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

Abstract

Background: 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.

Objectives: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: advance care planning; chronic kidney disease; electronic health records; geriatric and palliative nephrology; health services research; palliative care.