Letter: Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery

To the Editor: An article by Reponen et al1 suggests the importance of considering patient-reported and patient-centered health status for prognostication of neurosurgical patients. In an unselected sample of 322 adult patients undergoing elective craniotomy mostly for brain tumors and vascular lesions, the authors found that diminished cognitive functioning, worse subjective perceived overall health status, and poor perceived physical status before surgery were associated with increased risk for major postoperative in-hospital complications.1 Composite patient-reported factor score that included 2 questions about overall perceived health status and ability to climb 2 flights of stairs, as well as score on the Test Your Memory test had better predictive ability for in-hospital complication risk than the American Society of Anesthesiologists score that was not associated with postoperative complication risk. In multivariate regression analyses that included 3 patient-reported outcome measures, only cognitive status predicted complication risk. The study findings are intriguing and draw our attention towards patient safety and importance of considering patient-centered health status perspective for prognostication and surgical decision making of neurosurgical patients. However, it remains less clear if the proposed patient-reported prognostic model can improve prognostic value of commonly used clinical prognostic indicators. For example, advanced age is associated with greater risk of postoperative complications and adverse outcomes, and is commonly considered for surgical decision making.2 Cognitive functioning and physical status decline with advancing age; therefore, it is difficult to explain the observed association between cognitive and physical status with postoperative neurological and medical complication risk if the patient's age and disease severity are taken out of this equation. Preoperative steroid use was also linked to greater infectious complication risk after elective cranial neurosurgery but preoperative medication use was not considered in the present report.3 It would be interesting to see if the proposed prognostic model would retain its predictive ability independently from clinical prognostic indicators, such as patient age, disease severity, and medication use. The Test Your Memory score is well validated cognitive status assessment instrument.4 However, validity of questions pertaining to perceived health status and ability to climb 2 flights of stairs is less clear. For example, the stair climbing test is commonly used for assessment of cardiorespiratory fitness5 but reliability of self-report assessment is less clear. Therefore, it would be interesting to see if patient-reported factors used in the present report were reliable measures and were associated with patients’ age and clinical characteristics. Postoperative delirium is a common complication among elderly patients undergoing cranial and spinal neurosurgical procedures and was linked to greater complication risk and worse outcomes.6,7 Preoperative cognitive impairment, advanced age, and poor functional status are associated with greater postoperative delirium risk after neurosurgical procedures.7 The proposed preoperative risk stratification algorithm could aid towards identifying patients at elevated postoperative delirium risk after neurosurgery. Due to aging population and increasing life-expectancy, the number of elderly patients needing neurosurgical interventions and presenting with age-related comorbidities is constantly rising and will continue to grow.8,9 Prognostication of short-term and long-term outcomes of neurosurgical patients rests mainly on patient's age, functional status, and clinical disease severity.10,11 However, incurable and dismal nature of certain neurosurgical disorders underscores the importance of patient-centered health status consideration for patient-care and surgical decision making.12,13 The article by Reponen et al1 contributes to the growing body of literature underscoring the potential clinical value of patient-reported and patient-centered characteristics for surgical decision making and prognostication of neurosurgical patients. Evidence-based guidelines and recommendations by professional neurosurgical organizations regarding optimal assessment strategy of patient-centered health status could potentially enable wider adoption of patient-centered health status assessment for clinical purposes. Therefore, further research studies evaluating optimal patient-centered health status assessment strategies of neurosurgical patients are encouraged. Firstly, multidisciplinary research efforts should be directed towards identifying and/or establishing disease-specific and situation-specific patient-centered measures.13 While generic questionnaires are usually well-validated, commonly used and may allow comparing patient-centered health status across diseases, but they often prevent from taping the most important symptoms, lack sensitivity for detecting subtle temporal changes of perceived health status over time and their completion is usually time consuming.14,15 Secondly, diagnostic and psychometric properties as well as clinical prognostic value of the selected patient-centered health status assessment tools as well as the most optimal administration method (interview vs self-rating questionnaire) should be established. Only valid and reliable instrument should be used in clinical practice and for research purposes. Thirdly, it should be established whether incorporation of patient-centered health status assessment would not overburden available health-care resources and improve patient outcomes. Disclosures This research was supported by Research Council of Lithuania (grant number: MIP-044/2015). The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.