Response: Re: Developing and Validating a Novel Tool to Enhance Functional Status Assessment: The Tennessee Functional Status Questionnaire (TFSQ)

To the Editor: Thank you, Dr. Ogbeide, for your thoughtful inquiry regarding our article “Developing and Validating a Novel Tool to Enhance Functional Status Assessment: The Tennessee Functional Status Questionnaire (TFSQ).”^1,2 We are pleased that you see value in our published tool related to functional assessment. Our team is very excited at the prospect of the tool being utilized within your specific surgical specialty.

We would like to provide some clarification on the relative interpretation of the TFSQ in clinical practice. The TFSQ provides five distinct data points that may be viewed collectively or individually to inform on patient care regarding current and future functional status. Although an affirmative answer to TFSQ Question #5 (Acute Care) is statistically associated with a reduction in the METS reported for TFSQ Question #2 (Functional Capacity), this is meant to be more of an indication of how the functional capacity may be lower at present, as opposed to being a potential predictor of future surgical risk.

Our team recently collaborated with our surgical colleagues to develop a more robust preoperative surgical assessment instrument, the Tennessee Preoperative Assessment Tool (TPAT),³ where we incorporated the 5-question TFSQ with nine other questions associated with poor postoperative outcomes. In the preliminary implementation study, TFSQ Question #3 (decreased activity in the previous 60 days) strongly predicted numerous adverse postoperative events and TFSQ Question #5 was significantly associated with postoperative hemorrhage.

There is undoubtedly a difference between coincidental, postoperative emergency department (ED) visits and ED visits related to major surgical complications. Delineating between both occurrences may be of value for both functional and perioperative assessment. Thank you for that observation and suggestion. It may be pertinent to make a revision to TFSQ Question #5 so that the question focuses on an ED/hospital/surgery visits related to some sort of trauma, pathology, or detrimental medical diagnosis that could adversely affect METs. Indeed, one of our future research initiatives is to create a TFSQ index value to provide a single score that combines the METS values reported in TFSQ Question #1 (performance) and TFSQ Question #2 (capacity) with weighted modifiers based on responses to TFSQ Questions #3, #4 (Pain), and #5.

We hope that further simplifying the TFSQ reporting while maintaining the robust data collected from the five TFSQ items will increase the validity, interpretability, and utility of the tool. We also hope to equip clinicians with the information needed to advocate for functional optimization and appropriate patient care. Thank you again for your time and interest in our tool!