Eliminating the Surprise Question Leaves Home Care Providers With Few Options for Identifying Mortality Risk

Abstract

Background: Precision health initiatives for end-of-life planning require robust methods for identifying patient risk for decline and mortality. The Outcome and Assessment Information Set (OASIS) surprise question (SQ; M1034 Overall Status) is the primary tool for evaluating risks in homebound older adults. However, the OASIS-D, Released in 2019, eliminates this question. This study examines the prognostic ability of 12- and 24-month mortality risk reflected in the OASIS-SQ and develops an alternative approach for classifying mortality risk to support decision-making in the absence of the OASIS-SQ. Design: Retrospective secondary data analysis. Setting/Participants: A nationally representative sample of 69 097 OASIS-C assessments (2012) linked to the Master Beneficiary Summary file (2012 and 2013). Measurements: Survival analysis, k-means clustering, and Cohen κ coefficient with Z test. Results: The OASIS-SQ predicts mortality (35% at 12 and 45% at 24 months; P < .001). Cluster analysis identified 2 risk groups: OASIS activity of daily living “ADL total scores” >15 = (lower risk) and ≤15 = (higher risk) for 24-month mortality. Model agreement is weak for both cluster 1 and cluster 2, the OASIS-SQ κ = 0.20, 95% confidence interval (CI) = .19 to .21, and “alive/not alive” κ = .17, 95% CI = .16 to .18. Conclusion: The OASIS-SQ and “ADL total score” are almost equally likely to predict 24-month mortality; therefore, it was reasonable to use the “ADL total score” as a substitute for the OASIS-SQ. Removal of the OASIS-SQ leaves home care providers with few clear options for risk screening resulting in missed opportunities to refer to palliative or hospice services.