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Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa
  1. Christopher C Moore1,
  2. Riley Hazard2,
  3. Kacie J Saulters3,
  4. John Ainsworth4,
  5. Susan A Adakun5,
  6. Abdallah Amir6,
  7. Ben Andrews7,
  8. Mary Auma6,
  9. Tim Baker8,
  10. Patrick Banura9,
  11. John A Crump10,
  12. Martin P Grobusch11,
  13. Michaëla A M Huson11,
  14. Shevin T Jacob12,
  15. Olamide D Jarrett13,
  16. John Kellett14,
  17. Shabir Lakhi15,
  18. Albert Majwala6,
  19. Martin Opio16,
  20. Matthew P Rubach17,
  21. Jamie Rylance18,
  22. W Michael Scheld1,
  23. John Schieffelin19,
  24. Richard Ssekitoleko5,
  25. India Wheeler18,
  26. Laura E Barnes20
  1. 1Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
  2. 2College of Arts and Sciences, University of Virginia, Charlottesville, Virginia, USA
  3. 3Department of Medicine, Georgetown University, Washington, District of Columbia, USA
  4. 4Healthsystem Information Technology, University of Virginia Health Systems, Charlottesville, Virginia, USA
  5. 5Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
  6. 6Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
  7. 7Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
  8. 8Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  9. 9Department of Pediatrics, Masaka Regional Referral Hospital, Masaka, Uganda
  10. 10Centre for International Health, University of Otago, Dunedin, New Zealand
  11. 11Center of Tropical Medicine and Travel Medicine, University of Amsterdam, Amsterdam, The Netherlands
  12. 12Department of Medicine, University of Washington, Seattle, Washington, USA
  13. 13Department of Medicine, University of Illinois at Chicago School of Medicine, Chicago, Illinois, USA
  14. 14Department of Acute and Emergency Medicine, University of Southern Denmark, Odense, Denmark
  15. 15Zambia Emory Research Project, Lusaka, Zambia
  16. 16Department of Medicine, Kitovu Hospital, Masaka, Uganda
  17. 17Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
  18. 18Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
  19. 19Departments of Pediatrics and Internal Medicine, Tulane University, New Orleans, Louisiana, USA
  20. 20Department of Systems and Information Engineering, University of Virginia, Charlottesville, USA
  1. Correspondence to Dr Christopher C Moore; ccm5u{at}virginia.edu

Abstract

Background Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA.

Methods We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009–2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score.

Results Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27–49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)).

Conclusion We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.

  • Africa
  • critical illness
  • early warning score
  • MEWS
  • qSOFA
  • hospital mortality

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000344

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    Footnotes

    • Contributors CCM and LEB designed the study and analysis. SAA, AA, BA, MA, TB, PB, JAC, MPG, MAMH, STJ, ODJ, JK, SL, AM, MO, MPR, JR, JS, WMS, RS and IW all contributed data. CCM, RH, KJS and LEB collected data and prepared the data sets. CCM, RH, KJS, JA and LEB analysed the data. CCM and RH drafted the manuscript. CCM and LEB reviewed, edited and revised the manuscript, as well as supervised all the processes. All authors interpreted data and revised the manuscript critically for intellectual content. Finally, all the authors read and approved the final version.

    • Funding Data collection in Lusaka, Zambia, was supported by the National Institutes of Health Office of the Director and Fogarty International Center through the International Clinical Research Fellows Program at Vanderbilt University (R24 TW007988 to BA). Data collection in Moshi, Tanzania, was supported by the International Studies on AIDS Associated Co-infections, US National Institutes of Health (U01 AI062563 to JAC). RH received a University of Virginia Harrison Undergraduate Research Award to support this work. Funding for studies in Masaka, Mbarara and Kampala, Uganda, was provided to CCM, SAA, AA, MA, PB, STJ, AM, WMS and RS by the Pfizer Initiative in International Health and the Center for Global Health at the University of Virginia. This initiative was conceived to fund global infectious disease research and exchange programmes between postdoctoral fellows and students from the University of Virginia and several international partners to conduct research on global health issues. The major purpose of this programme was to foster and enhance bidirectional research training. An independent board at the University of Virginia determined the research proposals that were funded. Pfizer provided funds to promote the initiative but had no role in the planning, execution or analysis of research protocols, including the study described in this article.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.