Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD

The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflows have slowed SQ implementation in practice.

The aims of this study were: (1) to evaluate implementation outcomes after the use of electronic health record (EHR) decision support to automate the collection of the SQ; and (2) to assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits.

We developed and implemented a best practice alert (BPA) in the EHR to identify nephrology outpatients ≥60 years of age with an eGFR <30 ml/min per 1.73 m². At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses.

Among 510 patients for whom the BPA triggered, 95 (19%) had the SQ completed by 16 physicians. Among those completed, nearly all (98%) were on appointment day, and 61 (64%) the first time the BPA fired. Providers answered "no" for 27 (28%) and "yes" for 68 (72%) patients. By 12 months, six (22%) "no" patients died; three (4%) "yes" patients died (hazard ratio [HR] 2.86, ref: yes, 95% CI, 1.06 to 7.69). About 35% of "no" patients and 32% of "yes" patients had a hospital encounter by 12 months (HR, 1.85, ref: yes, 95% CI, 0.93 to 3.69). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary.

We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.