In Reply

We thank Drs. Avidan and Weiniger for their comments related to our article, “Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients.”¹  They posit that the addition of objective examples to the previously subjective American Society of Anesthesiologists Physical Status (ASA-PS) Classification System may hinder the universal application of the ASA-PS score by unnecessarily increasing the complexity of the system.

As stated in their letter, “the ASA score has penetrated beyond anesthesia.” It is our belief that this is exactly why the examples should be used. With the increasing use of the ASA-PS score by nonanesthesia providers, there are many assigning ASA-PS who do not have the anesthesia-related training to understand the differences between classifications. Although we agree that physician anesthesiologists currently use “common sense” in determining the ASA-PS, the gestalt that many of us have in applying the ASA-PS in practice may not exist for those who do not have experience in anesthesiology. Additionally, poor interrater reliability for the ASA-PS has been shown repeatedly.^2–4  For these reasons, the ASA-PS examples may ultimately prove more useful for nonanesthesia providers than anesthesia ones. As we demonstrated, with examples there was improvement in correct assignment for anesthesia and nonanesthesia providers with no significant difference in the rate of correct assignment between anesthesia-trained and nonanesthesia clinicians.¹  We reiterate that the examples are guidelines and recognize the list is not comprehensive; the examples should provide a framework indicating the most likely appropriate ASA-PS score for commonly encountered diseases. The final determination of ASA-PS should be made by a physician anesthesiologist. We recognize that until further studies are done, the true effect of these examples in clinical practice is yet to be seen. We agree that uniform application across the board, even with examples, is unlikely, but given the inconsistency that already exists with ASA-PS score assignments, it is hard to argue that an addition with the potential to improve objective scoring should not be used clinically.