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PRISM III: an updated Pediatric Risk of Mortality score
M M Pollack1, K M Patel, U E Ruttimann
1Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA.
Insights
The Pediatric Risk of Mortality III (PRISM III) score enhances pediatric intensive care unit (ICU) mortality prediction using updated physiologic variables and age adjustments. This validated tool offers improved accuracy for risk assessment in critically ill children.
Area of Science:
- Pediatric critical care medicine
- Clinical informatics
- Biostatistics
Background:
- The evolving landscape of pediatric intensive care necessitates updated tools for accurate mortality risk assessment.
- Previous pediatric scoring systems require reevaluation with new treatment protocols and changing patient demographics.
Purpose of the Study:
- To develop and validate a third-generation pediatric physiology-based score for mortality risk, named Pediatric Risk of Mortality III (PRISM III).
- To improve upon existing pediatric mortality prediction models by incorporating updated variables and methodologies.
Main Methods:
- A prospective cohort study was conducted across 32 pediatric intensive care units (ICUs).
- Physiologic data from the first 12 and 24 hours of ICU stay were collected, with variables stratified by age.
- Logistic regression analysis was used to develop the PRISM III score, incorporating 17 physiologic variables and additional risk factors.
Main Results:
- The PRISM III score demonstrated excellent discrimination and accuracy, with areas under the receiver operating curve ranging from 0.941 to 0.958.
- Key predictors of mortality included minimum systolic blood pressure, abnormal pupillary reflexes, and stupor/coma.
- The score showed good calibration across different patient groups, including age- and diagnosis-stratified cohorts.
Conclusions:
- PRISM III offers significant improvements over previous versions, providing a more accurate and discriminative model for pediatric mortality risk.
- The inclusion of reassessed physiologic variables, better age adjustments, and additional risk factors enhances its predictive power.
- The validation across a diverse range of US ICUs suggests PRISM III is broadly applicable and representative.
Objectives:
The relationship between physiologic status and mortality risk should be reevaluated as new treatment protocols, therapeutic interventions, and monitoring strategies are introduced and as patient populations change. We developed and validated a third-generation pediatric physiology-based score for mortality risk, Pediatric Risk of Mortality III (PRISM III).
Design:
Prospective cohort.
Setting:
There were 32 pediatric intensive care units (ICUs): 16 pediatric ICUs were randomly chosen and 16 volunteered.
Patients:
Consecutive admissions at each site were included until at least 11 deaths per site occurred.
Measurements And Main Results:
Physiologic data included the most abnormal values from the first 12 and the second 12 hrs of ICU stay. Outcomes and descriptive data were also collected. Physiologic variables where normal values change with age were stratified by age (neonate, infant, child, adolescent). The database was randomly split into development (90%) and validation (10%) sets. Variables and their ranges were chosen by computing the risk of death (odds ratios) relative to the midrange of survivors for each physiologic variable. Univariate and multivariate statistical procedures, including multiple logistic regression analysis, were used to develop the PRISM III score and mortality risk predictors. Data were collected on 11,165 admissions (543 deaths). The PRISM III score has 17 physiologic variables subdivided into 26 ranges. The variables most predictive of mortality were minimum systolic blood pressure, abnormal pupillary reflexes, and stupor/coma. Other risk factors, including two acute and two chronic diagnoses, and four additional risk factors, were used in the final predictors. The PRISM III score and the additional risk factors were applied to the first 12 hrs of stay (PRISM III-12) and the first 24 hours of stay (PRISM III-24). The Hosmer-Lemeshow chi-square goodness-of-fit evaluations demonstrated absence of significant calibration errors (p values: PRISM III-12 development = .2496; PRISM III-24 development = .1374; PRISM III-12 validation = .4168; PRISM III-24 validation = .5504). The area under the receiver operating curve and Flora's z-statistic indicated excellent discrimination and accuracy (area under the receiver operating curve - PRISM III-12 development 947 +/- 0.007; PRISM III-24 development 0.958 +/- 0.006; PRISM III-12 validation 0.941 +/- 0.021; PRISM III-24 validation 0.944 +/- 0.021; Flora's z-statistic - PRISM III-12 validation = .7479; PRISM III-24 validation = .9225), although generally, the PRISM III-24 performed better than the PRISM III-12 models. Excellent goodness-of-fit was also found for patient groups stratified by age (significance levels: PRISM III-12 = .1622; PRISM III-24 = .4137), and by diagnosis (significance levels: PRISM III-12 = .5992; PRISM III-24 = .7939).
Conclusions:
PRISM III resulted in several improvements over the original PRISM. Reassessment of physiologic variables and their ranges, better age adjustment for selected variables, and additional risk factors resulted in a mortality risk model that is more accurate and discriminates better. The large number of diverse ICUs in the database indicates PRISM III is more likely to be representative of United States units.
