title: Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, United States of America.|Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, United States of America.
authors.forename: Shubhada
authors.identifier: http://orcid.org/0000-0003-4596-448X
authors.initials: S
authors.lastname: Hooli
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Norman
authors.initials: N
authors.lastname: Lufesi
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.affiliation: Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, United States of America.
authors.forename: Satid
authors.initials: S
authors.lastname: Thammasitboon
authors.affiliation: Parent and Child Health Initiative, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Makwenda
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.|Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Eric D
authors.initials: ED
authors.lastname: McCollum
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Carina
authors.initials: C
authors.lastname: King
mesh_terms: D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008295:Malawi; D008297:Male; D011014:Pneumonia / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index