Derivation and validation of a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality in 20 countries

Abstract

Introduction: Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality across various settings.

Methods: We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool.

Results: A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84).

Conclusions: The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.

Keywords: Paediatrics; Pneumonia.

Figure 1. Selection of hospital-based studies included in the derivation and validation of the novel PREPARE risk assessment tool to identify children 2–59 months of age at risk of hospitalised pneumonia-related mortality. ^*Candidate variables include age, sex, weight-for-age z-score, temperature, respiratory rate, oxygen saturation, presence of chest indrawing, unconsciousness/decreased consciousness, convulsions and cyanosis. PREPARE, Pneumonia Research Partnership to Assess WHO Recommendations.

Figure 2. Receiver operating characteristic curve for the PREPARE risk assessment tool for children at risk of hospitalised pneumonia-related mortality among children 2–59 months of age (n=27 388). Area under receiver operating curve: 0.83 (95% CI 0.81 to 0.84). PREPARE, Pneumonia Research Partnership to Assess WHO Recommendations.