A Prospective, observational cohort study to identify neonates and children at risk of postdischarge mortality in Dar es Salaam, Tanzania and Monrovia, Liberia: the PPDM study protocol

Abstract

IntroductionOver half of the 5 million annual deaths among children aged 0–59 months occur in sub-Saharan Africa. The period immediately after hospitalisation is a vulnerable time in the life of a child in sub-Saharan Africa as postdischarge mortality rates are as high as 1%–18%. Identification of neonates and children who are at highest risk for postdischarge mortality may allow for the direction of interventions to target patients at highest risk.Methods and analysisThe Predicting Post-Discharge Mortality study is a prospective, observational study being conducted at Muhimbili National Hospital (Dar es Salaam, Tanzania) and John F. Kennedy Medical Center (Monrovia, Liberia). The aim is to derive and validate two, age population specific, clinical prediction rules for the identification of neonates (n=2000) and children aged 1–59 months (n=2000) at risk for all-cause mortality within 60 days of discharge from the neonatal intensive care unit or paediatric ward. Caregivers of participants will receive phone calls 7, 14, 30, 45 and 60 days after discharge to assess vital status. Candidate predictor variables will include demographic, anthropometric and clinical factors. Elastic net regression will be used to derive the clinical prediction rules. Bootstrapped selection with repetitions will be used for internal validation. Planned secondary analyses include the external validation of existing clinical prediction models, determination of clinicians’ ability to identify neonates and children at risk of postdischarge mortality at discharge, analysis of factors associated with hospital readmission and unplanned clinic visits and description of health-seeking behaviours in the postdischarge period.Ethics and disseminationThis study received ethical clearance from the Tanzania National Institute of Medical Research, Muhimbili University of Health and Allied Sciences, the John F. Kennedy Medical Center Institutional Review Board, and the Boston Children’s Hospital Institutional Review Board. Findings will be disseminated at scientific conferences and as peer-reviewed publications.

Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool

“…Our risk assessment tool demonstrated good discriminatory ability when internally validated and excellent calibration for low-risk neonates. The discriminatory ability of our risk assessment tool far outpaced that of clinician impression alone to identify at risk neonates 13. Despite its enhanced discriminatory ability, the calibration was best for low risk neonates.…”

“…Enrolment began in October 2019 and concluded in January 2022. The protocol for this study has been published previously 22. We adhered to the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines 23…”

“…However, prior risk assessment tools for childhood post-discharge mortality have largely excluded neonates, and those that have included neonates have not accounted for unique neonatal clinical factors 10 11. Moreover, clinicians often underestimate risk of post-discharge mortality and have demonstrated a suboptimal ability to identify specific neonates at risk for post-discharge mortality using clinical judgement alone 12 13…”

Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia

“…Details of our study protocol have been published previously. 15 Besides differences in estimated and actual enrolment, there were no deviations from that protocol. Neonates and young children aged 1–59 months were enrolled at discharge from the neonatal or paediatric wards at each facility.…”

Morbidity and unplanned healthcare encounters after hospital discharge among young children in Dar es Salaam, Tanzania and Monrovia, Liberia

“…The study protocol and rationale have been previously published. 13 The ethical review boards of the Tanzania National Institute of Medical Research, the Muhimbili University of Health and Allied Sciences Research and Ethics Committee, the John F. Kennedy Medical Centre, Boston Children’s Hospital, and Emory University reviewed and approved this study.…”