Nicole Michael, BA John Smith, MD Tricia St. Hilaire, MPH

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Complication Classification for Growing Spine Surgery has Strong Observer Agreement Nicole Michael, BA John Smith, MD Tricia St. Hilaire, MPH Claire Palmer, MS Micaela Cyr, BA Jessica Morgan, BS Victoria Heagy, MS Nikki Bloch, BA Mark Erickson, MD, MMM Children’s Spine Study Group Sumeet Garg, MD sumeet.garg@childrenscolorado.org

Complication Severity Score for Growth Friendly Surgery Background Complication Severity Score for Growth Friendly Surgery Grade Device Related Disease Related I Does not require unplanned surgery Outpatient medical management only II Inpatient medical management IIA Requires 1 unplanned surgery IIB Requires multiple unplanned surgeries III Requires abandoning growth-friendly strategy IV Death Smith JT, Johnston C, Skaggs D, Flynn J, Vitale M. A New Classification System to Report Complications in Growing Spine Surgery: A Multicenter Consensus Study. Journal of Pediatric Orthopaedics. 2015 Dec;35(8):798-803.

Research Question Purpose Hypothesis To show the inter-rater and intra-rater reliability for use of the Complication Severity Score for Growing Spine Surgery Hypothesis The Complication Severity Score will show high levels of both inter- and intra-rater reliability

Methods Two pediatric hospitals queried an Early Onset Scoliosis database for complications of patients undergoing growth friendly treatment Block randomization was used to select complication cases and build survey 63-question survey sent to pediatric spine faculty and research coordinators Reviewers determined the complication severity score Surveys sent twice to test intra-rater reliability 20 total participants completed the survey twice 12 faculty, and 8 research coordinators

Methods Cohen’s Kappa used to asses intra-rater reliability Kappa value Degree of agreement <=0 Poor 0-0.2 Slight 0.2 - 0.4 Fair 0.4 - 0.6 Moderate 0.6 - 0.8 Substantial 0.8 - 1 Almost perfect Cohen’s Kappa used to asses intra-rater reliability Fleiss Kappa used to asses inter-rater reliability

Results Overall Cohen’s Kappa for intra-rater reliability: almost perfect All raters, 0.86 (95% CI: 0.84-0.88) Faculty, 0.87 (95% CI: 0.85-0.90) Coordinators, 0.85 (95% CI: 0.81-0.88)

Results Overall Fleiss Kappa for inter-rater reliability: almost perfect All raters, 0.86 (95%Cl: 0.86-0.87) Faculty, 0.86 (95% CI: 0.85-0.88) Coordinators, 0.87 (95% CI: 0.85-0.88)

Device related complications: inter-rater reliability with 95% CI *Fellows not included because there were only 2 responses Almost perfect for Device I and IIB Did not measure reliability for Device Related IV category because no applicable complications from either institution.

Disease related complications: inter-rater reliability with 95% CI *Fellows not included because there were only 2 responses Almost perfect for Disease I, II, and IV Did not measure reliability for Disease III category because no applicable complications from either institution.

Conclusions Complication Severity Score for Growth Friendly Surgery shows very strong levels of inter-rater and intra-rater reliability Both overall and among individual severity score Device IIA and III are more difficult to classify This is a reliable tool for standardizing inconsistencies in reporting complications *Fellows not included because there were only 2 responses

References 1. Lenke, L.G., et al., Adolescent idiopathic scoliosis a new classification to determine extent of spinal arthrodesis. The Journal of Bone & Joint Surgery, 2001. 83(8): p. 1169-1181. 2. Clavien, P.A., et al., The Clavien-Dindo classification of surgical complications: five-year experience. Annals of surgery, 2009. 250(2): p. 187-196. 3. Sink, E.L., et al., Reliability of a complication classification system for orthopaedic surgery. Clinical Orthopaedics and Related Research®, 2012. 470(8): p. 2220-2226. 4. Williams, B.A., et al., Development and Initial Validation of the Classification of Early-Onset Scoliosis (C- EOS). The Journal of Bone & Joint Surgery, 2014. 96(16): p. 1359-1367. 5. Park, H.Y. The Classification for Early Onset Scoliosis (C-EOS) Predicts Timing of VEPTR Anchor Failure. in 2013 AAP National Conference and Exhibition. 2013. American Academy of Pediatrics. 6. Cummings, R.J., et al., Interobserver Reliability and Intraobserver Reproducibility of the System of King et al. for the Classification of Adolescent Idiopathic Scoliosis*. The Journal of Bone & Joint Surgery, 1998. 80(8): p. 1107-11. 7. Fleiss, J.L., B. Levin, and M.C. Paik, Statistical methods for rates and proportions. 2013: John Wiley & Sons. 8. Cohen, J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 1960. 20(1): p. 37-46. 9. Landis, J.R. and G.G. Koch, The measurement of observer agreement for categorical data. biometrics, 1977: p. 159-174. 10. Smith JT, Johnston C, Skaggs D, Flynn J, Vitale M. A New Classification System to Report Complications in Growing Spine Surgery: A Multicenter Consensus Study. Journal of Pediatric Orthopaedics. 2015 Dec;35(8):798-803.