Discussing Serious Illness Could Cut Costs, Improve End-of-Life Care

Results of a new study from Brigham and Women’s Hospital could provide insight to physicians that could improve the experience and mitigate unnecessary healthcare expenses at the end of a patient’s life.

Through incorporating the question, “Would you be surprised if your patient died in the next one month?” into their electronic medical record, investigators found implementing the question could lead to greater access to appropriate illness conversations and palliative care services for older populations.

"In order to best help our patients nearing the end of life, we need ways to identify patients who should be offered palliative care consultation or have serious illness conversations as soon as they are admitted," said study author Kei Ouchi, MD, MPH, a physician in Emergency Medicine at Brigham and Women’s.

In an effort to improve the quality of end-of-life care for patients, investigators conducted a prospective cohort study at the emergency department of the Maine Medical Center that included 10,737 older adults in 16,223 visits. The mean age of the cohort was 75.9 years, 52% (n=5532) were women, and the majority (94.6%, n=10,157) of patients were white.

Death records were obtained from the National Death Index and were verified using the patient’s Social Security number, first and last names, and date of birth. All visits took place between January 1, 2014 and December 31, 2015. Follow-up of death records occurred on January 1, 2018.

Upon placing a bed request physicians were prompted with the mandatory question, “Would you be surprised if your patient died in the next one month?” — which the investigators refer to as the “surprise” question. The primary outcome measure of the study was the accuracy of clinicians’ response to the question in identifying patients with 1-month mortality. Secondary outcomes included accuracy of responses from emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying patients with high 6- or 12-month mortality.

The mortality rates for the study cohort were 8.3% at 1 month, 17.2% at 6 months, and 28.5% at 12 months. Clinicians stated they would not be surprised if that patient died in the next month for 2104 (19.6%) patients and 893 (8.3%) of the 10737 patients died within 1 month.

In bivariate analysis, patients had a 3.3-fold higher risk of 1-month mortality when clinicians answered they would not be surprised if they died within 1 month (OR, 3.3 (95% CI, 3.0-3.7); P<0.001). In a multivariable analysis adjusting for factors including age, sex, race, and comorbid conditions, that risk was 2.4-fold greater if clinicians said they would not be surprised (OR, 2.4 (95% CI, 2.2-2.7); P<0.001).

Based on results, investigators determined the overall diagnostic test characteristics of the question were poor with 20% sensitivity, 93% specificity, 43% positive predictive value, 82% negative predictive value, and 78% accuracy (area under receiver operating curve 0.73 (95% CI, 0.72-0.74; P<0.001)). Investigators noted in their conclusion the question could be a valuable tool for identifying patients at high risk of 1-month mortality.

"Patients who have serious illness conversations experience a 36-percent reduction in the cost of end-of-life care, with an average cost savings of $1,041 in the last week of life. Having tools at our disposal to identify patients at greater risk could allow us to have these conversations sooner and change what end-of-life care looks like in this country," Ouchi said.

This study, “Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital,” was published online in JAMA Network Open.