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Reliability of the Pediatric-Specific American Society of Anesthesiologists Physical Status (ASA-PS) Classification
Lucy Liu1,2, Lucy Foote1, Evgenia Kolyvaki3
1Department of Anaesthesia, Great Ormond Street Hospital for Children, London, UK.
Insights
Inter-rater reliability for the American Society of Anesthesiologists Physical Status (ASA-PS) classification in pediatric patients shows moderate agreement. Many pediatric patients are underscored, highlighting the need for improved ASA-PS scoring accuracy.
Area of Science:
- Anesthesiology
- Pediatric Surgery
- Patient Safety
Background:
- The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is a standard for assessing patient comorbidities and perioperative risk.
- Modifications have been made to the ASA-PS system since its 1941 inception, including pediatric-specific guidance in 2020.
Purpose of the Study:
- To evaluate the inter-rater reliability of the ASA-PS classification system within the pediatric population.
- To identify factors contributing to discrepancies in ASA-PS scoring among pediatric patients.
Main Methods:
- A retrospective analysis of 364 pediatric patients at a quaternary hospital.
- Three ASA-PS scores were assigned to each patient: one by the case anesthetist and two by independent consultant anesthetists.
- Concordance was assessed using weighted kappa coefficients, with analysis of reasons for discordant scores.
Main Results:
- Strong concordance was observed between the two independent consultant anesthetists (kappa = 0.76).
- Moderate concordance was found between the case anesthetist and independent anesthetists (kappa = 0.5).
- Discrepancies often involved the case anesthetist underscoring the ASA-PS score by one point, particularly in patients with complex conditions like symptomatic cardiac disease, abnormal BMI, oncologic states, brain malformations, or difficult airways.
Conclusions:
- Moderate inter-rater variability exists in pediatric ASA-PS scoring, with a tendency for underscoring.
- Utilizing the 2020 ASA guidance for pediatric cases enhances scoring reliability.
- Improved ASA-PS scoring accuracy can lead to better communication of perioperative risks in children.
Background:
The American Society of Anesthesiologists Physical Status (ASA-PS) classification system is widely used to classify patient comorbidities prior to surgery and is often used as a marker of perioperative risk. Since its inception in 1941, it has undergone modifications to adapt to changing clinical needs and to improve its reliability. In 2020, a version of the ASA-PS was released with pediatric-specific case examples.
Aim:
To explore inter-rater reliability in ASA-PS scoring in the pediatric population.
Methods:
This single-center retrospective study evaluated the assigned ASA-PS scores of 364 patients at a quaternary pediatric hospital. Each patient was assigned three ASA-PS scores-one by the case anesthetist and one each by two independent consultant anesthetists using the ASA guidance issued in 2020. Concordance was measured between the assigned scores, and potential reasons for discordant scores were identified.
Results:
There was strong concordance of ASA-PS scores between the two independently scoring anesthetists (weighted kappa coefficient 0.76), but only moderate concordance between the case anesthetist and the independent anesthetists (weighted kappa coefficient 0.5). Where there was a discrepancy, the case anesthetist had usually underscored the ASA-PS by 1 point. Patients who had symptomatic cardiac disease, abnormal body mass index for age, an oncologic state, brain malformation, or a difficult airway were more likely to be assigned an incorrect ASA-PS score.
Conclusions:
Moderate inter-rater variability exists in the assignment of ASA-PS scores in the pediatric population, and many patients are being underscored. Use of ASA guidance to assist with pediatric ASA-PS scoring improves the reliability of scoring and may improve accurate communication of perioperative risk.
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