American society of anesthesiologists physical status classification for pediatrics: a multicenter study
Dominguez, Oscar Daniel
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BACKGROUND: Currently there is no system with high reliability to classify pediatric patients prior to surgery based on their physical status. The American Society of Anesthesiologists Physical Status (ASA-PS) classification system focuses on adult definitions and examples which exhibit high subjectivity along with low effectiveness for the pediatric patient population. The goal of this study was to optimize the ASA–PS system for pediatric populations by measuring interrater agreement of a pediatric adapted ASA–PS system with the collaboration from national and international perspectives. METHODS: A mixed–methods, prospective study of 197 pediatric anesthesiologists from 13 hospitals in the U.S., Europe and Australia were surveyed in May and July of 2019. Participants were given 15 pediatric cases with a mix of acute and chronic health conditions undergoing a myriad of surgical and nonsurgical procedures. The participants were instructed to assign ASA–PS scores (I to V) using the previously published pediatric adapted definitions of the ASA–PS system, which were provided. Using a two-way mixed effects model to account for multiple readers assigning scores for the same set of cases, intraclass correlation coefficient (ICC) of the ASA–PS scores among survey participants and their hospitals was estimated. The survey allowed for qualitative feedback on the pediatric adapted ASA–PS system via a free-text comments section which was analyzed using line–by–line assessment. RESULTS: Out of 197 participants there were 165 responses to the survey which gave a response rate of 83.8%. Across all 15 clinical cases the ICC agreement among all respondents to the ASA–PS scoring survey was 0.58 (95% CI: 0.42, 0.77). There was no significant variance in ICC based on years of anesthesiology practice. ICC was variable across all hospitals with a range from 0.34 to 0.79. The lowest level of agreement occurred in cases where ASA–PS scores of II and III were assigned; cases assigned ASA–PS scores of I, IV and V had the highest level of the agreement. Qualitatively, clarification on level of control with respect to a chronic condition and scoring in the setting of an acute illness were the two most common themes suggested in order to increase the validity of the pediatric-adapted ASA–PS definitions. CONCLUSIONS: Compared to past literature the pediatric–adapted ASA–PS scoring system resulted in an increased interrater reliability when dealing with pediatric specific cases. Overall, the pediatric – adapted ASA– PS system had moderate interrater reliability among the pediatric anesthesiologists surveyed in this study, suggesting further refinement is needed. Specifically, the lower reliability of scoring for cases assigned ASA-PS scores II and III support the necessity for optimization of a pediatric specific ASA–PS system.