Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

Ogero, Morris; Sarguta, Rachel; Malla, Lucas; Aluvaala, Jalemba; Agweyu, Ambrose; English, Mike; Onyango, Nelson Owuor; Akech, Samuel

doi:10.1136/bmjopen-2019-035045

Cited by 17 publications

(22 citation statements)

References 74 publications

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“…A recent systematic review by Ogero et al identified 21 models predicting in-hospital pediatric mortality in LMICs [ 37 ]. Of note, all these 21 models used clinical signs on admission, while none used daily clinical data to predict outcomes later during hospitalization.…”

Section: Discussionmentioning

confidence: 99%

“…Most models had several important methodological concerns, such as a priori selection of predictors and ignoring censoring with the use of logistic models. Some models require monitoring of vital signs or laboratory measurements, which pose difficulties to implementation [ 37 ]. Therefore, the present study is unique in its inclusion of daily clinical parameters (not selected beforehand) capturing disease dynamics throughout hospitalization in predicting in-patient mortality.…”

Section: Discussionmentioning

confidence: 99%

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Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs

Wen

Brals

Bourdon

et al. 2021

BMC Med

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Background Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM. Methods This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell’s concordance index (C-index) and time-dependent area under the curve (tAUC). Results Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77–0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74–0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively. Conclusions This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children. Trial registration NCT02246296

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs

Wen

Brals

Bourdon

et al. 2021

BMC Med

View full text Add to dashboard Cite

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“…These risk scores have not been widely validated using data from low- and middle-income settings outside sub-Saharan Africa [ 8 , 9 ]. The RISC score for HIV-negative children had fair discriminatory value when retrospectively applied to the PERCH and RISC-Malawi data sets, both of which were done after the pneumococcal vaccine became available and large scale prevention of mother to child transmission of HIV implementation [ 6 , 7 ].…”

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confidence: 99%

External validation of the RISC, RISC-Malawi, and PERCH clinical prediction rules to identify risk of death in children hospitalized with pneumonia

Rees¹,

Hooli²,

King³

et al. 2021

J Glob Health

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Background Existing scores to identify children at risk of hospitalized pneumonia-related mortality lack broad external validation. Our objective was to externally validate three such risk scores. Methods We applied the Respiratory Index of Severity in Children (RISC) for HIV-negative children, the RISC-Malawi, and the Pneumonia Etiology Research for Child Health (PERCH) scores to hospitalized children in the Pneumonia REsearch Partnerships to Assess WHO REcommendations (PREPARE) data set. The PREPARE data set includes pooled data from 41 studies on pediatric pneumonia from across the world. We calculated test characteristics and the area under the curve (AUC) for each of these clinical prediction rules. Results The RISC score for HIV-negative children was applied to 3574 children 0-24 months and demonstrated poor discriminatory ability (AUC = 0.66, 95% confidence interval (CI) = 0.58-0.73) in the identification of children at risk of hospitalized pneumonia-related mortality. The RISC-Malawi score had fair discriminatory value (AUC = 0.75, 95% CI = 0.74-0.77) among 17 864 children 2-59 months. The PERCH score was applied to 732 children 1-59 months and also demonstrated poor discriminatory value (AUC = 0.55, 95% CI = 0.37-0.73). Conclusions In a large external application of the RISC, RISC-Malawi, and PERCH scores, a substantial number of children were misclassified for their risk of hospitalized pneumonia-related mortality. Although pneumonia risk scores have performed well among the cohorts in which they were derived, their performance diminished when externally applied. A generalizable risk assessment tool with higher sensitivity and specificity to identify children at risk of hospitalized pneumonia-related mortality may be needed. Such a generalizable risk assessment tool would need context-specific validation prior to implementation in that setting.

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“…Implementation of FASTER monitoring with sufficient caregiver education on goals to hasten interventions and without the label of a red flag may help address this issue. Given recent data on mortality predictions scores improving by including at least one element of the four top categories of altered consciousness, vital signs, signs of respiratory distress and indicators of malnutrition, addition of mid-upper arm circumference is important to consider to increase sensitivity and specificity of the FASTER tool ( 20 ).…”

Section: Discussionmentioning

confidence: 99%

Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Resource Settings—A Two-Arm Interventional Feasibility Study

et al. 2022

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IntroductionPediatric mortality remains unacceptably high in many low-resource settings, with inpatient deaths often associated with delayed recognition of clinical deterioration. The Family-Assisted Severe Febrile Illness ThERapy (FASTER) tool has been developed for caregivers to assist in monitoring their hospitalized children and alert clinicians. This study evaluates feasibility of implementation by caregivers and clinicians.MethodsRandomized controlled feasibility study at Kenyatta National Hospital, Kenya. Children hospitalized with acute febrile illness with caregivers at the bedside for 24 h were enrolled. Caregivers were trained using the FASTER tool. The primary outcome was the frequency of clinician reassessments between intervention (FASTER) and standard care arms. Poisson regression with random intercept for grouping by patient was used, adjusting for admission pediatric early warning score, age, gender. Secondary outcomes included survey assessments of clinician and caregiver experiences with FASTER.ResultsOne hundred and fifty patient/caregiver pairs were enrolled, 139 included in the analysis, 74 in the intervention, 65 in the control arm. Patients' median age was 0.9 (range 0.2–10) and 1.1 years (range 0.2–12) in intervention vs. control arms. The most common diagnoses were pneumonia (80[58%]), meningitis (58[38%]) and malaria (34 [24%]). 134 (96%) caregivers were patients' mothers. Clinician visits/hour increased with patients' illness severity in both arms, but without difference in frequency between arms (point estimate for difference −0.9%, p = 0.97). Of the 16 deaths, 8 (four/arm) occurred within 2 days of enrollment. Forty clinicians were surveyed, 33 (82%) reporting that FASTER could improve outcomes of very sick children in low-resource settings; 26 (65%) rating caregivers as able to adequately capture patients' severity of illness. Of 70 caregivers surveyed, 63 (90%) reported that FASTER training was easy to understand; all (100%) agreed that the intervention would improve care of hospitalized children and help identify sick children in their community.DiscussionWe observed no difference in recorded frequency of clinician visits with FASTER monitoring. However, the tool was rated positively by caregivers and clinicians., Implementation appears feasible but requires optimization. These feasibility data may inform a larger trial powered to measure morbidity and mortality outcomes to determine the utility of FASTER in detecting and responding to clinical deterioration in low-resource settings.Clinical Trial RegistrationClinicalTrials.gov, identifier: NCT03513861.

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Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

Cited by 17 publications

References 74 publications

Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs

Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs

External validation of the RISC, RISC-Malawi, and PERCH clinical prediction rules to identify risk of death in children hospitalized with pneumonia

Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Resource Settings—A Two-Arm Interventional Feasibility Study

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