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PIM2) in Argentina: a Prospective, Multicenter, Observational Study

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PIM2) in Argentina: a Prospective, Multicenter, Observational Study Original article Validation of the Pediatric Index of Mortality 2 (PIM2) in Argentina: a prospective, multicenter, observational study Ariel L. Fernández, M.Sc.,a María P. Arias López, M.D.,b María E. Ratto, M.D.,c Liliana Saligari, M.D.,d Alejandro Siaba Serrate, M.D.,e Marcela de la Rosa, M.D.,f Norma Raúl, M.D.,g Nancy Boada, M.D.,h Paola Gallardo, M.D.,i InjaKo, M.D.,b and Eduardo Schnitzler, M.D.e ABSTRACT and the different investments made Introduction. The Pediatric Index of Mortality 2 by each region in their healthcare (PIM2) is one of the most commonly used scoring systems to predict mortality in patients systems. Critical care distribution and admitted to pediatric intensive care units (PICU) quality are not homogeneous within in Argentina. The objective of this study was to each country either, which leads to validate the PIM2 score in PICUs participating differences in results and a likely in the Quality of Care Program promoted by the Argentine Society of Intensive Care. impact on overall health indicators, Population and Methods. Multicenter, such as child mortality rates.1 prospective, observational, cross-sectional study. In order to implement any quality All patients between 1 month and 16 years old improvement initiative, results should a. FUNDASAMIN admitted to participating PICUs between January (Fundación para 1st, 2009 and December 31st, 2009 were included. be objectively measured. Prognostic la Salud Materno The discrimination and calibration of the PIM2 scores of mortality in intensive care Infantil). score were assessed in the entire population and units (ICU) have been developed to b. Hospital de in different subgroups (risk of mortality, age, objectively quantify the relationship Niños Dr. Ricardo diagnoses on admission). Gutiérrez. Results. Two thousand, eight hundred and thirty- between the clinical status of critically- c. Hospital de Niños two patients were included. PIM2 predicted ill patients at the time of admission Sor María Ludovica 246 deaths; however, 297 patients died (p < 0.01). to the ICU and their risk of death.2-6 de La Plata. The standardized mortality ratio was 1.20 These scores use regression models d. Hospital Nacional (95% confidence interval [CI]: 1.01-1.43). The Profesor Alejandro area under the ROC curve was 0.84 (95% CI: that yield an equation describing the Posadas. 0.82-0.86). Statistically significant differences relationship among different predictor e. Hospital were detected between the observed and the variables (physiological, demographic Universitario predicted mortality for the entire population Austral. and clinical) and the likelihood of and for the different risk intervals (χ²: 71.02, df: 7 f. Hospital El Cruce 8, p < 0.001). Statistically significant differences death. Indicators such as the Dr. Néstor Carlos were also found between observed and predicted standardized mortality ratio (SMR), Kirchner. Alta mortality in adolescent patients (37/22, p = 0.03) which compares observed mortality Complejidad en Red. and in those hospitalized due to respiratory with that predicted by scores, are g. Hospital Italiano disease (105/81, p = 0.03). La Plata. Conclusions. The PIM2 score adequately useful tools to assess care provided h. Hospital de Pediatría discriminates survivors from non-survivors. at ICUs. However, when interpreting S. A. M. I. C. However, it underscores the overall risk of these indicators, it is necessary to Profesor Dr. Juan P. death, especially in adolescent patients and consider whether the score used Garrahan. those hospitalized due to respiratory disease. It i. Hospital del Niño is critical to take such differences into account to predict mortality is reliable and Jesús de Tucumán. when interpreting results. adequate for the studied population. Key words: pediatric intensive care unit, mortality, The model should allow to adjust E-mail Address: pediatrics, benchmarking, disease severity index, mortality risk based on factors other Ariel L. Fernández, PIM2. M. Sc.: hardineros@ than care provided, which might have hardineros.com.ar. an impact on results. Since 1999, the Argentine Funding: None. Society of Intensive Care (Sociedad INTRODUCTION Argentina de Cuidados Intensivos, Conflict of Interest: Worldwide, the quality and access SATI) has implemented a Quality None. to pediatric intensive care are not of Care Program called SATI-Q,8 an Received: 9-25-2014 equitable due to major differences initiative aimed at improving care Accepted: 12-15-2014 in terms of resource availability provided at ICUs in Argentina. Original article Neonatal, pediatric and adult ICUs take part in In order to minimize missing data in the this program voluntarily. Participating pediatric outcome measures of the study, databases were intensive care units (PICU) are allowed to use analyzed on a quarterly basis. Every quarter, five one of two mortality prediction models: either randomly selected records were analyzed for each the Pediatric Risk of Mortality (PRISM) score9 PICU, and the percentage of missing data was or the PIM2 score.10,11 The latter is the score assessed. The PIM2 score was also recalculated most commonly used in PICUs. This may be for analyzed patients considering data obtained either because the PIM2 is easily calculated, from the case history. Data quality was assessed has been widely disseminated in Argentina, or by comparing the likelihood of death estimated is free, unlike PRISM III, which is the updated for both cases using the Bland-Altman test.15 version of PRISM. In addition, unlike PRISM and Each participating PICU sent their encrypted PRISM III, the PIM2 score takes into consideration database for review via e-mail. In order to aspects related to the patient’s status prior to maintain data security and protect personal PICU admission and is not affected by the information, all patient identifying data were treatment provided in the first 24 hours following anonymized. The database has been registered hospitalization.12 before the National Argentine Department of Although the PIM2 score can be used in Personal Data Protection. populations different than those participating Ethical considerations: The ethical and scientific in the original study, it is fundamental to test its aspects of the protocol were assessed and effectiveness in a representative sample of patients approved by members of the Pediatric Chapter, in order to confirm whether the model is also an the Management, Quality Control and Score adequate predictor of death at a local level.3,13,14 Committee, and the Bioethics Committee of SATI. The objective of this study is to validate the PIM2 This Committee exempted the need of having score in Argentine PICUs that are part of the an informed consent based on the observational SATI-Q Program. nature of the study, the fact that data were routinely collected at each participating PICU, POPULATION AND METHODS and that data protection requirements were A multicenter, prospective, observational, complied with. cross-sectional study was designed. All PICUs in Statistical analysis: Continuous quantitative the SATI-Q Program were invited to participate. outcome measures were expressed as All patients between 1 month and 16 years mean ± standard deviation or as median and old and who required intensive care between interquartile range (IQR). Discrete quantitative January 1st, 2009 and December 31st, 2009 were outcome measures were expressed as average consecutively included in the analysis. and range. Categorical outcome measures were Patients still hospitalized at the end of the data indicated as frequency and percentage. The χ2 collection period, or referred to another PICU test was used to compare categorical outcome to continue treatment, and those younger than measures, while the Mann-Whitney U test was 1 month old were excluded from the analysis. used to compare continuous outcome measures Newborn infants were also excluded because, in given their lack of normal distribution. A value Argentina, they are usually managed in neonatal of p < 0.05 was accepted as statistically significant. intensive care units. The Mid-P method was used to estimate the The following data were collected for each SMR and its 95% confidence interval (95% CI).16 patient: diagnosis on admission, date of admission Calibration or degree of acceptance between and discharge from the PICU, age, sex, length the number of predicted and observed events was of stay in days, days on mechanical ventilation estimated using Hosmer-Lemeshow goodness-of- (MV), outcome at the time of discharge from the fit test for the general population and stratified PICU, and every other information necessary to by risk deciles.17 Discrimination or the model’s estimate the PIM2 score. The PIM2 equation and capability to differentiate non-survivors from other variables are described in Table 1.11 survivors was assessed estimating the area under Data were collected using the SATI-Q software. the receiver operating characteristic (ROC) curve. This is the software used by ICUs participating The sample was stratified by age and diagnosis in the SATI-Q Program to record data related to groups on admission to assess the effectiveness of quality standards.8 the score in these subgroups. Age was categorized Validation of the Pediatric Index of Mortality 2 (PIM2) in Argentina: a prospective, multicenter, observational study using Medline’s MeSH category.18 For a greater RESULTS precision in the analysis, the MeSH category The SATI-Q Program includes 15 PICUs; all “infants” was divided into two groups: infants 1 were invited to participate in the study, and nine (1-11 months old) and infants 2 (12-23 months accepted. One PICU was excluded because it old). The group “Adolescents” was censored as failed to send data at the end of the study period. of 16 years old. Diagnosis groups on admission The analysis included information recorded by were classified into 6 subgroups based on the eight PICUs: four general hospitals, and four subgroups used in the original PIM2 study. For children hospitals. The average number of beds each age subgroup and diagnostic category, the in participating PICUs was 16 (range: 7-25).
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