Performance Assessment of the Universal Vital Assessment Score vs Other Illness Severity Scores for Predicting Risk of In-Hospital Death Among Adult Febrile Inpatients in Northern Tanzania, 2016-2019

Abstract

IMPORTANCE Severity scores are used to improve triage of hospitalized patients in high-income settings, but the scores may not translate well to low-and middle-income settings such as sub-Saharan Africa. OBJECTIVE To assess the performance of the Universal Vital Assessment (UVA) score, derived in 2017, compared with other illness severity scores for predicting in-hospital mortality among adults with febrile illness in northern Tanzania. DESIGN, SETTING, AND PARTICIPANTSThis prognostic study used clinical data collected for the duration of hospitalization among patients with febrile illness admitted to Kilimanjaro Christian Medical Centre or Mawenzi Regional Referral Hospital in Moshi, Tanzania, from September 2016 through May 2019. All adult and pediatric patients with a history of fever within 72 hours or a tympanic temperature of 38.0 °C or higher at screening were eligible for enrollment. Of 3761 eligible participants, 1132 (30.1%) were enrolled in the parent study; of those, 597 adults 18 years or older were included in this analysis. Data were analyzed from December 2019 to September 2021. EXPOSURES Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) assessment, and UVA. MAIN OUTCOMES AND MEASURESThe main outcome was in-hospital mortality during the same hospitalization as the participant's enrollment. Crude risk ratios and 95% CIs for in-hospital death were calculated using log-binomial risk regression for proposed score cutoffs for each of the illness severity scores. The area under the receiver operating characteristic curve (AUROC) for estimating the risk of in-hospital death was calculated for each score. RESULTS Among 597 participants, the median age was 43 years (IQR, 31-56 years); 300 participants (50.3%) were female, 198 (33.2%) were HIV-infected, and in-hospital death occurred in 55 (9.2%).By higher risk score strata for each score, compared with lower risk strata, risk ratios for in-hospital death were 3.7 (95% CI, 2.2-6.2) for a MEWS of 5 or higher; 2.7 (95% CI, 0.9-7.8) for a NEWS of 5 or 6; 9.6 (95% CI, 4.2-22.2) for a NEWS of 7 or higher; 4.8 (95% CI, 1.2-20.2) for a qSOFA score of 1; 15.4 (95% CI, 3.8-63.1) for a qSOFA score of 2 or higher; 2.5 (95% CI, 1.2-5.2) for a SIRS score of 2 or higher; 9.1 (95% CI, 2.7-30.3) for a UVA score of 2 to 4; and 30.6 (95% CI, 9.6-97.8) for a UVA score of 5 or higher. The AUROCs, using all ordinal values, were 0.85 (95% CI, 0.80-0.90) for the UVA score, 0.81 (95% CI, 0.75-0.87) for the NEWS, 0.75 (95% CI, 0.69-0.82) for the MEWS, 0.73 (95% CI, 0.67-0.79) for the qSOFA score, and 0.63 (95% CI, 0.56-0.71) for the SIRS score. The AUROC for the UVA score (continued) Key Points Question How does the Universal Vital Assessment (UVA) score perform compared with other common illness severity scores in predicting in-hospital death for febrile hospitalized patients in a lower-income setting? Findings In this prognostic study of 597 adults hospitalize...

Clinical Severity Prediction Scores in Low-Resource Settings and the Conundrum of Missing Data

“…Bonnewell and colleagues report the results of their prospective assessment of the ability of several clinical illness severity scores to predict in-hospital death among febrile adults admitted to 2 hospitals in Tanzania over a 2.5-year period. Participants underwent a standardized clinical history and physical examination as well as a battery of laboratory testing including HIV antibody testing and blood cultures.…”

“…Further work to refine the UVA score and other illness severity tests will be necessary to develop a tool, or perhaps a set of tools for different clinical environments, that can be easily implemented with minimal missing data in a real-world setting and that have good prognostic accuracy. The strong performance of the UVA score in the study by Bonnewell et al 5 suggests that evaluation of how to further improve its performance may be helpful. In addition, a direct comparison of the UVA score with the Tropical Intensive Care Score, 4 which was not included in the study by Bonnewell et al, 5 would offer useful data.…”

“…The strong performance of the UVA score in the study by Bonnewell et al 5 suggests that evaluation of how to further improve its performance may be helpful. In addition, a direct comparison of the UVA score with the Tropical Intensive Care Score, 4 which was not included in the study by Bonnewell et al, 5 would offer useful data. The Tropical Intensive Care Score has been shown to have good score performance compared with the Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II among 3855 critically ill patients in 18 South Asian intensive care units, but we are unaware of any studies directly comparing it with the UVA score.…”

Association of clinical prediction scores with hospital mortality in an adult medical and surgical intensive care unit in Kenya

“…We also noted an increased risk of mortality in those with scores ≥4, but UVA did not perform as well when comparing AUROC. A prospective cohort study conducted in two hospitals in Tanzania showed that UVA performed favorably compared to MEWS, SIRS, and qSOFA in predicting in-hospital mortality among patients with a febrile illness ( 19 ). One reason that our findings may have differed was the fact that only 3% of the patients in that study were missing data, as clinical assessment and laboratory evaluation as performed prospectively by the study team.…”

“…The MEWS score was originally developed to identify medical inpatients that might deteriorate to the point of requiring ICU care ( 18 ). The predictive accuracy of the MEWS for hospital mortality has previously been evaluated among hospitalized adults in Uganda and Tanzania ( 8 , 19 ). MEWS scores range from 0 to 14.…”