Study finds evidence gaps among functional capacity assessment tools used before elective surgeries
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00413
Editorial: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02405
URL goes live when the embargo lifts
A scoping review of studies evaluating the performance of functional capacity (measure of a patient’s cardiopulmonary fitness) assessment tools administered before elective non-cardiac surgery found that prior research has overwhelmingly focused on predictive validity of functional capacity tests, including cardiopulmonary exercise testing (CPET). The majority of patients in the evaluated studies were involved in studies of CPET (accurate but not accessible) or unstructured assessment (accessible but not accurate). This is important because nearly every preoperative evaluation of a patient scheduled for surgery involves an assessment of functional capacity. The findings are published in Annals of Internal Medicine.
Researchers from Unity Health Toronto and the University of Toronto conducted a scoping review of 243 original studies to identify which assessment tools have been studied before surgery, what key performance characteristics of these tools have been included in studies, and if clinically relevant subgroups of patients (older adults and patients with obesity, lower limb arthritis or physical disability) have been included in studies. Of the studies reviewed, the researchers identified 26 different tools to assess functional capacity. The researchers found that studies of functional capacity assessment tools focused extensively on their ability to predict future clinical events, and just 4% focused on acceptability to patients, suggesting a mismatch between the research being done and the clinical needs in many health care settings. Most studies included an older patient population, and many studies excluded patients with a physical impairment, with more than a quarter of studies excluding those with a disability. CPET, which is widely considered the gold standard of assessing functional capacity, remains the most extensively researched tool in the surgical setting, however, widespread implementation of CPET is limited because it relies on expensive equipment and skilled personnel and is also time consuming.
According to the study authors, the review highlights some important areas for research -such as the role of simpler objective exercise tests (e.g., walking tests), the feasibility of different exercise tests, the accuracy of standardized questionnaires, and the performance of tests in vulnerable populations (e.g., individuals with obesity, arthritis, or disability). In addition, research has focused narrowly on whether a tool can predict outcomes, as opposed to some other important characteristics, such as whether patients find it acceptable, whether it is feasible, and whether the results impact on clinical care in a meaningful manner.
An accompanying editorial by Lauren E. Gibson, MD and Jeanine P. Wiener-Kronish, MD of Massachusetts General Hospital highlights the opportunities for the preoperative cardiovascular assessment landscape to evolve in the next 50 years. The authors note that the focus of the preoperative assessment is no longer to avoid complications but to optimize patients for surgery. They suggest a holistic approach that includes assessing a patient’s baseline functional status, enhancing cardiopulmonary endurance and cognition before surgery through prehabilitation and laying out a plan for postoperative rehabilitation. The authors state that by embracing new strategies and tools, including utilization of wearables and adoption of prehabilitation to optimize physical and cognitive health before surgery, we can transform surgery from a hurdle to a launching pad for improved health.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Duminda N. Wijeysundera MD PhD FRCPC, please email communications@unityhealth.to.
