巴西重症监护病房中儿童死亡风险IV评分的表现：一项多中心前瞻性研究。
Performance of Pediatric Risk of Mortality IV in Brazilian PICUs: A Multicenter Prospective Study.
作者信息
Rodrigues-Santos Gustavo, Prata-Barbosa Arnaldo, Lima-Setta Fernanda, Silami Pedro Henrique Nunes Costa, de Oliveira Mariana Barros Genuíno, Robaina Jaqueline Rodrigues, Júnior José Colleti, de Oliveira Felipe Rezende Caino, de Carvalho Luís Fernando Andrade, Digiovanni Mariana, Novaes Bellinat Ana Paula, Peres da Silva Thiago, de Castilho Taisa Roberta Ramos Nantes, Gregory Simone Camera, Scarlato Ana Carolina Cabral Pinheiro, Riveiro Paula Marins, Filho José Oliva Proença, Alves da Cunha Antonio José Ledo, de Magalhães-Barbosa Maria Clara, de Souza Lopes Claudia
机构信息
Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Brazil.
Department of Pediatrics, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil.
出版信息
Crit Care Explor. 2025 Mar 28;7(4):e1243. doi: 10.1097/CCE.0000000000001243. eCollection 2025 Apr 1.
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.
重要性
这是巴西第一项评估儿童死亡风险（PRISM）IV性能的研究，也是第一项使用校准带技术的研究。
目的
本研究旨在评估PRISM IV在大量入住巴西重症监护病房（PICU）患者中的性能。
设计、背景和参与者：这是一项纵向、前瞻性、多中心研究，在巴西36个PICU进行，研究对象为2020年3月至2022年3月期间收治的29天至18岁的儿童。
主要结局和测量指标
使用标准化死亡率（SMR）、受试者操作特征曲线下面积（AUROC）及其95%置信区间，以及80%和95%置信区间的校准带评估PRISM IV的性能。
结果
共纳入来自36个PICU的12046例患者。观察到的总体院内死亡率高于预测值：观察值=249例（2.1%）×预测值=188.1例（1.56%）（SMR=1.32[95%置信区间，1.16 - 1.50]）；辨别能力良好（AUROC=0.86[95%置信区间，0.83 - 0.89]），但校准不佳，在广泛的预测死亡率范围内（2% - 61%）低估了死亡率。为探讨2019冠状病毒病（COVID - 19）大流行对PRISM IV性能的影响，我们将研究期分为疫苗接种前和疫苗接种后两个阶段。在疫苗接种前阶段，SMR为1.38（95%置信区间，1.17 - 1.62），AUROC为0.84（95%置信区间，0.80 - 0.88），校准错误范围比整个队列更宽（在2% - 98%范围内低估）。在疫苗接种后阶段，SMR为1.26（95%置信区间，1.03 - 1.51），AUROC为0.90（95%置信区间，0.86 - 0.94），校准带在预测死亡率的3% - 46%较窄范围内低估了死亡率。
结论及相关性
在一个大型队列中，PRISM IV在广泛的预测死亡率范围和不同的COVID - 19大流行时期显示出良好的辨别能力，但校准存在错误。需要进行进一步的亚组分析研究，以制定策略来改善PRISM IV在不同且异质性的巴西医疗环境中的性能。
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