Association of an In-Hospital Desirability of Outcomes Ranking Scale With Postdischarge Health-Related Quality of Life: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation

Abstract

Objectives: To develop a desirability of outcome ranking (DOOR) scale for use in children with septic shock and determine its correlation with a decrease in 3-month postadmission health-related quality of life (HRQL) or death.

Design: Secondary analysis of the Life After Pediatric Sepsis Evaluation prospective study.

Setting: Twelve U.S. PICUs, 2013-2017.

Patients: Children (1 mo-18 yr) with septic shock.

Interventions: None.

Measurements and main results: We applied a 7-point pediatric critical care (PCC) DOOR scale: 7: death; 6: extracorporeal life support; 5: supported by life-sustaining therapies (continuous renal replacement therapy, vasoactive, or invasive ventilation); 4: hospitalized with or 3: without organ dysfunction; 2: discharged with or 1: without new morbidity to patients by assigning the highest applicable score on specific days post-PICU admission. We analyzed Spearman rank-order correlations (95% CIs) between proximal outcomes (PCC-DOOR scale on days 7, 14, and 21, ventilator-free days, cumulative 28-day Pediatric Logistic Organ Dysfunction-2 (PELOD-2) scores, and PICU-free days) and 3-month decrease in HRQL or death. HRQL was measured by Pediatric Quality of Life Inventory 4.0 or Functional Status II-R for patients with developmental delay. Patients who died were assigned the worst possible HRQL score. PCC-DOOR scores were applied to 385 patients, median age 6 years (interquartile range 2, 13) and 177 (46%) with a complex chronic condition(s). Three-month outcomes were available for 245 patients (64%) and 42 patients (17%) died. PCC-DOOR scale on days 7, 14, and 21 demonstrated fair correlation with the primary outcome (-0.42 [-0.52, -0.31], -0.47 [-0.56, -0.36], and -0.52 [-0.61, -0.42]), similar to the correlations for cumulative 28-day PELOD-2 scores (-0.51 [-0.59, -0.41]), ventilator-free days (0.43 [0.32, 0.53]), and PICU-free days (0.46 [0.35, 0.55]).

Conclusions: The PCC-DOOR scale is a feasible, practical outcome for pediatric sepsis trials and demonstrates fair correlation with decrease in HRQL or death at 3 months.

Figure 1.

Pediatric Critical Care Desirability of Outcome Ranking (PCC-DOOR) scale distribution during post-PICU admission days 1 through 28. ^aLife-sustaining therapies were defined as receipt of invasive mechanical ventilation, vasoactive support, and/or continuous renal replacement therapy. ^bOrgan dysfunction was defined by a Pediatric Logistic Organ Dysfuction-2 (PELOD-2) score of ≥ 2. ^c”Remains in this hospital without organ dysfunction” was defined as patients who were either in the PICU with a PELOD-2 score of < 2 or had been transferred out of the PICU with the assumption they had achieved resolution of significant organ dysfunction. ^dNew morbidity was defined by the Functional Status Scale (FSS) score at discharge relative to pre-admission baseline as having an increase of ≥ 3 points in the total FSS score or an increase of ≥ 2 points in a domain-specific score.

Figure 2A, 2B and 2C.

Three-month outcome of decreased health-related quality of life (HRQL) measured by combined PedsQL^™ and FS-IIR or death by PCC-DOOR categories on day 7 (2A), day 14 (2B) and day 21 (2C) as represented by alluvial plots. ¹HRQL categories are scaled according to MCID (4.5- point increments). ²Additional description of the PCC-DOOR scale components is listed in Figure 1. * Surviving patients without assignment to a 3-month outcome were lost to follow-up or had insufficient data to calculate PedsQL^™ or FS-IIR.