Interrater variability in ASA physical status assignment: an analysis in the pediatric cancer setting

Tollinche, Luis; Yang, Gloria; Tan, Kay-See; Borchardt, Ruth

doi:10.1007/s00540-018-2463-2

Cited by 23 publications

(20 citation statements)

References 20 publications

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“…Variability is also seen in retrospective chart review comparing the ASA-PS class assigned at a preoperative clinic versus the ASA-PS class assigned in the operating room (Sankar et al 2014 ). Inter-rater reliability is not the only issue with the ASA-PS class system, but intra-rater reliability which one would expect to show near perfect agreement has shown only moderate agreement in the pediatric cancer setting (Tollinche et al 2018 ). Not only is there disagreement between anesthesia providers, but providers of different specialties also lack consistency.…”

Section: Introductionmentioning

confidence: 99%

Clinical agreement in the American Society of Anesthesiologists physical status classification

2018

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BackgroundThe American Society of Anesthesiologists physical status (ASA-PS) classification is not intended to predict risk, but increasing ASA-PS class has been associated with increased perioperative mortality. The ASA-PS class is being used by many institutions to identify patients that may require further workup or exams preoperatively. Studies regarding the ASA-PS classification system show significant variability in class assignment by anesthesiologists as well as providers of different specialties when provided with short clinical scenarios. Discrepancies in the ASA-PS accuracy have the potential to lead to unnecessary testing and cancelation of surgical procedures. Our study aimed to determine whether these differences in ASA-PS classification were present when actual patients were evaluated rather than previously published scenario-based studies.MethodsA retrospective chart review was completed for patients >/= 65 years of age undergoing elective total hip or total knee replacements. One hundred seventy-seven records were reviewed of which 101 records had the necessary data. The outcome measures noted were the ASA-PS classification assigned by the internal medicine clinic provider, the ASA-PS classification assigned by the Pre-Anesthesia Unit (PAU) clinic provider, and the ASA-PS classification assigned on the day of surgery (DOS) by the anesthesia provider conducting the anesthetic care.ResultsA statistically significant difference was shown between the internal medicine and the PAU preoperative ASA-PS designation as well as between the internal medicine and DOS designation (McNemar p = 0.034 and p = 0.025). Low kappa values were obtained confirming the inter-observer variation in the application of the ASA-PS classification of patients by providers of different specialties [Kappa of 0.170 (− 0.001, 0.340) and 0.156 (− 0.015, 0.327)].ConclusionsThere was disagreement in the ASA-PS class designation between two providers of different specialties when evaluating the same patients with access to full medical records. When the anesthesia-run PAU and the anesthesia assigned DOS ASA-PS class designations were evaluated, there was agreement. This agreement was seen between anesthesia providers regardless of education or training level. The difference in the application of the ASA-PS classification in our study appeared to be reflective of department membership and not reflective of the individual provider’s level of training.

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Section: Introductionmentioning

confidence: 99%

Clinical agreement in the American Society of Anesthesiologists physical status classification

2018

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“…For example, based on our findings, those patients with severe systemic disease might be advised not to have their excision done at an outpatient surgery center owing to the possibility for postoperative mechanical ventilation. While inter‐rater reliability of ASA classification has largely been found to be fair to moderate, one recent study found poor inter‐rater agreement among cancer patients, perhaps owing to the upgrading of ASA two patients to ASA 3 due to those patients’ cancer diagnoses . It therefore behooves the clinician to ensure as much as possible the proper ASA grading of patients in the application of this study's findings, taking into account the classification's limitations.…”

Section: Discussionmentioning

confidence: 81%

Predictive factors for adverse outcomes in pediatric patients undergoing low‐risk skin and soft tissue surgery: A database analysis of 6730 patients

Cheon

Longhini

Lee

et al. 2018

Pediatric Anesthesia

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Summary Background There is a paucity of data regarding risk stratification of pediatric patients presenting for low‐risk skin and soft tissue surgery. Aims We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30‐day readmission in a cohort of children undergoing low‐risk skin and soft tissue surgery. Methods The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two‐year period. The primary outcome was a 30‐day postoperative complication composite. The secondary outcome was unplanned 30‐day readmission. Results The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound‐related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30‐day readmission. Conclusion Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low‐risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30‐day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.

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“…Multiple studies have reported moderate to poor concordance of the ASA class among various clinicians 14 , anesthesiologists [15][16][17][18][19][20] or restricted to speci c patient cohorts [21][22][23] . One study examined speci cally the agreement between anesthesiologists and surgeons using hypothetical patient scenarios 24 .…”

Section: Introductionmentioning

confidence: 99%

Discordant American Society of Anesthesiologists Physical Status Classification between Anesthesiologists and Surgeons and its correlation with Adverse Patient Outcomes

Kwa

Cui

Lim

et al. 2022

Preprint

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The American Society of Anesthesiologists Physical Status Classification (ASA) is used for communication of patient health status, risk scoring, benchmarking and financial claims. Prior studies using hypothetical scenarios have shown poor concordance of ASA classification among healthcare providers. There is a paucity of studies using clinical data, and of clinical factors or patient outcomes associated with discordant classification. The study aims to assess ASA classification concordance between surgeons and anesthesiologists, factors surrounding discordance and its impact on patient outcomes. This retrospective cohort study was conducted in a tertiary medical center on 46284 consecutive patients undergoing elective surgery between January 2017 and December 2019. The ASA class showed moderate concordance (weighted Cohen’s 𝜅 0.53) between surgeons and anesthesiologists. We found significant associations between discordant classification and patient comorbidities, age and race. Patients with discordant classification had a higher risk of 30-day mortality (odds ratio (OR) 2.00, 95% confidence interval (CI) = 1.52-2.62, p<0.0001), 1-year mortality (OR 1.53, 95% CI = 1.38-1.69, p < 0.0001), and Intensive Care Unit admission >24 hours (OR 1.69, 95% CI = 1.47-1.94, p< 0.0001). Hence, there is a need for improved standardization of ASA scoring and cross-specialty review in ASA-discordant cases.

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Interrater variability in ASA physical status assignment: an analysis in the pediatric cancer setting

Cited by 23 publications

References 20 publications

Clinical agreement in the American Society of Anesthesiologists physical status classification

Clinical agreement in the American Society of Anesthesiologists physical status classification

Predictive factors for adverse outcomes in pediatric patients undergoing low‐risk skin and soft tissue surgery: A database analysis of 6730 patients

Discordant American Society of Anesthesiologists Physical Status Classification between Anesthesiologists and Surgeons and its correlation with Adverse Patient Outcomes

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