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The Pediatric Risk of Mortality Score: Update 2015*

Pollack, Murray M. MD1; Holubkov, Richard PhD2; Funai, Tomohiko MS2; Dean, J. Michael MD2; Berger, John T. MD3; Wessel, David L. MD3; Meert, Kathleen MD4; Berg, Robert A. MD5; Newth, Christopher J. L. MD, FRCPC6; Harrison, Rick E. MD7; Carcillo, Joseph MD8; Dalton, Heidi MD9; Shanley, Thomas MD10; Jenkins, Tammara L. MSN, RN11; Tamburro, Robert MD, MSc11

Pediatric Critical Care Medicine: January 2016 - Volume 17 - Issue 1 - p 2–9
doi: 10.1097/PCC.0000000000000558
Feature Articles

Objectives: Severity of illness measures have long been used in pediatric critical care. The Pediatric Risk of Mortality is a physiologically based score used to quantify physiologic status, and when combined with other independent variables, it can compute expected mortality risk and expected morbidity risk. Although the physiologic ranges for the Pediatric Risk of Mortality variables have not changed, recent Pediatric Risk of Mortality data collection improvements have been made to adapt to new practice patterns, minimize bias, and reduce potential sources of error. These include changing the outcome to hospital survival/death for the first PICU admission only, shortening the data collection period and altering the Pediatric Risk of Mortality data collection period for patients admitted for “optimizing” care before cardiac surgery or interventional catheterization. This analysis incorporates those changes, assesses the potential for Pediatric Risk of Mortality physiologic variable subcategories to improve score performance, and recalibrates the Pediatric Risk of Mortality score, placing the algorithms (Pediatric Risk of Mortality IV) in the public domain.

Design: Prospective cohort study from December 4, 2011, to April 7, 2013.

Measurements and Main Results: Among 10,078 admissions, the unadjusted mortality rate was 2.7% (site range, 1.3–5.0%). Data were divided into derivation (75%) and validation (25%) sets. The new Pediatric Risk of Mortality prediction algorithm (Pediatric Risk of Mortality IV) includes the same Pediatric Risk of Mortality physiologic variable ranges with the subcategories of neurologic and nonneurologic Pediatric Risk of Mortality scores, age, admission source, cardiopulmonary arrest within 24 hours before admission, cancer, and low-risk systems of primary dysfunction. The area under the receiver operating characteristic curve for the development and validation sets was 0.88 ± 0.013 and 0.90 ± 0.018, respectively. The Hosmer-Lemeshow goodness of fit statistics indicated adequate model fit for both the development (p = 0.39) and validation (p = 0.50) sets.

Conclusions: The new Pediatric Risk of Mortality data collection methods include significant improvements that minimize the potential for bias and errors, and the new Pediatric Risk of Mortality IV algorithm for survival and death has excellent prediction performance.

Supplemental Digital Content is available in the text.

1Department of Pediatrics, Children’s National Medical Center and the George Washington University School of Medicine and Health Sciences, Washington DC.

2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT.

3Department of Pediatrics, Children’s National Medical Center, Washington DC.

4Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI.

5Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA.

6Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA.

7Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA.

8Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

9Department of Child Health, Phoenix Children’s Hospital and University of Arizona College of Medicine-Phoenix, Phoenix, AZ.

10Department of Pediatrics, University of Michigan, Ann Arbor, MI.

11Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institutes of Health (NIH), Bethesda, MD.

*See also p. 83.

Drs. Pollack and Holubkov had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services: U10HD050096, U10HD049981, U10HD049983, U10HD050012, U10HD063108, U10HD063106, U10HD063114, and U01HD049934. This content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health.

Dr. Pollack received grant support from the National Institute of Child Health and Human Development (NICHD), has patent applications through Children’s National Medical Center (his not-for-profit employer), and received support for article research from the National Institutes of Health (NIH). Dr. Holubkov served as a board member for Pfizer, the National Burn Association, and Fibrocell (Data Safety Board membership); consulted for St. Jude Medical, Physicians Committee for Responsible Medicine, and Covidien (biostatistical consulting); received support for article research from the NIH. Dr. Holubkov and his institution received grant support (salary support [biostatistician]) and support for travel (steering committee meeting travel) from the NIH. Dr. Funai received support for article research from the NIH. Dr. Funai and his institution received grant support from the NIH (salaries support biostatistician). Dr. Dean received support for article research from the NIH. His institution received grant support from the NIH and Health Services and Resources Administration. Dr. Berger received support for article research from the NIH. His institution received grant support from the NIH and the Association for Pediatric Pulmonary Hypertension. Dr. Wessel received support for article research from the NIH. His institution received grant support from the NIH (ongoing). Dr. Meert received consulting fees and support for article research from the NIH. Her institution received grant support from the NIH. Dr. Berg received grant support from the NICHD and received support for article research from the NIH. Dr. Carcillo received support for article research from the NIH. His institution received grant support and support for travel. Dr. Dalton lectured for rEVO Biologics, received royalties from the Society of Critical Care Medicine (SCCM) for Pediatric Multidisciplinary Board Review Book, and received support for article research from the NIH. Her institution received grant support from the NIH. Dr. Newth received support for article research from the NIH. His institution received grant support from the NIH/NICHD (Collaborative Pediatric Critical Care Research Network). Dr. Shanley received support for article research from the NIH and served as a board member for International Pediatric Research Foundation (Society for Pediatric Research Representative on Executive Committee). His institution received grant support from the NICHD (Collaborative Pediatric Critical Care Research Network [CPCCRN] grant) and the NIH (Clinical and Translational Science Award grant) and received support for travel from the NICHD (CPCCRN grant). Dr. Harrison lectured for the SCCM (board review lectures for my professional society) and received support for article research from the NIH. His institution received grant support from the NIH (CPCCRN funding and Therapeutic Hypothermia for Pediatric Cardiac Arrest trial funding via NIH). Ms Jenkins received support for article research from the NIH and disclosed government work. Dr. Tamburro received grant support from the U.S. Food and Drug Administration Office of Orphan Product Development Grant to study calfactant in pediatric stem cell transplant patients (no longer coprincipal investigator on the trial secondary to accepting a new position), received royalties from Springer Publisher (received royalties for serving as an associate editor on a pediatric critical care textbook and study guide), received support for article research from the NIH, and disclosed government work.

For information regarding this article, E-mail: mpollack@childrensnational.org

©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies