Currently submitted to: JMIR Perioperative Medicine
Date Submitted: Apr 28, 2026
Open Peer Review Period: May 15, 2026 - Jul 10, 2026
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Preoperative mortality risk prediction and equity: Retrospective cohort validation of POSPOM in a diverse U.S. surgical population
ABSTRACT
Background:
The PreOperative Score to Predict PostOperative Mortality (POSPOM) is a validated tool developed in European cohorts, but its performance in diverse U.S. populations and across socioeconomic subgroups remains unclear.
Objective:
To evaluate the performance of POSPOM in a diverse U.S. cohort and evaluate its performance in high-risk surgical patients and across sociodemographic subgroups.
Methods:
We performed a retrospective cohort study using the All of Us Research Program. Adults (≥18 years) undergoing POSPOM-eligible surgeries were included. POSPOM scores were calculated using age, procedure type, and comorbidities. Outcomes included 30-day and 1-year postoperative mortality. Logistic regression was used to assess the association between POSPOM score and mortality. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), with subgroup analyses by race, ethnicity, income, and education. A high-risk subgroup (procedure points ≥14) was analyzed separately.
Results:
The study analyzed a total of 17,262 patients, observing a 30-day mortality rate of 0.07% and a 1-year mortality rate of 0.26%. For 30-day mortality, the POSPOM score demonstrated an AUC of 0.764 and an odds ratio (OR) of 1.112 per point (95% CI 1.040–1.190), while for 1-year mortality, the AUC was 0.638 with an OR of 1.054 (95% CI 1.017–1.092). Within the high-risk subgroup (n=536), the AUC for 30-day mortality was 0.583. For 1-year mortality in this same subgroup, the AUC was 0.692, and the OR was 0.882 (95% CI 0.781–0.998), reflecting an inverse association between the score and mortality. Finally, race-stratified analyses indicated that Black patients had higher observed mortality and higher AUC values when compared to White patients.
Conclusions:
POSPOM performs well for short-term mortality in a diverse U.S. cohort but shows reduced and inconsistent performance in high-risk populations and across demographic subgroups, highlighting the need for recalibration and more equitable risk prediction tools.
Citation
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