 83.6% (C.I ) MCC = 0.53 Log rank P < MONTHS FROM SURPRISE QUESTION PREDICTIVE VALUE PPV 83.8% (C.I ) No NPV 69.0% (C.I ) Moroni M et al, Palliat Med, March 2014

6 Hazard Variable 95% CI p value MULTIVARIATE RatioCOX REGRESSION Age (years) (0.994, 1.036) Sex (reference=male) (0.484, 1.241) Site of cancer (reference=lung) Hazard (0.392, 1.121) Variabile (reference=breast) Ratio (0.986, 3.993) (reference =colon) (0.662, 2.884) (reference Site of cancer =pancreas) (0.176, 0.714) (reference=prostate) (pancreas) (0.862, ) (reference=ovary uterus) (0.615, 6.216) Specialisation (reference=yes) (0.727, 2.162) (reference=yes) surprise question (reference=yes) (3.747, ) Doctor s experience (0.963, 1.042) The Surprise Question RESULTS 5 RESULTS 4 UNIVARIATE COX REGRESSION TO PREDICT STATUS AT1 YEAR surprise question TO PREDICT STATUS AT 1 YEAR 95% CI p value (0.772, 6.432) (2.418, ) Moroni M et al, Palliat Med, March 2014

7 CONCLUSIONS 1 The answer to the 1 year surprise question given by generalists is a fairly accurate predictorofadvancedcancerpatients status at 12 months. THE STUDY When the answer to the SQ was positive, physicians accurately predicted survival in more than 4/5 of the patients. CONCLUSIONS At the univariate Cox analysis the hazard ratio (HR) of a negative response to the surprise question was 6.99 (95% CI: ). Patients in the No group had an odds ratio of (95%CI: ) of being dead within the year, when compared to those in the Yes group (p=0.000).

8 CONCLUSIONS 2 The SQ s PPV (83,8%) suggests that the surprise question is a good screening test to identify patients with an increased risk of death within the year, among a population affected by advanced stage cancer (stage IV). The study suggests that the GP s have a tendency to underestimate the prognosis of their patients with advanced neoplastic disease. 39 patients out of the 126 (30.7%) assigned to the No group resulted to have lived beyond the 12 month observation period

9 The 'surprise' question in advanced cancer patients: A prospective study among general practitioners Matteo Moroni, Donato Zocchi, Deborah Bolognesi, Amy Abernethy, Roberto Rondelli, Giandomenico Savorani, Marcello Salera, Filippo G. Dall Olio, Giulia Galli, Guido Biasco on behalf of the SUQ P Group. Published online 24 March 2014 Palliat Med; DOI: / THE AUTHORS WOULD LIKE TO THANK Surprise Question Practitioners group (SUQ P group) of the Emilia Romagna Region, Italy: Antonio Balduzzi, Giulio Bandi, Laura Baraldini, Salvatore Bauleo, Luigi Bertini, Paolo Borghi, Paolo Calzoni, Maurizio Camanzi, Antonino Cammarata, Piero Casarini, Roberto Cau, Cecilia Deni, Shirley Ehrlich, Giuliano Ermini, Livio Franco, Giancarlo Furlò, Marina Grandi, Antonio Luigi Lalli, Marco Maccaferri, Carla Marzo, Angelo Masi, Annunzio Matrà, Piero Mazzetti Gaito, Federico Montanari, Massimo Oggianu, Gianluca Ognibene, Maria Palasciano, Saida Palestini, Fernando Perrone, Stefano Quadrelli, Antonino Rappacciolo, Stefano Rubini, Marcello Salera, Sandra Santi, Giandomenico Savorani, Alberto Serio, Anna Maria Severino, Matteo Siena, Pietro Speziali, Luigi Spinnato, Cesare Tosetti, Pietro Velonà, Andrea Verri, Donato Zocchi. Contact author:

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