title: Reliability and Utility of the Surprise Question in CKD Stages 4 to 5.
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.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  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.
  
  
  METHODS
  Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response.
  
  
  RESULTS
  Mortality, test-retest reliability, and blinded inter-rater reliability.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
authors.forename: Andrei D
authors.initials: AD
authors.lastname: Javier
authors.affiliation: Division of Nephrology, University of New Mexico, Albuquerque, NM.
authors.forename: Rocio
authors.initials: R
authors.lastname: Figueroa
authors.affiliation: Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
authors.forename: Edward D
authors.initials: ED
authors.lastname: Siew
authors.affiliation: Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
authors.forename: Huzaifah
authors.initials: H
authors.lastname: Salat
authors.affiliation: Department of Biostatistics, Vanderbilt University, Nashville, TN.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Morse
authors.affiliation: Department of Biostatistics, Vanderbilt University, Nashville, TN.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Stewart
authors.affiliation: Division of Nephrology, University of California at San Diego, San Diego, CA.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Malhotra
authors.affiliation: Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Manisha
authors.initials: M
authors.lastname: Jhamb
authors.affiliation: 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.
authors.forename: Jane O
authors.initials: JO
authors.lastname: Schell
authors.affiliation: Division of Nephrology, Meharry Medical College, Nashville, TN.
authors.forename: Cesar Y
authors.initials: CY
authors.lastname: Cardona
authors.affiliation: The School of Nursing, Vanderbilt University, Nashville, TN.
authors.forename: Cathy A
authors.initials: CA
authors.lastname: Maxwell
authors.affiliation: Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
authors.forename: T Alp
authors.initials: TA
authors.lastname: Ikizler
authors.affiliation: 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.
authors.forename: Khaled
authors.initials: K
authors.lastname: Abdel-Kader
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000401:mortality*; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires
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