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Reliability and Utility of the Surprise Question in CKD Stages 4 to 5
Andrei D Javier1, Rocio Figueroa2, Edward D Siew1
1Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
Insights
The surprise question aids in predicting mortality for patients with advanced chronic kidney disease (CKD). This tool shows moderate to good reliability, supporting its use in care planning for non-dialysis-dependent CKD patients.
Area of Science:
- Nephrology
- Geriatrics
- Palliative Care
Background:
- Prognostic uncertainty hinders goals-of-care discussions in chronic kidney disease (CKD).
- The surprise question is a tool to aid prognostication but lacks study in non-dialysis-dependent CKD.
- Its reliability in this patient population is unknown.
Purpose of the Study:
- To evaluate the surprise question's association with mortality in patients with non-dialysis-dependent CKD stages 4-5.
- To assess the reliability (test-retest and inter-rater) of the surprise question in this population.
Main Methods:
- Observational study of 388 patients (≥60 years) with non-dialysis-dependent CKD stages 4-5.
- Utilized trinary (Yes, Neutral, No) and binary (Yes, No) surprise question responses.
- Assessed mortality, test-retest reliability, and blinded inter-rater reliability, alongside baseline clinical factors.
Main Results:
- Median age was 71 years; 13% of patients died during 1.4 years of follow-up.
- Mortality rates differed significantly by surprise question response (5% for Yes, 15% for Neutral, 27% for No).
- Trinary surprise question showed moderate to good reliability (inter-rater: 0.58, test-retest: 0.63) and moderate sensitivity/specificity for mortality.
Conclusions:
- The surprise question is associated with mortality in advanced CKD stages 4-5.
- The tool demonstrates moderate to good reliability in this population.
- Further research is needed to optimize its use in advance care planning for non-dialysis-dependent CKD.
Background:
Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown.
Study Design:
Observational study.
Setting & Participants:
388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic.
Predictor:
Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.
Outcomes:
Mortality, test-retest reliability, and blinded inter-rater reliability.
Measurements:
Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin).
Results:
Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary).
Limitations:
Single center, small number of deaths.
Conclusions:
The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.
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