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Am J Kidney Dis. 2017 Jul;70(1):93-101. doi: 10.1053/j.ajkd.2016.11.025. Epub 2017 Feb 15.

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

Author information

1
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
2
Division of Nephrology, University of New Mexico, Albuquerque, NM.
3
Department of Biostatistics, Vanderbilt University, Nashville, TN.
4
Division of Nephrology, University of California at San Diego, San Diego, CA.
5
Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA.
6
Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
7
Division of Nephrology, Meharry Medical College, Nashville, TN.
8
The School of Nursing, Vanderbilt University, Nashville, TN.
9
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN. Electronic address: khaled.abdel-kader@vanderbilt.edu.

Abstract

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.

KEYWORDS:

Chronic kidney disease (CKD); advance planning; advanced CKD; clinical prediction; clinical trajectory; end-of-life preferences; geriatric; goals-of-care discussions; mortality; mortality risk prediction; nephrology provider; non–dialysis-dependent CKD; prognostication; reliability; subjective health measure; survival

PMID:
28215946
PMCID:
PMC5771496
DOI:
10.1053/j.ajkd.2016.11.025
[Indexed for MEDLINE]
Free PMC Article

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