An online international comparison of thresholds for triggering a negative response to the "Surprise Question": a study protocol

Abstract

Background: The Surprise Question (SQ) "would I be surprised if this patient were to die in the next 12 months?" has been suggested to help clinicians, and especially General Practitioners (GPs), identify people who might benefit from palliative care. The prognostic accuracy of this approach is unclear and little is known about how GPs use this tool in practice. Are GPs consistent, individually and as a group? Are there international differences in the use of the tool? Does including the alternative Surprise Question ("Would I be surprised if the patient were still alive after 12 months?") alter the response? What is the impact on the treatment plan in response to the SQ? This study aims to address these questions.

Methods: An online study will be completed by 600 (100 per country) registered GPs. They will be asked to review 20 hypothetical patient vignettes. For each vignette they will be asked to provide a response to the following four questions: (1) the SQ [Yes/No]; (2) the alternative SQ [Yes/No]; (3) the percentage probability of dying [0% no chance - 100% certain death]; and (4) the proposed treatment plan [multiple choice]. A "surprise threshold" for each participant will be calculated by comparing the responses to the SQ with the probability estimates of death. We will use linear regression to explore any differences in thresholds between countries and other clinician-related factors, such as years of experience. We will describe the actions taken by the clinicians and explore the differences between groups. We will also investigate the relationship between the alternative SQ and the other responses. Participants will receive a certificate of completion and the option to receive feedback on their performance.

Discussion: This study explores the extent to which the SQ is consistently used at an individual, group, and national level. The findings of this study will help to understand the clinical value of using the SQ in routine practice.

Trial registration: Clinicaltrials.gov NCT03697213 (05/10/2018). Prospectively registered.

Keywords: Death; Palliative care; Prognosis; Surprise question; Survival.

Conflict of interest statement

Ethics approval and consent to participate

This study gained ethics approval from University College London REC on the 9th August 2018 (ref 8675/003), University of Antwerp REC on the 7th January 2019 (ref 18/50/589), University of Mainz REC on the 26th November 2018, Radboud University Medical Center REC on the 20th December 2018 (ref 2018–4949), Bern Ethics Committee on the 29th August 2018 (ref 2018–00710) and University of Bologna REC on the 25th January 2019 (ref 12,590). In case any protocol amendments are required, these will be reviewed by the study team before submission to the relevant committees, and the trial registry will be updated where necessary. Consent is obtained electronically through a series of check boxes, see section “Methods, Methods: Participants, interventions, and outcomes” for further detail.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

Example hypothetical vignette

Fig. 2

GP 1’s responses

Fig. 3

GP 2’s responses

Fig. 4

GP 3’s responses