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Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool
Shubhada Hooli1,2, Tim Colbourn3, Norman Lufesi4
1Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, United States of America.
Insights
A new RISC-Malawi score improved prediction of in-hospital mortality for children with pneumonia in Malawi. This locally developed tool, incorporating malnutrition indicators, outperformed existing scores, aiding resource allocation and potentially reducing child deaths.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Epidemiology
- Health Services Research
Background:
- Pneumonia is a primary cause of death in children under five in sub-Saharan Africa.
- Clinical prediction tools can aid in classifying pneumonia cases, prioritizing treatment, and managing hospital resources.
- External validation of existing tools and development of local alternatives are crucial for improving care in resource-limited settings.
Purpose of the Study:
- To externally validate the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores.
- To develop and validate a locally relevant prediction tool for in-hospital mortality in children with pneumonia in Malawi.
- To compare the performance of existing and locally developed tools in identifying high-risk pediatric pneumonia patients.
Main Methods:
- Retrospective analysis of a prospectively collected dataset of pediatric pneumonia cases from seven Malawian hospitals (2011-2014).
- External validation of RISC (HIV-uninfected and HIV-infected) and mRISC scores.
- Development of a local score (RISC-Malawi) using multivariable logistic regression, including mid-upper arm circumference for malnutrition.
- Performance assessment using c-statistics, sensitivity, specificity, and predictive values.
Main Results:
- Analysis included 16,475 pneumonia episodes (case-fatality rate: 3.2%); 9,533 had complete data (CFR: 2.0%).
- The RISC (HIV-uninfected) score achieved a c-statistic of 0.72.
- The locally developed RISC-Malawi score demonstrated improved performance with a c-statistic of 0.79.
- Comprehensive validation of RISC (HIV-infected) and mRISC was not possible due to missing data for key parameters.
Conclusions:
- The RISC (HIV-uninfected) score effectively identified Malawian children with WHO-defined pneumonia at high risk of in-hospital mortality.
- The RISC-Malawi score, incorporating malnutrition indicators, showed superior performance compared to existing tools.
- Prospective studies are recommended to evaluate the impact of these scores on reducing in-hospital case-fatality rates in routine clinical practice.
Background:
Pneumonia is the leading infectious cause of under-5 mortality in sub-Saharan Africa. Clinical prediction tools may aide case classification, triage, and allocation of hospital resources. We performed an external validation of two published prediction tools and compared this to a locally developed tool to identify children admitted with pneumonia at increased risk for in-hospital mortality in Malawi.
Methods:
We retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011-2014. RISC has both an HIV-infected and HIV-uninfected tool. A local score (RISC-Malawi) was developed using multivariable logistic regression with missing data multiply imputed using chained equations. Score performances were assessed using c-statistics, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood statistics.
Results:
16,475 in-patient pneumonia episodes were recorded (case-fatality rate (CFR): 3.2%), 9,533 with complete data (CFR: 2.0%). The c-statistic for the RISC (HIV-uninfected) score, used to assess its ability to differentiate between children who survived to discharge and those that died, was 0.72. The RISC-Malawi score, using mid-upper arm circumference as an indicator of malnutrition severity, had a c-statistic of 0.79. We were unable to perform a comprehensive external validation of RISC (HIV-infected) and mRISC as both scores include parameters that were not routinely documented variables in our dataset.
Conclusion:
In our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality. However the refinement of parameters and resultant creation of RISC-Malawi improved performance. Next steps include prospectively studying both scores to determine if incorporation into routine care delivery can have a meaningful impact on in-hospital CFRs of children with WHO-defined pneumonia.
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