Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 4, pp 461–466 | Cite as

Four questions to identify patients with ASA III or higher

  • Bernhard Springer
  • Ulrich Bechler
  • Andi Kolodny
  • Kilian Rueckl
  • Friedrich BoettnerEmail author
Orthopaedic Surgery



Increased age, obesity, and American Society of Anesthesiologists (ASA) Physical Status class III and IV have been reported as predictors for mortality and perioperative complications. High-volume institutions rely on central referral services as first contact point for patients. The current study reports on a simple four-step questionnaire to identify patients with ASA-physical status class III and IV to improve referral processes and optimize perioperative work ups.

Materials and methods

Seven hundred and seventy-five patients who called the physician referral service (PRS) at the author’s institution and subsequently underwent surgery were enrolled in this study. The answers to the initial PRS questionnaire were analyzed. The study cohort consisted of 414 women (53.4%) and 361 men (46.6%) with an average age of 61.4 years (range 44–90 years) at the time of surgery.


Binary logistic regression revealed hypertension, diabetes mellitus (using medication), using blood thinner (other than Aspirin) and a number of 4–9 prescribed medication, respectively, as predictors for ASA III and IV. Receiver-operating characteristic (ROC) curve analysis identified a sensitivity of 82.4%, a specificity of 82.9%, and an accuracy of 82.8%, when two of these four questions are answered “yes”. The area under the curve for this analysis was 0.876 [95% confidence interval (CI) 0.845–0.908]. Positive and negative likelihood ratios were 4.8 (95% CI 4.0–5.8) and 0.2 (95% CI 0.1–0.3), respectively.


This study revealed a simple four-step questionnaire to identify patients with ASA III or IV before a medical appointment. This helps to balance referrals between multiple providers in high-volume medical groups.


Total hip arthroplasty (THA) Total knee arthroplasty (TKA) ASA-physical status classification Questionnaire Prediction of perioperative risk 



No external funding was received for this study.

Compliance with ethical standards

Conflict of interest

Dr. Boettner has received royalties by Smith and Nephew and Orthodevelopment. 
Dr. Boettner has also received compensation by Smith and Nephew, Orthodevelopment, and DePuy. All other authors have no conflict of interest.

Research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Adult Reconstruction and Joint Replacement DivisionHospital for Special SurgeryNew YorkUSA
  2. 2.Physician Referral ServiceHospital for Special SurgeryNew YorkUSA

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