Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

<div><p>Background</p><p>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.</p><p>Methods</p><p>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.</p><p>Results</p><p>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.</p><p>Conclusion</p><p>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.</p></div

Risk Predictiveness Curve for patients aged 2–59 months old using MUAC as an indicator of nutrition status, following multiple imputation.

<p>TPF: true positive fraction; FPF: false positive fraction</p

Description of inpatient pneumonia patients in dataset.

<p>Description of inpatient pneumonia patients in dataset.</p

Predictors of inpatient mortality and weighted score after multiple imputation.

<p>Predictors of inpatient mortality and weighted score after multiple imputation.</p

RISC (HIV-uninfected) performance and inpatient case fatality rate by HIV Status and Pneumonia Classification.

<p>RISC (HIV-uninfected) performance and inpatient case fatality rate by HIV Status and Pneumonia Classification.</p

RISC-Malawi (MUAC) sensitivity, specificity, and percentage of hospitalized patients identified as high risk at different score thresholds.

<p>RISC-Malawi (MUAC) sensitivity, specificity, and percentage of hospitalized patients identified as high risk at different score thresholds.</p

Malawi Ministry of Health case management guidelines for the diagnosis of pneumonia in children 0–59 months of age.

<p>Malawi Ministry of Health case management guidelines for the diagnosis of pneumonia in children 0–59 months of age.</p

Criteria for RISC and mRISC Scores.

<p>Criteria for RISC and mRISC Scores.</p

Participant recruitment diagram.

Participant recruitment diagram.</p

Active work, exercise and dietary consumption in survey 1 and 2.

Active work, exercise and dietary consumption in survey 1 and 2.</p