Validation of a risk-prediction model for pediatric post-discharge mortality after hospital admission in Rwanda

Abstract Mortality following hospital discharge remains a significant threat to child health, particularly in resource-limited settings. In Uganda, the Smart Discharges risk-prediction models have successfully predicted children at the highest risk of death after hospital admission for sepsis to guide a risk-based approach to post-discharge care. We externally validated five models derived from Smart Discharges Uganda in a new cohort of children ages 0 days to 60 months admitted for suspected sepsis at two hospitals in Rwanda. Of 1218 total children (n=413, Kigali; n=805, Ruhengeri), 1161 lived to discharge (95.3%) and 1123 of those completed 6-month follow-up (96.7%). The overall rate of post-discharge mortality was 4.8% (n=58). All five prediction models tested achieved an area under the receiver-operating curve (AUROC) greater than 0.7 (range 0.706 - 0.738). Low outcome rates resulted in moderately wide confidence intervals. Model degradation ranged from 1.1% to 7.7%, as determined by the percent reduction in AUROC between the internal validation of the original Ugandan cohort and the external Rwandan cohort. Calibration plots showed good calibration for all models at predicted probabilities below 10%. There were too few outcomes to assess calibration among those at the highest predicted risk levels. Discrimination was good with minimal degradation of the model despite low outcome rates. Future work to assess model calibration among the highest risk groups is required to ensure models are broadly generalizable to all children with suspected sepsis in Rwanda and in similar, resource-limited settings. Competing Interest Statement The authors have declared no competing interest. Funding Statement This study was funded by: A Thrasher Foundation Early Career Award (Hooft) University of British Columbia University of California San Francisco Emergency Medicine Global Health Section Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of IRB of UCSF, UBC, University of Rwanda, and University Teaching Hospital of Kigali all provided ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data availability Study materials (protocol, consent forms, data collection tools, and metadata) are publicly available through the Pediatric Sepsis Data CoLaboratory’s (Sepsis CoLab) Dataverse on Borealis, the Canadian Dataverse Repository.(17) Due to the sensitive nature of clinical data and the potential risk for re-identification of research participants, the de-identified dataset is available through moderated access.(47) Access to these data will be granted on a case-by-case basis following approval from the authors and the Data Governance Committees.