Keywords
pediatric patients, questionnaire, perioperative assessment, preanesthesia
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Arfaoui S, Htira M, Akremi S et al. Utility and Reliability of a Pediatric Preanesthesia Questionnaire: A Monocentric Prospective Study in a Tunisian Public Hospital [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:917 (https://doi.org/10.12688/f1000research.169194.1)
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Research Article
Utility and Reliability of a Pediatric Preanesthesia Questionnaire: A Monocentric Prospective Study in a Tunisian Public Hospital
[version 1; peer review: awaiting peer review]
PUBLISHED 12 Sep 2025
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Abstract
Corresponding author:
Samia Arfaoui
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2025 Arfaoui S et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Arfaoui S, Htira M, Akremi S et al. Utility and Reliability of a Pediatric Preanesthesia Questionnaire: A Monocentric Prospective Study in a Tunisian Public Hospital [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:917 (https://doi.org/10.12688/f1000research.169194.1)
First published: 12 Sep 2025, 14:917 (https://doi.org/10.12688/f1000research.169194.1)
Latest published: 12 Sep 2025, 14:917 (https://doi.org/10.12688/f1000research.169194.1)
Introduction
Preoperative evaluation is an essential step to ensure perioperative safety and effective anesthetic management, specifically in pediatric populations where physiological immaturity and variable medical histories demand tailored anesthetic planning. This evaluation is legally mandated in Tunisia through Circulars 206/2015 and 773/2015,1,2 and its importance is reinforced by international guidelines such as the American Society of Anesthesiologists’ ASA Practice Advisory on Preanesthesia Evaluation.3
At Habib Thameur Hospital, in accordance with practices in public health institutions,1,2 pediatric patients undergo a multi-step process: initial evaluation in pediatric surgery, routine laboratory and radiologic testing, followed by referral to the anesthesia clinic. Depending on the initial assessment, patients are either referred for further examinations or specialist consultations, or directly scheduled for surgery. This pathway, while comprehensive, is time- and resource-intensive, and often not adapted to low-risk patients, contributing to outpatient clinic saturation and logistical burden for families.
In response to these challenges, several international studies have assessed the utility of preanesthetic screening questionnaires as triage tools to enhance resource use.4–6 These tools have shown potential to reduce unnecessary in-person consultations while maintaining safety and quality of care.
The present study takes a step forward by evaluating the feasibility and potential benefits of integrating an easily accessible tool—the pediatric preanesthesia questionnaire—into the organizational framework of anesthesia consultation in a Tunisian public hospital.
Methods
Study design
This prospective, evaluative, single-center study was conducted from October 2022 to May 2023 in the Anesthesiology Outpatient Clinic of Habib Thameur Hospital, Tunis. The study was non-interventional, based on self-reported questionnaire data and medical assessment records.
We developed a questionnaire designed to be completed by the legal parents of minor patients, or with the help of trusted persons (pediatrician, close relative). It is a “paper-and-pencil” questionnaire available in two versions (Arabic and French), based on local medical experience in preanesthesia assessment and on guidelines from the literature.3–5 It consists of 43 closed questions divided into items related to medical and surgical history, anesthesia history and complications, allergies, blood transfusion history, current treatments, pregnancy and childbirth information, and infant and child health and growth information. Parents of pediatric patients answered dichotomous questions, with space provided for further optional details. The consulting nurse provided the questionnaire to parents on the day they scheduled their preanesthesia consultation and informed them about its purpose and content. All parents, especially those with limited literacy, were advised that if they sought help from a third party to complete the questionnaire, this would involve disclosing confidential medical information about their child to that individual. In this situation, we declined responsibility for such disclosures and informed parents of their option to withdraw from participation. The consent form was provided in both French and Arabic. Parents returned the questionnaire to the nurse on the day of the medical appointment.
The anesthesiologist examining the patient did not have access to the questionnaire data and conducted the medical assessment as usual.
A comparison between the data from the medical evaluation and the questionnaire data was subsequently carried out item by item.
Ethical considerations
This study was approved by the Habib Thameur Teaching Hospital Ethics Committee (Project Reference: HTHEC-2022-38). Informed consent was obtained from the legal guardians of all participating pediatric patients. The study adhered to the Declaration of Helsinki and ensured confidentiality by anonymizing patient data. Parents were informed about the voluntary nature of participation and the potential disclosure of medical information if third-party assistance was required.
Objective
The objective of our study was to establish the reliability and accuracy of our pediatric preanesthetic questionnaire in the preoperative management of the pediatric population.
Study population & sampling
We included 300 pediatric patients aged 1 month to 18 years, classified within the first three categories of the American Society of Anesthesiologists Physical Status Classification (ASA I–III), and scheduled for elective surgery or diagnostic procedures under general or local anesthesia.
Exclusion criteria included emergency surgeries, parental refusal to participate, and assessments conducted outside the outpatient clinic, where the questionnaire was not administered.
Statistical analysis
Data collection was conducted using IBM SPSS 25, and subsequent statistical analysis was performed with the same software. Statistical significance was set at a threshold of p < 0.05.
Our statistical approach consisted of two steps repeated for all items, and a third step for the ASA PS Class analysis:
▪ Step 1: The specialist preanesthetic medical evaluation was considered the “gold standard.” We compared preanesthesia questionnaire responses with medical assessment responses by examining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
▪ Step 2: We considered the medical evaluation and the preanesthesia questionnaire to be equivalent in terms of preanesthesia assessment and examined the agreement between the two methods as evidence of criterion validity.7 The agreement was measured using Cohen’s kappa coefficient (κ)7,8 and its statistical significance (p = 0.05). The κ coefficient serves as a criterion validity measure, with values ranging from +1 to −1; +1 signifies perfect agreement, 0 indicates agreement no better than chance, and −1 indicates complete disagreement. The interpretation of values between 1 and 0 is detailed below:
▪ Step 3: The study team generated an ASA PS classification for each patient based on the data in the corresponding questionnaire, then compared it with the actual ASA PS classification in the medical assessment document and analyzed the agreement using Cohen’s kappa coefficient (κ).
Sample size justification
The required sample size was calculated using the Cochrane formula for estimating proportions in clinical research:
Where:
▪ n is the required sample size,
▪ z is the z-score corresponding to the desired confidence level (1.96 for 95%),
▪ p is the estimated population proportion (set at 0.5 to account for maximum variability),
▪ m is the accepted margin of error (0.05 in this study).
Applying these parameters yielded an initial sample size of n=384.16. Given that the target population (N) comprised 1,278 pediatric patients aged 1 month to 18 years seen between October 1, 2022, and May 31, 2023, the finite population correction formula was applied:
This yielded an adjusted minimum sample size of 295.55, rounded to 296. As 300 patients were included in the study, the final sample exceeds the required threshold and is considered representative of the target population.
Data collection & blinding
Parents completed the paper-based questionnaire upon scheduling their preanesthesia consultation.
An independent anesthesiologist, blinded to the questionnaire responses, performed the standard medical evaluation.
A secondary comparison of questionnaire responses and medical assessment findings was conducted using sensitivity, specificity, PPV, NPV, and Cohen’s kappa coefficient (κ).
Results
Patient population and general characteristics
Among 300 consecutive pediatric patients assessed for eligibility in the preanesthesia clinic, all met the inclusion criteria (age 1 month–18 years, ASA I–III status, elective surgery) with no exclusions. A 100% questionnaire completion rate was achieved (n = 300), with all Arabic-language versions returned for analysis. Comparative evaluation against gold-standard medical assessments revealed excellent agreement (κ > 0.8) for 34 of 43 questionnaire items. The ASA Physical Status classification demonstrated near-perfect concordance (κ = 0.953), with nine items showing moderate-to-weak concordance and only five discordant cases (1.7%) requiring secondary review. No missing data were reported in any analyzed domain.
We included 300 pediatric patients in our evaluation over an 8-month period from October 2022 to May 2023.
The median age of patients was 48 months (IQR = [30–72]), with extremes ranging from 2 months to 17 years. Children under the age of 4 represented a substantial proportion of the study population (43.3%), indicating that nearly half of the patients undergoing elective procedures were in early childhood.
A male predominance was observed in our study series, with 254 boys (84.6%) participating in the survey.
Pediatric patients classified as ASA Physical Status II or III accounted for only 21.7% of the study population.
The literacy rate of our participants’ parents was 88%, and 71.7% of them had attained a secondary or university level of education.
Accuracy assessment
The questionnaire demonstrated strong predictive performance, with negative predictive values exceeding 90% across all items. Sensitivity ranged from 50% to 100%, reflecting a broad range of item responsiveness. In contrast, specificity remained consistently high, with only one exception—item 37, which showed a specificity of 75%. The accuracy parameters of the pediatric preanesthesia questionnaire are provided as extended data (Table I).9
Study of agreement
Agreement metrics for the questionnaire in comparison with the medical assessment components are provided in extended data (Table II).10 Eight out of 43 items showed a relatively lower level of agreement, with κ values ranging from 0.397 to 0.798. Conversely, perfect agreement (κ = 1) was observed for three items. This metric was not applicable (N/A) to item 28.
Except for the previously mentioned item 28, all other items demonstrated p-values below 0.05 for the kappa coefficient of agreement. This indicates a statistically significant level of agreement for these items.
Questionnaire items are arranged according to their corresponding kappa coefficients in extended data (Table III).11
ASA physical status class agreement
The ASA PS Class analysis showed a high level of agreement between the questionnaire-derived ASA classification and the medical assessment (κ = 0.953, p < 0.001).
The crosstabulation of ASA Physical Status classification shows an accuracy of 98.33% (295/300), available in extended data (Table IV).12
Discussion
Key findings
The pediatric preanesthesia questionnaire demonstrated strong diagnostic validity and operational feasibility. It achieved a 100% completion rate, reflecting high parental acceptability, likely facilitated by the 88% literacy rate among caregivers and the culturally adapted Arabic version, which was consistently chosen despite the availability of a bilingual format.
A substantial proportion of the studied population—43.3%—was under the age of 4, highlighting the predominance of early childhood within the surgical population. Given the developmental characteristics of this age group, including limited verbal communication, cognitive immaturity, and the necessity of proxy-reported anamnesis, these findings reinforce the relevance of using structured, parent-administered screening tools tailored to younger pediatric patients.
The study cohort was predominantly composed of ASA Physical Status I patients (78.3%), in alignment with the elective and low-risk profile of most procedures. The questionnaire displayed excellent specificity (>90%) in 42 out of 43 items and negative predictive values above 90% across all items, supporting its efficacy in ruling out anesthetic risk factors. While 13 items demonstrated sensitivity below 90%, the tool maintained an overall high discriminatory capacity.
Overall agreement between questionnaire responses and physician assessments was high, with Cohen’s kappa coefficients > 0.8 in 34 of the 43 items, signifying excellent reliability. Perfect agreement (κ = 1.000; p < 0.001) was observed in three key items: gastroesophageal reflux, prematurity, and cardiopathy, reflecting consistent recognition of clinically important conditions by caregivers.
Notably, the comparison between ASA classifications inferred from the questionnaire and those determined by physicians showed 98.3% concordance (295/300 cases) and a Cohen’s kappa of 0.953 (p < 0.001), reflecting near-perfect agreement. This validates the questionnaire’s capacity to accurately assess preanesthetic risk, specifically in identifying ASA I–III status, thereby supporting its role as a triage tool for optimizing outpatient workflows in pediatric anesthesia.
Limitations
Despite remarkable accuracy metrics, the questionnaire may sometimes provide incomplete or false information about a child’s health, which could jeopardize their safety. In 5 out of 300 cases, the ASA classifications were discordant. A systematic preanesthetic medical check-up can address this issue. Future studies should analyze why misclassifications occur and whether specific items contribute to these discrepancies.
To measure the questionnaire’s consistency over time and the stability of participant responses, future research should conduct a test–retest analysis by re-administering the questionnaire after 15 days. Goldbloom et al. used five different test–retest sequences to analyze the reliability of the pediatric HealthQuiz.5
Although the 100% completion rate suggests acceptance, a formal satisfaction assessment (e.g., Likert scale) is crucial to evaluate parental perceptions of the pediatric preanesthesia questionnaire.
One notable drawback is the reliance on physical presence, as patients need to visit the healthcare facility to complete the questionnaire on paper. This format could also create logistical challenges related to physical storage, retrieval, and maintenance of paper records, which may pose security and privacy issues.
As technology advances, a digital version could enhance accessibility, though low digital literacy in our population may limit adoption.
The evolution of assessment methods
Preanesthetic assessment has evolved significantly in response to increasing demands for safety, efficiency, and adaptability in perioperative care.
Dr. Alfred Lee first proposed the concept of structured preoperative evaluation in 1949,13 emphasizing early patient optimization and criticizing last-minute assessments. He advocated for dedicated preanesthesia clinics, particularly for medically complex patients. In the early 1990s, Fischer14 expanded on this model at Stanford University by creating a multidisciplinary clinic integrating consultations, laboratory services, and access to medical records.
To reduce hospital visits, Digner introduced a telephone-based preanesthesia evaluation for outpatient surgery candidates,15 effectively reducing hospital stays and cancellations. A French study further confirmed that phone-based assessments were as practical as in-person consultations for cardiopulmonary risk screening and were well appreciated by patients.16
An important advance came with the use of preanesthesia questionnaires, particularly in non-cardiac surgery. Badner et al.6 developed a screening system in which only patients with positive responses were referred to anesthesiologists, reducing unnecessary consultations by up to 84%, with only 6% misclassification.
Later studies confirmed the utility of computer-assisted questionnaires, which improved the accuracy of patient history and were well accepted by both adults and parents of pediatric patients.17,18 They also proved effective in identifying cases requiring face-to-face consultation.19,20 One study in the 1980s reported 96% accuracy in computerized history-taking (p < 0.0005), and anesthetist information uptake improved significantly when summaries were available (82.18% vs. 73.75%; p < 0.005).17
In pediatrics, Goldbloom et al.5 validated the HealthQuiz, a digital tool for children aged 1 month to 12 years, demonstrating high reliability and agreement, similar to our findings. However, our study relied on a bilingual, paper-based format specifically adapted to the Tunisian population and included a broader age range, including patients up to 18 years old.
More recently, in 2016, a team at the University of Alabama at Birmingham developed a tablet-based preanesthesia questionnaire.21 A single positive response triggered a face-to-face consultation, typically delaying surgery by 21 days. The tool was validated by four anesthesiologists, ensuring its clinical reliability.
Parental role
The involvement of parents in pediatric anamnesis is a key component due to the unique challenges in obtaining comprehensive information from young children. The limited cognitive and expressive abilities of children, combined with their developmental immaturity, make it difficult for practitioners to fully understand their condition. Consequently, parents serve as essential informants, bridging this communication gap and providing valuable insights into their child’s health, developmental milestones, previous illnesses, and any notable concerns or observations.22,23
General applicability and future perspectives
The pediatric preanesthesia questionnaire demonstrated robust reliability and high agreement with physician assessments, evidenced by a 100% completion rate and its applicability to a wide pediatric age range (1 month to 18 years). These elements support its feasibility and representativeness within elective pediatric surgery. However, several factors may influence its generalizability.
The study was conducted in one public hospital in Tunisia, using consecutive sampling rather than randomization, which may introduce selection bias. As a result, applying these findings to different healthcare settings, especially those with distinct cultural, economic, or systemic characteristics, requires careful consideration. The study focused on patients categorized as ASA Physical Status I to III, deliberately excluding emergency procedures and higher-risk populations. This choice limits the questionnaire’s applicability in more acute or complex perioperative scenarios. Furthermore, rare but clinically important conditions such as inherited anesthesia-related disorders and certain myopathies were not well represented, which may limit the tool’s effectiveness in identifying risks in these less common but high-stakes situations.
The linguistic and cultural relevance of the tool was underscored by the fact that all caregivers selected the Arabic version of the questionnaire, despite the availability of a bilingual format. This finding emphasizes the need for validated translations and cultural adaptations before its application in non-Arabic-speaking populations. The literacy rate among caregivers in our cohort (88%) likely contributed to the tool’s acceptability; however, its use in populations with lower literacy levels may require simplified or assisted formats to maintain effectiveness and reliability.
This study builds upon existing questionnaire-based models, such as those developed by Badner et al.6 for adults and Goldbloom et al.5 for children, which have demonstrated the potential to reduce unnecessary in-person consultations by up to 84%. Unlike models implemented in fully digitized or AI-assisted healthcare systems,24 our study relied on a paper-based format and did not assess integration with telemedicine or electronic medical record systems in modern healthcare environments.
Future perspectives include developing and validating a digital version of the questionnaire with adaptive features to enable remote preanesthetic triage via telehealth platforms. To enhance external validity, future research should involve multicenter studies across diverse healthcare settings, including populations with lower literacy levels, different linguistic backgrounds, and higher-risk surgical profiles.
Conclusion
The pediatric preanesthesia questionnaire is a simple, feasible, and well-accepted triage tool that optimizes outpatient workflows, particularly for ASA I patients, by reducing unnecessary face-to-face consultations and potentially lowering healthcare costs. While it cannot replace the mandatory anesthetic consultation, it can streamline preoperative assessment without compromising patient safety.
Future research should explore its impact on anesthetic decision-making, assess test–retest reliability, and evaluate parental satisfaction. Developing a digital version suitable for telemedicine could improve accessibility and efficiency, though attention should be paid to equity in digital access, especially in low-resource settings.
In summary, the questionnaire shows strong potential as a supportive tool to enhance preanesthetic evaluation, particularly in resource-limited healthcare environments.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Habib Thameur Teaching Hospital (Project Reference: HTHEC-2022-38). Written informed consent was obtained from the legal guardians of all participating pediatric patients. The study adhered to the Declaration of Helsinki.
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how to cite this article
Arfaoui S, Htira M, Akremi S et al. Utility and Reliability of a Pediatric Preanesthesia Questionnaire: A Monocentric Prospective Study in a Tunisian Public Hospital [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:917 (https://doi.org/10.12688/f1000research.169194.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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