Impact of daily, weekly, and seasonal surgical timing on postoperative outcomes in high-risk patients undergoing elective non-cardiac surgery: A retrospective, single-center study

Ji-Hoon Sim; Yong-Seok Park; Bumwoo Park; Yeseul Choi; Joon Seo Lim; Seungil Ha; Joung Uk Kim

doi:10.1016/j.jclinane.2025.111879

Impact of daily, weekly, and seasonal surgical timing on postoperative outcomes in high-risk patients undergoing elective non-cardiac surgery: A retrospective, single-center study

J Clin Anesth. 2025 May 26:105:111879. doi: 10.1016/j.jclinane.2025.111879. Online ahead of print.

Authors

Ji-Hoon Sim¹, Yong-Seok Park², Bumwoo Park³, Yeseul Choi⁴, Joon Seo Lim⁵, Seungil Ha², Joung Uk Kim²

Affiliations

¹ Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address: jihoon_sim@amc.seoul.kr.
² Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
³ Big Data Research Center, Asan Medical Center, Seoul, Republic of Korea.
⁴ Division of Artificial Intelligence and Software, Ewha Womans University, Seoul, Republic of Korea.
⁵ Clinical Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

PMID: 40424777
DOI: 10.1016/j.jclinane.2025.111879

Abstract

Background: Limited knowledge exists on the impact of surgical start timing on outcomes in high-risk patients. This study assessed its association with mortality, morbidity, and healthcare resource utilization in elective non-cardiac surgery.

Methods: A retrospective cohort study was conducted at a tertiary medical center, including 14,394 high-risk patients (ASA ≥ 3) undergoing elective non-cardiac surgery from 2012 to 2021. Patients were grouped by surgical start time into detailed time intervals (8:00-11:00 a.m., 11:00 a.m.-1:00 p.m., 1:00-3:00 p.m., 3:00-6:00 p.m.) and broader periods (morning vs. afternoon). Weekly (Monday-Wednesday vs. Thursday-Friday) and seasonal (spring, summer, fall, winter) variations were analyzed. Cox and logistic regression models assessed mortality, complications, and healthcare utilization.

Results: Afternoon surgeries were associated with higher mortality at 90 days (adjusted hazard ratio [aHR]: 1.28, 95 % confidence interval [CI]: 1.05-1.57, P = 0.016), 180 days (aHR: 1.30, 95 % CI: 1.12-1.51, P < 0.001), and 1 year (aHR: 1.26, 95 % CI: 1.13-1.40, P < 0.001), as well as overall mortality (aHR: 1.16, 95 % CI: 1.09-1.23, P < 0.001). Afternoon surgeries were also linked to higher composite complications (adjusted odds ratio [aOR]: 1.21, 95 % CI: 1.11-1.33, P < 0.001) along with higher intensive care unit admission (aOR: 1.40, 95 % CI: 1.28-1.52, P < 0.001) and red blood cell transfusion (aOR: 1.40, 95 % CI: 1.22-1.61, P < 0.001). Surgeries starting between 3:00 and 6:00 p.m. had the highest risk of 1-year mortality (aHR: 1.33, 95 % CI: 1.15-1.54, P < 0.001) and composite complications (aOR: 1.32, 95 % CI: 1.17-1.50, P < 0.001). Seasonal analysis showed higher 30-day (aHR: 1.80, 95 % CI: 1.08-2.99, P = 0.023) and 90-day mortality (aHR: 1.32, 95 % CI: 1.00-1.74, P = 0.048) in summer, and higher overall mortality (aHR: 1.10, 95 % CI: 1.01-1.19, P = 0.030) in winter. Subgroup analyses revealed variability by surgical type.

Conclusions: Surgical start timing was significantly associated with postoperative outcomes in high-risk patients, underscoring the need for strategic scheduling.

Keywords: High-risk patients; Morbidity; Mortality; Non-cardiac surgery; Postoperative outcomes; Surgical start time.