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Lokhorst C, van der Werf S, Berger RMF, Douwes JM. Prognostic Value of Serial Risk Stratification in Adult and Pediatric Pulmonary Arterial Hypertension: A Systematic Review. J Am Heart Assoc 2024; 13:e034151. [PMID: 38904230 PMCID: PMC11255703 DOI: 10.1161/jaha.123.034151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/10/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND In pulmonary arterial hypertension, it is recommended to base therapeutic decisions on risk stratification. This systematic review aims to report the prognostic value of serial risk stratification in adult and pediatric pulmonary arterial hypertension and to explore the usability of serial risk stratification as treatment target. METHODS AND RESULTS Electronic databases PubMed, Embase, and Web of Science were searched up to January 30, 2023, using terms associated with pulmonary arterial hypertension, pediatric pulmonary hypertension, and risk stratification. Observational studies and clinical trials describing risk stratification at both baseline and follow-up were included. Sixty five studies were eligible for inclusion, including only 2 studies in a pediatric population. C-statistic range at baseline was 0.31 to 0.77 and improved to 0.30 to 0.91 at follow-up. In 53% of patients, risk status changed (42% improved, 12% worsened) over 168 days (interquartile range, 137-327 days; n=22 studies). The average proportion of low-risk patients increased from 18% at baseline to 36% at a median follow-up of 244 days (interquartile range, 140-365 days; n=40 studies). In placebo-controlled drug studies, risk statuses of the intervention groups improved more and worsened less compared with the placebo groups. Furthermore, a low-risk status, but also an improved risk status, at follow-up was associated with a better outcome. Similar results were found in the 2 pediatric studies. CONCLUSIONS Follow-up risk stratification has improved prognostic value compared with baseline risk stratification, and change in risk status between baseline and follow-up corresponded to a change in survival. These data support the use of serial risk stratification as treatment target in pulmonary arterial hypertension.
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Affiliation(s)
- Chantal Lokhorst
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Sjoukje van der Werf
- Central Medical LibraryUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Rolf M. F. Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
| | - Johannes M. Douwes
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children’s HospitalUniversity Medical Center Groningen, University of Groningenthe Netherlands
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Zhou AX, Aczon MD, Laksana E, Ledbetter DR, Wetzel RC. Narrowing the gap: expected versus deployment performance. J Am Med Inform Assoc 2023; 30:1474-1485. [PMID: 37311708 PMCID: PMC10436142 DOI: 10.1093/jamia/ocad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/25/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVES Successful model development requires both an accurate a priori understanding of future performance and high performance on deployment. Optimistic estimations of model performance that are unrealized in real-world clinical settings can contribute to nonuse of predictive models. This study used 2 tasks, predicting ICU mortality and Bi-Level Positive Airway Pressure failure, to quantify: (1) how well internal test performances derived from different methods of partitioning data into development and test sets estimate future deployment performance of Recurrent Neural Network models and (2) the effects of including older data in the training set on models' performance. MATERIALS AND METHODS The cohort consisted of patients admitted between 2010 and 2020 to the Pediatric Intensive Care Unit of a large quaternary children's hospital. 2010-2018 data were partitioned into different development and test sets to measure internal test performance. Deployable models were trained on 2010-2018 data and assessed on 2019-2020 data, which was conceptualized to represent a real-world deployment scenario. Optimism, defined as the overestimation of the deployed performance by internal test performance, was measured. Performances of deployable models were also compared with each other to quantify the effect of including older data during training. RESULTS, DISCUSSION, AND CONCLUSION Longitudinal partitioning methods, where models are tested on newer data than the development set, yielded the least optimism. Including older years in the training dataset did not degrade deployable model performance. Using all available data for model development fully leveraged longitudinal partitioning by measuring year-to-year performance.
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Affiliation(s)
- Alice X Zhou
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Melissa D Aczon
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Eugene Laksana
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - David R Ledbetter
- Advanced Analytics for Healthcare, KPMG International Limited, Dallas, Texas, USA
| | - Randall C Wetzel
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics and Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Perez JM, Melvin PR, Berry JG, Mullen MP, Graham RJ. Outcomes for Children With Pulmonary Hypertension Undergoing Tracheostomy Placement: A Multi-Institutional Analysis. Pediatr Crit Care Med 2022; 23:717-726. [PMID: 35687103 DOI: 10.1097/pcc.0000000000003002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe epidemiology, interventions, outcomes, and the health services experience for a cohort of children with pulmonary hypertension (PH) who underwent tracheostomy placement and to identify risk factors for inhospital mortality and 30-day readmissions. DESIGN Retrospective cohort study of the Pediatric Health Information System database. SETTING Thirty-seven freestanding U.S. children's hospitals. PATIENTS Patients 31 days to 21 years old who were discharged from the hospital between January 1, 2009, and December 31, 2017, with a diagnosis of primary or secondary PH, and who underwent tracheostomy placement. Outcomes were examined over a 2-year period from the time of discharge from the index encounter. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 793 patients with PH who underwent tracheostomy placement. The overall inhospital mortality rate was 23.7%. Secondary PH due to congenital heart disease (CHD) was significantly associated with overall inhospital mortality (adjusted odds ratio [OR], 2.36; 95% CI, 1.38-4.04). The rate of 30-day readmissions for patients over the 2-year follow-up period was 33.3%. Tracheostomy during the index encounter and the diagnosis of secondary PH due to CHD were significantly associated with lower rates of 30-day readmissions (adjusted OR, 0.34; 95% CI, 0.19-0.61; and adjusted OR, 0.43; 95% CI, 0.24-0.77, respectively). CONCLUSIONS In the context of expanding utilization of tracheostomy and long-term ventilation, children with PH are among the highest risk cohorts for extended and repeated hospitalization and death. Tracheostomy placement during the index encounter was associated with fewer 30-day readmissions over the 2-year follow-up period. Further understanding of which subgroups may benefit from earlier intervention and which subgroups are at highest risk may offer important clinical insight when considering optimal timing of tracheostomy and may enhance informed decision-making for all stakeholders.
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Affiliation(s)
- Jennifer M Perez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Patrice R Melvin
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Rahmatinejad Z, Rahmatinejad F, Sezavar M, Tohidinezhad F, Abu-Hanna A, Eslami S. Internal validation and evaluation of the predictive performance of models based on the PRISM-3 (Pediatric Risk of Mortality) and PIM-3 (Pediatric Index of Mortality) scoring systems for predicting mortality in Pediatric Intensive Care Units (PICUs). BMC Pediatr 2022; 22:199. [PMID: 35413854 PMCID: PMC9004120 DOI: 10.1186/s12887-022-03228-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/13/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The study was aimed to assess the prognostic power The Pediatric Risk of Mortality-3 (PRISM-3) and the Pediatric Index of Mortality-3 (PIM-3) to predict in-hospital mortality in a sample of patients admitted to the PICUs. DESIGN AND METHODS The study was performed to include all children younger than 18 years of age admitted to receive critical care in two hospitals, Mashhad, northeast of Iran from December 2017 to November 2018. The predictive performance was quantified in terms of the overall performance by measuring the Brier Score (BS) and standardized mortality ratio (SMR), discrimination by assessing the AUC, and calibration by applying the Hosmer-Lemeshow test. RESULTS A total of 2446 patients with the median age of 4.2 months (56% male) were included in the study. The PICU and in-hospital mortality were 12.4 and 16.14%, respectively. The BS of the PRISM-3 and PIM-3 was 0.088 and 0.093 for PICU mortality and 0.108 and 0.113 for in-hospital mortality. For the entire sample, the SMR of the PRISM-3 and PIM-3 were 1.34 and 1.37 for PICU mortality and 1.73 and 1.78 for in-hospital mortality, respectively. The PRISM-3 demonstrated significantly higher discrimination power in comparison with the PIM-3 (AUC = 0.829 vs 0.745) for in-hospital mortality. (AUC = 0.779 vs 0.739) for in-hospital mortality. The HL test revealed poor calibration for both models in both outcomes. CONCLUSIONS The performance measures of PRISM-3 were better than PIM-3 in both PICU and in-hospital mortality. However, further recalibration and modification studies are required to improve the predictive power to a clinically acceptable level before daily clinical use. PRACTICE IMPLICATIONS The calibration of the PRISM-3 model is more satisfactory than PIM-3, however both models have fair discrimination power.
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Affiliation(s)
- Zahra Rahmatinejad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Rahmatinejad
- Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Majid Sezavar
- Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fariba Tohidinezhad
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Saeid Eslami
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. .,Department of Medical Informatics, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, the Netherlands.
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Morell E, Gaies M, Fineman JR, Charpie J, Rao R, Sasaki J, Zhang W, Reichle G, Banerjee M, Tabbutt S. Mortality from Pulmonary Hypertension in the Pediatric Cardiac ICU. Am J Respir Crit Care Med 2021; 204:454-461. [PMID: 33798036 DOI: 10.1164/rccm.202011-4183oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Patients with pulmonary hypertension (PH) admitted to pediatric cardiac ICUs are at high risk of mortality. Objectives: To identify factors associated with mortality in cardiac critical care admissions with PH. Methods: We evaluated medical admissions with PH to Pediatric Cardiac Critical Care Consortium institutions over 5 years. PH was standardly defined in the clinical registry by diagnosis and/or receipt of intensive care-level pulmonary vasodilator therapy. Multivariable logistic regression identified independent associations with mortality. Measurements and Main Results: We analyzed 2,602 admissions; mortality was 10% versus 3.9% for all other medical admissions. Covariates most strongly associated with mortality included invasive ventilation (adjusted odds ratio, 44.8; 95% confidence interval, 6.2-323), noninvasive ventilation (19.7; 2.8-140), cardiopulmonary resuscitation (8.9; 5.6-14.1), and vasoactive infusions (4.8; 2.6-8.8). Patients receiving both invasive ventilation and vasoactive infusions on admission Days 1 and 2 had an observed mortality rate of 29.2% and 28.6%, respectively, compared with <5% for those not receiving either. Vasoactive infusions emerged as the dominant early risk factor for mortality, increasing the absolute risk of mortality on average by 6.4% when present on admission Day 2. Conclusions: Patients with PH admitted to pediatric cardiac critical care units have high mortality rates. Those receiving invasive ventilation and vasoactive infusions on Day 1 or Day 2 had an observed mortality rate that was more than fivefold greater than that of those who did not. These data highlight the illness severity of patients with PH in this setting and could help inform conversations with families regarding the prognosis.
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Affiliation(s)
- Emily Morell
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Jeffrey R Fineman
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | | | - Rohit Rao
- Department of Pediatrics, School of Medicine, University of California San Diego, San Diego, California; and
| | - Jun Sasaki
- Department of Cardiology, Nicklaus Children's Hospital, Miami, Florida
| | | | | | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
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Pulmonary Hypertension and Extracorporeal Membrane Oxygenation-Disparate Causes, Worse Outcomes. Pediatr Crit Care Med 2020; 21:294-295. [PMID: 32142030 DOI: 10.1097/pcc.0000000000002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Settling the Score in Pulmonary Hypertension? Pediatr Crit Care Med 2018; 19:782-783. [PMID: 30095716 DOI: 10.1097/pcc.0000000000001651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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