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We developed and externally validated LiteSurgFormer, a lightweight explainable MLP\u2013attention risk-stratification model, in a retrospective multicenter cohort of 58,630 adult grade III\u2013IV surgical patients treated at six Chinese sites from 2021 to 2024. Predictions were anchored after final operating-room schedule confirmation and primary surgical-team assignment but before incision, using 25 structured patient, disease, procedure, and surgical-team\/scheduling predictors objectively available at that timestamp; intraoperative and postoperative variables were excluded. Zhejiang sites were used for model development and temporal internal validation, whereas a geographically external Xinjiang Alar affiliated-center cohort was isolated for final validation without refitting, recalibration, or domain adaptation. The primary endpoint was a 30-day composite of clinically significant postoperative adverse events. In external validation (\n                    <jats:italic>n<\/jats:italic>\n                    \u2009=\u20099772; 1308 events), LiteSurgFormer achieved an AUC of 0.912, Brier score of 0.070, and Hosmer\u2013Lemeshow\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.227, with higher decision-curve net benefit than machine-learning comparators and implementable clinical baselines across clinically relevant threshold probabilities. It outperformed ASA-only logistic regression (AUC 0.656) and a 21-predictor core-clinical logistic regression benchmark (AUC 0.895). In the \u2265\u200920% predicted-risk stratum, observed and predicted risks were closely aligned (48.5% vs. 48.0%; calibration slope 1.036; Hosmer\u2013Lemeshow\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.422). Discriminative performance was retained after removing surgical-team variables (AUC 0.896) or clinician-derived composite scores (AUC 0.886). These findings demonstrate retrospectively that LiteSurgFormer provides workflow-aligned risk stratification in comparable structured EHR settings, but portability to administratively unrelated health systems and clinical effectiveness after active deployment remain unproven.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:italic>Clinical trial number<\/jats:italic>\n                    Not applicable.\n                  <\/jats:p>","DOI":"10.1038\/s41598-026-60202-9","type":"journal-article","created":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T19:07:34Z","timestamp":1782760054000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Development and external validation of a lightweight, explainable clinical decision support system for personalized perioperative risk stratification using electronic health records"],"prefix":"10.1038","volume":"16","author":[{"given":"Jing","family":"Yang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheng","family":"Dai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hong","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiujun","family":"Cai\u00ef","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zongjiu","family":"Zhang\u00ef","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,29]]},"reference":[{"key":"60202_CR1","doi-asserted-by":"publisher","first-page":"e316","DOI":"10.1016\/S2214-109X(15)70115-4","volume":"3","author":"BC Alkire","year":"2015","unstructured":"Alkire, B. 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The study protocol was reviewed and approved by the Ethics Committee of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (Approval No.: 2024-Yan-1136). Given the retrospective nature of this study, which utilized de-identified and anonymized routine electronic health record data, the requirement for obtaining informed consent from individual patients was formally waived by the same Ethics Committee. Sir Run Run Shaw Hospital has an administrative counterpart-support relationship with the Alar Hospital in the Xinjiang Uygur Autonomous Region. For this retrospective study, ethical approval was obtained from the Ethics Committee of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, covering the de-identified data contributed by participating sites under the approved research protocol. This ethics arrangement should not be interpreted as implying that the Xinjiang Alar site was clinically identical to the Zhejiang development sites.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"29834"}}