Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia

Abstract

BackgroundThere are no validated clinical decision aids to identify neonates and young children at risk of hospital readmission or postdischarge mortality in sub-Saharan Africa, leaving the decision to discharge a child to a clinician’s impression. Our objective was to determine the precision of clinician impression to identify neonates and young children at risk for readmission and postdischarge mortality.MethodsWe conducted a survey study nested in a prospective observational cohort of neonates and children aged 1–59 months followed 60 days after hospital discharge from Muhimbili National Hospital in Dar es Salaam, Tanzania or John F. Kennedy Medical Center in Monrovia, Liberia. Clinicians who discharged each enrolled patient were surveyed to determine their perceived probability of the patient’s risk of 60-day hospital readmission or postdischarge mortality. We calculated the area under the precision-recall curve (AUPRC) to determine the precision of clinician impression for both outcomes.ResultsOf 4247 discharged patients, 3896 (91.7%) had available clinician surveys and 3847 (98.7%) had 60-day outcomes available: 187 (4.8%) were readmitted and 120 (3.1%) died within 60 days of hospital discharge. Clinician impression had poor precision in identifying neonates and young children at risk of hospital readmission (AUPRC: 0.06, 95% CI: 0.04 to 0.08) and postdischarge mortality (AUPRC: 0.05, 95% CI: 0.03 to 0.08). Patients for whom clinicians attributed inability to pay for future medical treatment as the reason for risk for unplanned hospital readmission had 4.76 times the odds hospital readmission (95% CI: 1.31 to 17.25, p=0.02).ConclusionsGiven the poor precision of clinician impression alone to identify neonates and young children at risk of hospital readmission and postdischarge mortality, validated clinical decision aids are needed to aid in the identification of young children at risk for these outcomes.

Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool

“…The discriminatory ability of our risk assessment tool far outpaced that of clinician impression alone to identify at risk neonates. 13 Despite its enhanced discriminatory ability, the calibration was Open access best for low risk neonates. Although Madrid et al developed a model for post-discharge mortality among infants aged<90 days at discharge in Mozambique, 11 to the best of our knowledge, this is the first risk assessment tool for post-discharge mortality specific to neonates discharged from a neonatal ward.…”

Morbidity and unplanned healthcare encounters after hospital discharge among young children in Dar es Salaam, Tanzania and Monrovia, Liberia

“…1 2 Prior studies have focused on the identification of risk factors to better identify children during hospitalisation who may be at risk for post-discharge mortality in sub-Saharan Africa. [3][4][5][6][7] Although risk stratification at the time of hospital discharge is immensely important to reduce post-discharge mortality, little attention has been paid to morbidity or unplanned healthcare encounters among children in the post-discharge period.…”