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Performance of Pediatric Risk of Mortality IV in Brazilian PICUs: A Multicenter Prospective Study

Gustavo Rodrigues-Santos1,2, Arnaldo Prata-Barbosa2,3, Fernanda Lima-Setta2,4

  • 1Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Brazil.

Critical Care Explorations
|March 28, 2025
PubMed

Insights

The Pediatric Risk of Mortality (PRISM) IV score demonstrated good discrimination but poor calibration in Brazilian pediatric intensive care units. Further research is needed to improve its performance in diverse healthcare settings.

Area of Science:

  • Pediatric critical care medicine
  • Health services research
  • Biostatistics

Background:

  • The Pediatric Risk of Mortality (PRISM) IV score is a widely used tool for predicting mortality in critically ill children.
  • Evaluating the performance of PRISM IV in diverse healthcare systems, such as Brazil's, is crucial for its effective application.

Purpose of the Study:

  • To assess the performance of the PRISM IV score in a large cohort of patients admitted to Brazilian pediatric intensive care units (PICUs).
  • To evaluate the score's discrimination and calibration using the standardized mortality ratio (SMR), area under the receiver operating characteristic curve (AUROC), and calibration belt technique.

Main Methods:

  • A longitudinal, prospective, multicenter study involving 36 Brazilian PICUs.
  • Inclusion of 12,046 children aged 29 days to 18 years admitted between March 2020 and March 2022.
  • Performance assessment using SMR, AUROC (95% CI), and calibration belt (80% and 95% CI).

Main Results:

  • Overall observed mortality (2.1%) was higher than predicted (1.56%), with an SMR of 1.32.
  • Good discrimination was observed (AUROC = 0.86), but calibration was poor, underestimating mortality across a wide range (2-61%).
  • Performance varied during the COVID-19 pandemic, with poorer calibration in the prevaccine period and improved, though still imperfect, calibration in the postvaccine period.

Conclusions:

  • PRISM IV exhibits good discriminative ability but significant miscalibration in Brazilian PICUs.
  • The score's performance is affected by the COVID-19 pandemic, necessitating adjustments for different temporal phases.
  • Further research, including subgroup analyses, is essential to enhance PRISM IV's accuracy within Brazil's heterogeneous healthcare contexts.
Abstract

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