Surgical Risk Avoidance in Metabolic Syndrome: Development and Validation of an Evidence-Based Framework for Perioperative Care

Metabolic Syndrome (MetS) is highly prevalent among adult surgical populations and is increasingly recognised as a significant contributor to postoperative morbidity, mortality, and healthcare utilisation. Despite extensive observational evidence linking MetS to adverse surgical outcomes, perioperative care pathways have not systematically addressed metabolic risk, and no structured intervention framework has previously been developed. This doctoral research programme addressed this gap by quantifying perioperative risk associated with MetS, estimating its economic burden in Australia, and developing a theory-informed, implementation-ready intervention framework. Guided by the Medical Research Council Framework for Developing and Evaluating Complex Interventions, the programme employed a staged mixed-methods design. First, a systematic review and meta-analysis of 63 observational studies involving more than 13 million surgical patients demonstrated that MetS was associated with significantly increased risks of short-term mortality, surgical site infection, cardiovascular complications, hospital readmission, and prolonged length of stay, establishing MetS as a distinct and clinically meaningful perioperative risk state. Second, a prevalence-based cost-of-illness analysis integrated national elective surgery volumes, pooled risk estimates, and Australian hospital cost data. MetS-related surgical complications were estimated to generate approximately AUD 1.98 billion in excess annual healthcare costs, representing around 1.2 percent of national health expenditure, with prolonged hospitalisation identified as the primary cost driver. Third, a theory-informed qualitative study using the Theoretical Domains Framework examined behavioural and organisational determinants of perioperative MetS management. Multidisciplinary clinician interviews supported the clinical logic of a structured metabolic risk approach while identifying key implementation barriers and facilitators. These findings informed refinement of the Surgical Risk Avoidance in MetS (S-RAM) Framework, encompassing screening, optimisation, perioperative management, postoperative rehabilitation, and primary care transition. Collectively, this research demonstrates that MetS is a prevalent, costly, and modifiable source of surgical risk insufficiently addressed in current practice. The S-RAM Framework provides the first empirically grounded and clinically validated model for proactive metabolic risk mitigation in perioperative care.