Performance of Pediatric Risk of Mortality IV in Brazilian PICUs: A Multicenter Prospective Study.

Q4 Medicine

Critical care explorations Pub Date : 2025-03-28 eCollection Date: 2025-04-01 DOI:10.1097/CCE.0000000000001243

Gustavo Rodrigues-Santos, Arnaldo Prata-Barbosa, Fernanda Lima-Setta, Pedro Henrique Nunes Costa Silami, Mariana Barros Genuíno de Oliveira, Jaqueline Rodrigues Robaina, José Colleti Júnior, Felipe Rezende Caino de Oliveira, Luís Fernando Andrade de Carvalho, Mariana Digiovanni, Ana Paula Novaes Bellinat, Thiago Peres da Silva, Taisa Roberta Ramos Nantes de Castilho, Simone Camera Gregory, Ana Carolina Cabral Pinheiro Scarlato, Paula Marins Riveiro, José Oliva Proença Filho, Antonio José Ledo Alves da Cunha, Maria Clara de Magalhães-Barbosa, Claudia de Souza Lopes

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Abstract

Importance: This is the first Brazilian study evaluating the performance of Pediatric Risk of Mortality (PRISM) IV and the first to use the calibration belt technique.

Objectives: This study aimed to evaluate the performance of PRISM IV in a large cohort of patients admitted to Brazilian PICUs.

Design, setting and participants: This is a longitudinal, prospective, multicenter study conducted in 36 Brazilian PICUs with children between 29 days and 18 years old admitted from March 2020 to March 2022.

Main outcomes and measures: PRISM IV's performance was assessed using the standardized mortality ratio (SMR), the area under the receiver operating characteristic curve (AUROC) with 95% CI, and the calibration belt with 80% and 95% CI.

Results: A total of 12,046 patients from 36 PICUs were included. Observed overall in-hospital mortality was higher than predicted: observed = 249 (2.1%) × predicted = 188.1 (1.56%) (SMR = 1.32 [95% CI, 1.16-1.50]); discrimination was good (AUROC = 0.86 [95% CI, 0.83-0.89]), and calibration was poor, underestimating mortality over a wide range of predicted mortality (2-61%). To explore the impact of the COVID-19 pandemic on PRISM IV's performance, we divided the study period into prevaccine and postvaccine. In the prevaccine period, the SMR was 1.38 (95% CI, 1.17-1.62), the AUROC was 0.84 (95% CI, 0.80-0.88), and the range of miscalibration was broader than in the total cohort (underestimation in the 2-98% range). In the postvaccine period, the SMR was 1.26 (95% CI, 1.03-1.51), the AUROC was 0.90 (95% CI, 0.86-0.94), and the calibration belt underestimated mortality in a narrower range of 3-46% of predicted mortality.

Conclusions and relevance: PRISM IV showed good discrimination but miscalibration across a wide range of predicted mortality and different COVID-19 pandemic periods in a large cohort. Further research with subgroup analyses are needed to develop strategies to improve the performance of PRISM IV in different and heterogeneous Brazilian healthcare contexts.

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重要性：这是巴西第一项评估儿科死亡率风险（PRISM）IV 性能的研究，也是第一项使用校准带技术的研究：本研究旨在对巴西儿童重症监护病房收治的大批患者进行 PRISM IV 性能评估：这是一项纵向、前瞻性、多中心研究，在巴西 36 个 PICU 中进行，收治 2020 年 3 月至 2022 年 3 月期间出生 29 天至 18 岁的儿童：使用标准化死亡率（SMR）、接收器操作特征曲线下面积（AUROC）（95% CI）以及校准带（80% 和 95% CI）评估 PRISM IV 的性能：结果：共纳入了 36 个 PICU 的 12,046 名患者。观察到的总体院内死亡率高于预测值：观察值 = 249 (2.1%) × 预测值 = 188.1 (1.56%)（SMR = 1.32 [95% CI, 1.16-1.50]）；分辨能力较好（AUROC = 0.86 [95% CI, 0.83-0.89]），校准能力较差，在预测死亡率（2%-61%）的较大范围内低估了死亡率。为了探讨 COVID-19 大流行对 PRISM IV 性能的影响，我们将研究期间分为疫苗接种前和疫苗接种后。在疫苗接种前，SMR 为 1.38 (95% CI, 1.17-1.62)，AUROC 为 0.84 (95% CI, 0.80-0.88)，误判范围比总体队列更广（低估范围在 2-98% 之间）。在疫苗接种后，SMR 为 1.26（95% CI，1.03-1.51），AUROC 为 0.90（95% CI，0.86-0.94），校准带低估的死亡率范围较窄，为预测死亡率的 3-46%：PRISM IV显示出良好的分辨能力，但在预测死亡率的较大范围内和COVID-19大流行的不同时期，PRISM IV存在校准误差。需要进一步开展亚组分析研究，以制定策略，提高 PRISM IV 在巴西不同的异质性医疗环境中的性能。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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