The Pediatric-Specific American Society of Anesthesiologists Physical Status Score: A Multicenter Study

Anesth Analg. 2021 Mar 1;132(3):807-817. doi: 10.1213/ANE.0000000000005025.


Background: When applied to the pediatric population, the American Society of Anesthesiologists physical status (ASA-PS) classification has exhibited poor reliability due to its subjective and adult-focused definitions. This study was done to measure interrater agreement of a pediatric-adapted ASA-PS classification and to solicit multicenter perspectives to optimize the pediatric ASA-PS classification.

Methods: A prospective, mixed-methods study of 197 pediatric anesthesiologists from 13 academic pediatric hospitals in the United States, Europe, and Australia surveyed in May and July 2019. Participants assigned ASA-PS scores (I to V) for 15 pediatric cases with a heterogeneous mix of acute and chronic health conditions undergoing a variety of surgical and related procedures. Pediatric-adapted definitions of ASA-PS were provided. The intraclass correlation coefficient (ICC) was used to assess interrater reliability of ASA-PS scores. The ICC was estimated using 2-way mixed-effects modeling, accounting for multiple raters assigning scores for the same set of cases. Qualitative feedback on the pediatric-adapted ASA-PS classification was analyzed with line-by-line coding.

Results: The survey response rate was 83.8% (165 of 197). The ICC agreement among participants on ASA-PS scoring across all 15 clinical cases was 0.58 (95% confidence interval [CI], 0.42-0.77). ICC did not vary significantly by years of anesthesiology practice. ICC varied across hospitals (range: 0.34; 95% CI, 0.12-0.63 to 0.79; 95% CI, 0.66-0.91). The highest level of agreement occurred with cases most often scored as ASA-PS I, IV, and V; the lowest agreement occurred with cases most often scored ASA-PS II and III. Clarification of how well a chronic condition was controlled and presence of an acute illness were 2 common themes suggested to optimize the validity of the pediatric-adapted ASA-PS definitions.

Conclusions: The pediatric-adapted ASA-PS classification had moderate interrater reliability among pediatric anesthesiologists. The lower reliability of scoring for ASA-PS II and III cases, in particular, supports the need for further ASA-PS definition refinement for pediatric populations.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Age Factors
  • Anesthesiologists*
  • Australia
  • Child
  • Child, Preschool
  • Europe
  • Female
  • Health Status Indicators*
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Observer Variation
  • Perioperative Care
  • Predictive Value of Tests
  • Prospective Studies
  • Reproducibility of Results
  • Risk Assessment
  • Risk Factors
  • Surgical Procedures, Operative* / adverse effects
  • Surgical Procedures, Operative* / mortality
  • United States