Surgical risk assessment tools
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Overview of Surgical Risk Assessment Tools
Surgical risk assessment tools are designed to predict the likelihood of postoperative complications or mortality by analyzing patient and procedure-specific factors. These tools help clinicians in preoperative counseling, surgical decision-making, and resource allocation, and are used across various surgical specialties and patient populations, including pediatric, adult, and elderly patients 125.
Commonly Used Surgical Risk Assessment Tools and Their Performance
Several objective risk assessment tools are widely used, such as the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), Surgical Outcome Risk Tool (SORT), Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Hospital Frailty Risk Score (HFR), and the American College of Surgeons Surgical Risk Calculator (ACS-NSQIP) 2710. In total knee arthroplasty, for example, the ECI has been shown to outperform CCI and HFR in predicting 30-day postoperative outcomes, including mortality and complications . In emergency surgery, both the SURPAS and ACS-NSQIP calculators accurately predict mortality and specific complications, but SURPAS provides a more accurate estimate of overall morbidity .
In pediatric surgery, risk assessment tools often focus on factors such as cardiovascular or neurological diseases and history of prematurity. These models have demonstrated good to strong predictive ability, with c-statistic values ranging from 0.77 to 0.98 .
Subjective Versus Objective Risk Assessment
Despite the availability of validated risk calculators, many clinicians still rely heavily on subjective clinical judgment. Studies show that subjective assessment alone is used in the majority of cases, and its predictive accuracy is similar to that of the best objective tools, such as SORT. However, combining subjective assessment with objective tools further improves risk prediction accuracy (AUROC up to 0.92) .
Barriers to the Use of Risk Assessment Tools
Risk assessment tools remain underutilized in clinical practice. Surveys of surgeons and trainees reveal that only a minority use risk calculators routinely, with barriers including lack of time, inaccessibility, and concerns about accuracy 369. Surgeons are more likely to use their own experience and literature, while residents and trainees are more open to using risk calculators, especially for high-risk or elderly patients 369. In emergency general surgery, accessibility and perceived complexity are additional barriers .
Evolution and Future Directions in Risk Assessment
Risk assessment tools have evolved from broad, general stratification models to more sophisticated, procedure-specific calculators. In spine surgery, for example, newer models incorporate factors such as frailty, invasiveness, genetic biomarkers, and sarcopenia, and are increasingly using machine learning and artificial intelligence to improve predictive accuracy 48. For elderly patients, frailty-based tools like mFI and SURPAS are promising, as frailty may be a better predictor of risk than age alone .
Predicting Patient-Centered Outcomes
Recent research has focused on using risk assessment tools to predict not only complications and mortality but also patient-centered outcomes such as pain, disability, quality of life, and return to work. These models show fair to excellent performance (c-index 0.63–0.84) and can help guide shared decision-making and set realistic expectations for recovery .
Conclusion
Surgical risk assessment tools are valuable for predicting postoperative outcomes and guiding clinical decisions. While several validated tools exist and perform well, their routine use is limited by practical barriers and reliance on clinical judgment. Combining subjective and objective assessments offers the best predictive accuracy. Ongoing advancements, including the integration of frailty measures, patient-reported outcomes, and artificial intelligence, are likely to further enhance the utility and accuracy of surgical risk assessment tools across diverse patient populations and surgical specialties 12345678+2 MORE.
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