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Kidney Week

Abstract: PO0572

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

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

  • Ernecoff, Natalie C., University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
  • Abdel-Kader, Khaled, Vanderbilt University, Nashville, Tennessee, United States
  • Cai, Manqi, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
  • Yabes, Jonathan, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
  • Schell, Jane O., University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
  • Jhamb, Manisha, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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. Yet, barriers in clinical workflow have slowed SQ implementation into practice. We sought (1) To evaluate implementation outcomes following use of electronic health record (EHR) decision support to automate collection of the SQ, and (2) To assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visit.

Methods

We developed and implemented a synchronous decision support [best practice alert (BPA)] algorithm in the electronic health record (EHR) to identify patients attending an outpatient nephrology follow-up visit who were > 60 years of age with an eGFR<30. At the time of the visit, a ‘pop-up’ BPA was triggered, prompting the physician to answer the SQ (dichotomized). To evaluate implementation, we assessed provider response rate, and efficiency of responses. We assessed the SQ’s prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. We abstracted EHR data on patient sociodemographics and clinical characteristics. Physicians provided their demographic and clinical practice characteristics.

Results

Among 510 unique patients for whom the BPA triggered, 95 had the SQ completed (18.6%) by 16 unique providers. Among those patients with completed SQ, nearly all providers (97.9%) completed the SQ on the clinic 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 (6.3%) “No” patients died; 3 (3.2%) “Yes” patients died (age-adjusted hazards ratio [HR] 0.35, CI[0.13, 0.94]). About 40% of “No” patients and 25% of “Yes” patients had a hospital encounter by 12 months (HR 1.85, CI[0.927, 3.689]).

Conclusion

We successfully integrated the SQ into the EHR for routine collection to aid in clinical practice. Our response rate indicates additional implementation efforts are needed to encourage further integration of the SQ in clinical practice. Consistent with prior research, the SQ has reasonable prognostic utility for mortality and future hospital encounters.

Funding

  • Private Foundation Support