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 workflow have slowed SQ implementation into practice. Objectives. (1) To evaluate implementation outcomes following use of electronic health record (EHR) decision support to automate collection of the SQ. (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 electronic health record (EHR) to identify nephrology outpatients > 60 years of age with an eGFR<30 ml/min. 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 (18.6%) had the SQ completed by 16 physicians. Among those completed, nearly all (97.9%) were on appointment day, and 61 (64.2%) the first time the BPA fired. Providers answered "No" for 27 (28.4%) and "Yes" for 68 (71.6%) patients. By 12 months, 6 (22.2%) "No" patients died; 3 (4.4%) "Yes" patients died (hazards ratio [HR] 2.86, ref:Yes, 95% CI[1.06, 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, 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.