Daza JF; University of Toronto, Toronto, Ontario, Canada
Chesney TR; Morales JF; Xue Y; Lee S; Amado LA; Pivetta B;
Mbadjeu Hondjeu AR; Jolley R; Diep C; Alibhai SMH; Smith PM; Kennedy ED;
Racz E; Wilmshurst L; Wijeysundera DN

Annals of Internal Medicine. 178(1):75-87, 2025 Jan.

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.