Supplementary Material for: Nephrology Provider Surprise Question Response and Hospitalizations in Older Adults with Advanced CKD

Background: Older adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events. Methods: This prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient’s office visit, study staff asked the patient’s provider to rate the patient’s risk of death within the next year using the surprise question (“Would you be surprised if this patient died in the next 12 months?”) with a 5-point Likert scale response (1, “definitely not surprised” to 5, “very surprised”). We used a statewide database to ascertain hospitalization during follow-up. Results: There were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m². Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34–50), “very surprised”; 65 (95% CI: 55–76), “surprised”; 98 (95% CI: 85–113), “neutral”; 125 (95% CI: 107–144), “not surprised”; and 120 (95% CI: 94–151), “definitely not surprised.” In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be “definitely not surprised” if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be “very surprised” (odds ratio 2.4, 95% CI: 1.0–5.7). There was a similar association for time to first hospitalization. Conclusion: Nephrology providers’ responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.