Association between self-reported functional capacity and general postoperative complications: analysis of predefined outcomes of the MET-REPAIR international cohort study

Association between the Duke Activity Status Index and complications after noncardiac surgery: A systematic review

BACKGROUND

Individuals with poor functional capacity are at increased risk of perioperative complications. The Duke Activity Status Index (DASI) can ascertain the maximum physical activity achievable. However, the accuracy of the DASI score in identifying high-risk individuals is unclear. The objective of this systematic review was to determine the association between the DASI score and postoperative complications.

METHODS

Studies conducted in adults undergoing elective or emergency noncardiac surgery were eligible. The search strategy used MEDLINE, EMBASE, EMCARE and Cochrane CENTRAL, from January 1st, 1988 to August 8th, 2024. Study quality and risk of bias were evaluated independently by two assessors.

RESULTS

Of 5989 citations, nine studies (3100 participants) were included. The DASI score was associated with postoperative mortality (two studies, 732 participants) and postoperative cardiovascular complications (two studies, 2055 participants). The DASI score provided fair prediction of postoperative complications (three studies, area under the receiver operating characteristic curve range 0.71 to 0.75). Marked study heterogeneity precluded meta-analysis.

DISCUSSION

This systematic review found an association between low DASI scores and cardiovascular complications, postoperative complications and mortality, and variable association between DASI scores and hospital length of stay. The major limitation to the evidence was the significant heterogeneity of study population, outcome definitions, DASI thresholds and cardiovascular endpoints.

CONCLUSION

Amongst adults undergoing noncardiac surgery, the DASI score is associated with postoperative complications, cardiovascular complications and mortality. Further research is required to identify a DASI threshold (or confirm the DASI threshold of 34) that accurately predicts postoperative complications, including major cardiac events.

OTHER

This systematic review was registered with PROSPERO on March 4th, 2024 (CRD42024331864). No funding was obtained for this review.

Clinical Tools to Assess Functional Capacity During Risk Assessment Before Elective Noncardiac Surgery : A Scoping Review

BACKGROUND

Functional capacity is critical to preoperative risk assessment, yet guidance on its measurement in clinical practice remains lacking.

PURPOSE

To identify functional capacity assessment tools studied before surgery and characterize the extent of evidence regarding performance, including in populations where assessment is confounded by noncardiopulmonary reasons.

DATA SOURCES

MEDLINE, EMBASE, and EBM Reviews (until July 2024).

STUDY SELECTION

Studies evaluating performance of functional capacity assessment tools administered before elective noncardiac surgery to stratify risk for postoperative outcomes.

DATA EXTRACTION

Study details, measurement properties, pragmatic qualities, and/or clinical utility metrics.

DATA SYNTHESIS

6 categories of performance-based tests and 5 approaches using patient-reported exercise tolerance were identified. Cardiopulmonary exercise testing (CPET) was the most studied tool (132 studies, 32 662 patients) followed by field walking tests (58 studies, 9393 patients) among performance-based tests. Among patient-reported assessments, the Duke Activity Status Index (14 studies, 3303 patients) and unstructured assessments (19 studies, 28 520 patients) were most researched. Most evidence focused on predictive validity (92% of studies), specifically accuracy in predicting cardiorespiratory complications. Several tools lacked evidence on reliability (test consistency across similar measurements), pragmatic qualities (feasibility of implementation), or concurrent criterion validity (correlation to gold standard). Only CPET had evidence on clinical utility (whether administration improved postoperative outcomes). Older adults (≥65 years) were well represented across studies, whereas there were minimal data in patients with obesity, lower-limb arthritis, and disability.

LIMITATION

Synthesis focused on reported data without requesting missing information.

CONCLUSION

Though several tools for preoperative functional capacity assessment have been studied, research has overwhelmingly focused on CPET and only 1 aspect of validity (predictive validity). Important evidence gaps remain among vulnerable populations with obesity, arthritis, and physical disability.

PRIMARY FUNDING SOURCE

None. (Open Science Framework: https://osf.io/ah7u5).