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Background: Multiple preoperative calculators are available online to predict preoperative mortality risk for noncardiac surgical patients. However, it is currently unknown how these risk calculators perform across different raters. The current study investigated the interrater reliability of three preoperative mortality risk calculators in an elective high-risk noncardiac surgical patient population to evaluate if these calculators can be safely used for identification of high-risk noncardiac surgical patients for a preoperative multidisciplinary team discussion. Methods: Five anesthesiologists assessed the preoperative mortality risk of 34 high-risk patients using the preoperative score to calculate postoperative mortality risks (POSPOM), the American College of Surgeons surgical risk calculator (SRC), and the surgical outcome risk tool (SORT). In total, 170 calculations per calculator were gathered. Results: Interrater reliability was poor for SORT (ICC (C.I. 95%) = 0.46 (0.30–0.63)) and moderate for SRC (ICC = 0.65 (0.51–0.78)) and POSPOM (ICC = 0.63 (0.49–0.77). The absolute range of calculated mortality risk was 0.2–72% for POSPOM, 0–36% for SRC, and 0.4–17% for SORT. The coefficient of variation increased in higher risk classes for POSPOM and SORT. The extended Bland–Altman limits of agreement suggested that all raters contributed to the variation in calculated risks. Conclusion: The current results indicate that the preoperative risk calculators POSPOM, SRC, and SORT exhibit poor to moderate interrater reliability. These calculators are not sufficiently accurate for clinical identification and preoperative counseling of high-risk surgical patients. Clinicians should be trained in using mortality risk calculators. Also, clinicians should be cautious when using predicted mortality estimates from these calculators to identify high-risk noncardiac surgical patients for elective surgery. Highlights: -Interrater reliability for POSPOM, SRC and SORT preoperative mortality risk predictors is lower than expected. -Clinicians need to use preoperative mortality risk calculators with caution when using them for identification and preoperative counseling of high-risk noncardiac surgical patients. -In this study all raters using POSPOM, SRC and SORT for preoperative mortality risk calculation, contributed to variability in risk estimates. [ABSTRACT FROM AUTHOR]

Background and purpose — Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients. Patients and methods — Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference. Results — In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication. Interpretation — This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated. [ABSTRACT FROM AUTHOR]

Context.-- Total serum bilirubin (TSB) analysis is pivotal for diagnosing neonatal hyperbilirubinemia. Because of a routine change in laboratory equipment, our TSB assay changed from a diazo to a vanadate oxidase method. Upon implementation, TSB results were substantially higher in newborns than expected based on the validation. Objective.-- To investigate the application of TSB and intermethod differences in neonates and their impact on phototherapy treatment. Design.-- The diazo and vanadate methods were compared directly using neonatal and adult samples. Anonymized external quality control data were analyzed to explore interlaboratory differences among 8 commercial TSB assays. Clinical patient data were extracted from the medical records to investigate the number of newborns receiving phototherapy. Results.-- The mean bias of the vanadate versus the diazo TSB method was +17.4% and +3.7% in neonatal and adult samples, respectively. External quality control data showed that the bias of commercial TSB methods compared with the reference method varied from -3.6% to +20.2%. Within-method variation ranged from 5.2% to 16.0%. After implementation of the vanadate TSB method, the number of neonates treated with phototherapy increased approximately threefold. Conclusions.-- Currently available TSB assays lack harmonization for the diagnosis of neonatal hyperbilirubinemia. Between-methods differences are substantially higher in neonatal compared with adult samples, highlighting the importance of including neonatal samples during assay validation. Close collaboration between laboratory specialists and clinicians is essential to prevent overtreatment or undertreatment upon the implementation of novel analyzers or assays. Also, harmonization of TSB assays, with an emphasis on neonatal application, is warranted. [ABSTRACT FROM AUTHOR]