Self-reported fitness of American Society of Anesthesiologists class 3 patients undergoing endovascular aneurysm repair predicts patient survival

Update of a Model to Predict Outcomes after Endovascular Aneurysm Repair

BACKGROUND

Risk assessment models must be continuously validated and updated to ensure that predictions remain valid. Here, the Endovascular Aneurysm Repair Risk Assessment Model, developed in 2008, is updated and improved.

METHODS

We used prospectively collected data from Australian patients who underwent elective endovascular aneurysm repair between 2009 and 2013 (n = 695). Data were provided by treating surgeons and the National Death Index. Key outcomes were early and midterm survival, early complications (endoleak, operative, and graft-related) and late complications (endoleak and graft-related). Multinomial logistic regression determined which preoperative variables best predicted each outcome. Area under Receiver Operating Characteristic curve (AUROC), model P-value and internal validation statistics were used to select the best model.

RESULTS

Ten preoperative variables were included in the modeling for 10 key outcomes. The most valid outcomes with AUROC>0.7 were 1- and 3-year survival, 30 and 90-day mortality, early and late endoleak (types I, III and IV) and type II endoleak (with an increase in sac size ≥5 mm). The 10 preoperative variables that contributed to outcome models were self-reported fitness, American Society of Anesthesiologists physical status score, history of stroke/transient ischemic attack, age, aneurysm angle, infrarenal neck length, white cell count, respiratory assessment, diabetes and statin therapy. Fitness alone statistically significantly predicted 30 and 90-day deaths better than any other preoperative variable; achieving high AUROCs (0.78 and 0.80), and high odds ratios (12.8 [95% CI: 1.5-110.4] and 18.1 [95% CI: 2.2-149]).

CONCLUSIONS

An updated interactive predictive model of outcomes after endovascular aneurysm repair has been created. Many of the variables used in the 2008 model continued to be significant, however, new variables including fitness and respiratory assessment, improved the model. The new model uses variables routinely collected preoperatively, and hence can better support surgeon-patient discussions prior to operation. Informing patients of potential risks or likely outcomes following elective surgery can assist with preoperative shared decision-making.

Associations between ASA classification, self-estimated physical health, psychological wellbeing and anxiety among Swedish orthopaedic patients

BACKGROUND

The evaluation of one's physical health and psychological wellbeing may be subjective. Aspects of functional capacity, including the patients' own estimation of physical health and wellbeing, have been shown to be strong predictors of postoperative outcomes and should be the focus of further research.

AIM

This study aimed to explore the associations between ASA classification, self-estimated physical health, psychological wellbeing and anxiety among orthopaedic patients.

METHODS

This was a longitudinal study using a quantitative approach.

SETTINGS

A central county hospital in northern Sweden.

RESULTS

A high ASA classification rated by anaesthetists was not associated with physical health and psychological wellbeing self-estimated as less than good. A high ASA classification was significantly associated with self-estimated anxiety prior to surgery. Three days and one month post-surgery, the situation was reversed, and the ASA I/II group, to a significantly higher extent, rated that they felt anxiety.

CONCLUSION

Preoperative screening systems for orthopaedic patients should not only focus on the medical and objective physical issues but also include the patients' own estimation of their physical health and psychological wellbeing. It is essential that orthopaedic patients receive relevant information that provides a realistic outlook, as well as an honest and optimistic future view.

A Twelve-Week Moderate Exercise Programme Improved Symptoms of Depression, Insomnia, and Verbal Learning in Post-Aneurysmal Subarachnoid Haemorrhage Patients: A Comparison with Meningioma Patients and Healthy Controls

OBJECTIVES

Deficits in psychological functioning, cognitive functioning, and sleep are frequently experienced by individuals who have survived aneurysmal subarachnoid haemorrhage (aSAH). Exercise has been shown to improve these domains; to date, it has never been explored in patients following aSAH. The aim of this exploratory study is to compare the effects of an exercise programme in this population with another patient group, and a group of healthy controls.

METHODS

The present study explored the effects of 12 weeks of moderate aerobic exercise training on 15 aSAH patients, 16 meningioma patients, and 17 healthy controls. Data on symptoms of depression, hypochondria, perceived stress, satisfaction with life, verbal learning and memory, and subjective and objective sleep, were gathered at baseline, following intervention, and at 6-month follow-up.

RESULTS

aSAH patients and meningioma patients had decreased symptoms of depression and insomnia at follow-up. While perceived stress decreased in the meningioma group, in aSAH patients it increased. Total learning performance increased in all three groups.

CONCLUSIONS

An exercise programme had a positive effect on symptoms of depression, insomnia, and verbal learning in patients following aSAH. No positive changes in other domains were observed. This may be due to the cautious approach taken with regard to exercise intensity.

Self-reported functional status predicts post-operative outcomes in non-cardiac surgery patients with pulmonary hypertension

Background

Pulmonary hypertension (PHTN) is associated with increased post-procedure morbidity and mortality. Pre-procedure echocardiography (ECHO) is a widely used tool for evaluation of these patients, but its accuracy in predicting post-procedure outcomes is unproven. Self-reported exercise tolerance has not been evaluated for operative risk stratification of PHTN patients.

Objective

We analyzed whether self-reported exercise tolerance predicts outcomes (hospital length-of-stay [LOS], mortality and morbidity) in PHTN patients (WHO Class I–V) undergoing anesthesia and surgery.

Methods and findings

We reviewed 550 non-cardiac, non-obstetric procedures performed on 370 PHTN patients at a single institution between 2007 and 2013. All patients had cardiac ECHO documented within 1 year prior to the procedure. Pre-procedure comorbidities and ECHO data were collected. Functional status (< or ≥ 4 metabolic equivalents of task [METs]) was assigned based on responses to standard patient interview questions during the pre-anesthesia clinic visit. Multiple logistic regression was used to develop a risk score model (Pulmonary Hypertension Outcome Risk Score; PHORS) and determine its value in predicting post-procedure outcomes. In an adjusted model, functional status <4 METs was independently associated with a LOS >7 days (p < .003), as were higher ASA class (p < .002), open surgical approach (p < .002), procedure duration > 2 hours (p < .001), and the absence of systemic hypertension (p = .012). PHORS Score ≥2 was associated with an increased 30-day major complication rate (28.7% vs. 19.2%; p < 0.001) and ICU admission rate (8.6% s 2.8%; p = .007), but no statistical difference in hospital readmissions rate (17.6% vs. 14.0%; p = .29), or mortality (3.5% vs. 1.4%; p = .75). Similar ECHO findings did not further improve outcome prediction.

Conclusions

Poor functional status is associated with severe PHTN and predicts increased LOS and post-procedure complications in patients with moderate to severe pulmonary hypertension with different etiologies. A risk assessment model predicts increased LOS with fair accuracy. A thorough evaluation of underlying etiologies of PHTN should be undertaken in every patient.

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair

BACKGROUND

Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self-reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms.

METHODS

Data were extracted from a trial database. All patients were assigned a fitness level (A (fit) or B (unfit)) based on their self-reported ability to walk briskly for 1 km or climb two flights of stairs. Fitness was used to stratify ASA III patients, with fitter patients assigned ASA IIIA and less fit patients ASA IIIB. Outcomes assessed included survival, reinterventions, endoleak, all early and late complications and early operative complications.

RESULTS

A combined ASA/fitness scale (II, IIIA, IIIB and IV) correlated with 1- and 3-year survival (1-year P = 0.001, 3-year P = 0.001) and early and late complications (P = 0.001 and P = 0.05). On its own, ASA predicted early complications (P = 0.0004) and survival (1-year P = 0.01, 3-year P = 0.01). Fitness alone was predictive for survival (1-year P = 0.001, 3-year P = 0.001) and late complications (P = 0.009).

CONCLUSION

This study shows that even a superficial assessment of fitness is reflected in surgical outcomes, with fitter ASA III patients showing survival patterns similar to ASA II patients. Physicians should be alert to differences in fitness between patients in the ASA III group, despite similarities based on preexisting severe systemic disease.

Functional status predicts major complications and death after endovascular repair of abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status to EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR.

METHODS

Patients undergoing nonemergent EVAR for abdominal aortic aneurysm between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30-day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using the NSQIP-defined preoperative functional status, patients were stratified as independent or dependent (either partial or totally dependent) and compared by univariate and multivariable analyses.

RESULTS

Of 13,432 patients undergoing EVAR between 2010 and 2014, 13,043 were independent (97%) and 389 were dependent (3%) before surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independent risk factor for operative complications (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.5-3.9), systemic complications (OR, 2.8; 95% CI, 2.0-3.9), and 30-day mortality (OR, 3.4; 95% CI, 2.1-5.6). Secondary outcomes were worse among dependent patients.

CONCLUSIONS

Although EVAR is a minimally invasive procedure with substantially less physiologic stress than in open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk and may identify patients who may benefit from preoperative conditioning and specialized perioperative care.

Significant discrepancies exist between clinician assessment and patient self-assessment of functional capacity by validated scoring tools during preoperative evaluation

Background

Preoperative assessment of functional capacity is necessary to direct decisions regarding cardiac evaluation and may help identify patients at high risk for perioperative complications. Patient self-triage regarding functional capacity could be useful for discerning which patients benefit from a clinician evaluation at a Preoperative Evaluation Center prior to the day of surgery. We evaluated the feasibility of preoperative, patient self-triage regarding functional capacity.

Methods

Patients were recruited immediately prior to their preoperative evaluation. Study participants completed electronic versions of the Duke Activity Status Index (DASI) and the Patient-Reported Outcomes Measurement System (PROMIS)–Short Form 12a–Physical Function. DASI and PROMIS questionnaire responses were scored and evaluated for correlation with clinician assessments of functional capacity. Correlation was analyzed around the dichotomous outcome of <4 metabolic equivalents of task (METs) or ≥4 METs. Patients also evaluated the usability of the questionnaires.

Results

After IRB approval, 204 patients were enrolled and completed both DASI and PROMIS questionnaires. Clinicians assessed functional capacity at <4 METs for 109 patients (53.4 %) compared to 18 (8.8 %) patient self-assessments <4 METs as estimated by DASI. These results represent a significant discrepancy between assessments (Fisher’s exact, two-tailed P value <0.0001). The standard T-score of PROMIS estimates of functional capacity correlated with DASI estimates (R² 0.76). The mean and standard deviation for PROMIS T-scores were 43.3 and 9.86, respectively (mean 50.0; SD 10.0 for the general population).

Of the 203 patients who completed the entire study survey, 192 (94.6 %) stated that they did not require assistance from another person, and 187 (94 %) responded either “agree” or “strongly agree” to the DASI questionnaire being “easy to understand” and “easy to complete;” 186 (93 %) and 188 (94 %), respectively, responded similarly to the PROMIS questionnaire.

Conclusions

While both electronic questionnaires were easy to understand and complete for most study participants, there was a significant discrepancy between clinician assessments and patient self-assessments of functional capacity. Further study is needed to determine if either patient self-triage by means of activity questionnaires or clinician evaluation is valid and reliable in the preoperative setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13741-016-0041-4) contains supplementary material, which is available to authorized users.