When Is Old NOT Gold? Identifying Global Age Risk Surgical Thresholds to Improve Outcomes

Komal Abdul Rahim; Kinzah Razzak Ghazi; Kantesh Kumar; Aiman Arif; Saad Bin Zafar Mahmood; Saqib Kamran Bakhshi; Hasnain Zafar; Adil Hussain Haider

doi:10.1016/j.jss.2025.05.015

When Is Old NOT Gold? Identifying Global Age Risk Surgical Thresholds to Improve Outcomes

J Surg Res. 2025 Jun 28:312:177-184. doi: 10.1016/j.jss.2025.05.015. Online ahead of print.

Authors

Komal Abdul Rahim¹, Kinzah Razzak Ghazi², Kantesh Kumar³, Aiman Arif², Saad Bin Zafar Mahmood⁴, Saqib Kamran Bakhshi⁵, Hasnain Zafar⁶, Adil Hussain Haider⁷

Affiliations

¹ Centre of Excellence for Trauma and Emergencies & Dean's Office, Aga Khan University, Karachi, Pakistan. Electronic address: komal.rahim@aku.edu.
² Dean's Office, Aga Khan University, Karachi, Pakistan.
³ Centre of Excellence for Trauma and Emergencies, Aga Khan University, Karachi, Pakistan.
⁴ Department of Medicine, Aga Khan University, Karachi, Pakistan.
⁵ Neurosurgery, Aga Khan University, Karachi, Pakistan.
⁶ Department of Surgery, Aga Khan University, Karachi, Pakistan.
⁷ Deans Office, Department of Surgery and Community Health Sciences, The Aga Khan University, Karachi, Pakistan.

PMID: 40582072
DOI: 10.1016/j.jss.2025.05.015

Abstract

Introduction: Patient age has been shown to influence health-care outcomes; however, there is limited evidence on the optimal cutoff where age increases the risk of adverse outcomes. This study aims to identify the age at which patients undergoing surgery in Pakistan can be classified as high-risk using the modified frailty index which can help in preoperative risk stratification, optimizing surgical outcomes, and guiding clinical decision-making.

Methods: American College of Surgeons National Surgical Quality Improvement Program data of adult patients undergoing major elective surgeries from 2019 to 2022 were used. High-risk patients were identified using the modified frailty index tool with a score of 2 and above. A receiver-operator curve (ROC) was used to determine the optimal age threshold for high-risk patients. Cox proportional regression identified hazard ratios for low and high-risk patients.

Results: A total of 10,060 surgical patients were identified. The optimal age threshold was 52.595 years (sensitivity: 79%, specificity: 72%, area under the curve 0.72). An age of 52.595 years and above was the high-risk group. The postoperative mortality was twice in the high-risk group compared to the low-risk group (2.95% & 1.11%; P value<0.001). All postoperative complications were higher in the high-risk compared to the low-risk group (27.01% & 19.28%). Case acuity and postoperative cardiac complication were significantly associated with mortality in low- and high-risk group.

Conclusions: Our findings indicated that age was associated with adverse outcomes in surgical population. Determining this age threshold in low- and middle-income countries is crucial for improving surgical outcomes via targeted interventions.

Keywords: Frailty assessment; High-risk surgical patients; Low- and middle-income countries (LMICs); Modified frailty index; Mortality; Optimal age threshold; Surgical risk stratification.