Khaled Abdel-Kader
Last active: 11/29/2018

Reliability and Utility of the Surprise Question in CKD Stages 4 to 5.

Javier AD, Figueroa R, Siew ED, Salat H, Morse J, Stewart TG, Malhotra R, Jhamb M, Schell JO, Cardona CY, Maxwell CA, Ikizler TA, Abdel-Kader K
Am J Kidney Dis. 2017 70 (1): 93-101

PMID: 28215946 · PMCID: PMC5771496 · DOI:10.1053/j.ajkd.2016.11.025

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.

Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

MeSH Terms (12)

Aged Aged, 80 and over Female Humans Male Middle Aged Prognosis Prospective Studies Renal Insufficiency, Chronic Reproducibility of Results Severity of Illness Index Surveys and Questionnaires

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