ASN's Mission

To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

learn more

Contact ASN

1401 H St, NW, Ste 900, Washington, DC 20005


The Latest on Twitter

Kidney Week

Abstract: TH-PO1144

Surprise Question and Time-to-Hospitalization in Advanced CKD

Session Information

Category: CKD (Non-Dialysis)

  • 1902 CKD (Non-Dialysis): Clinical, Outcomes, and Trials


  • Baddour, Nicolas, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
  • Robinson-Cohen, Cassianne, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Lipworth, Loren, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Bian, Aihua, Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Stewart, Thomas G., Vanderbilt University Medical Center, Nashville, Tennessee, United States
  • Abdel-Kader, Khaled, Vanderbilt University Medical Center, Nashville, Tennessee, United States

Hospitalization is a common and high-risk event for patients with CKD. The surprise question (SQ) is a provider-based subjective health measure (i.e., “Would you be surprised if this patient died in the next 12 months?”) that associates with mortality in advanced CKD; however, the association with hospitalization has not been examined.


We enrolled 488 ambulatory patients with stage 4 or 5 CKD who were ≥ 60 years of age and followed in nephrology clinic. Providers were asked the SQ using a binary and 5-point Likert scale following each office visit. Hospitalizations were determined by linkage to a statewide health database. Death was determined through linkage with national or local public health records as well as obituary searches. Other covariates were abstracted by chart review using structured forms. We determined hazard ratios for time to first hospitalization using cox proportional hazards regression. In addition to the SQ Likert scale, our multivariable model included age, gender, race, marital status, insurance status, diabetes, hypertension, cardiovascular disease, heart failure, malignancy, liver disease, chronic lung disease, number of hospitalizations in the prior year, number of medications, BMI, eGFR, serum albumin, and hemoglobin.


293 (60%) patients were hospitalized. Median time to first hospitalization was 591 days in patients with SQ binary ‘surprised’ answer versus 277 days in ‘not surprised’ counterparts. 16 (3.3%) patients died before a hospitalization. The Likert SQ response was significantly associated (p = 0.01) with time to hospitalization with hazard ratios (95 % CI) of 1.67 (0.88 – 3.17), 2.25 (1.46 – 3.5), 1.60 (1.08 – 2.37), and 1.51 (1.01 – 2.26) for 1 (not at all surprised), 2, 3, and 4, respectively (versus reference: 5 very surprised).


Provider response to the SQ is associated with time-to-hospitalization in older adults with Stage 4 and 5 CKD. Future studies should examine whether the SQ is useful in identifying patients with high healthcare utilization.


  • Private Foundation Support