Competing risks modeling of length of hospital stay enhances risk-stratification of patient care: application to under-five children hospitalized in Malawi

Public Deposited
Analytics

Downloadable Content

Download PDF
Request Version for Screen Reader
Creator
  • Stanley, Christopher C.
    • Other Affiliation: Kamuzu University of Health Sciences
  • Zulu, Madalitso
    • Affiliation: School of Medicine, UNC Project-Malawi
  • Msuku, Harrison
    • Other Affiliation: Kamuzu University of Health Sciences
  • Phiri, Vincent S.
    • Other Affiliation: Kamuzu University of Health Sciences
  • Kazembe, Lawrence N.
    • Other Affiliation: University of Namibia
  • Chinkhumba, Jobiba
    • Other Affiliation: Kamuzu University of Health Sciences
  • Mvalo, Tisungane
    • Affiliation: School of Medicine, Department of Pediatrics
  • Mathanga, Don P.
    • Other Affiliation: Kamuzu University of Health Sciences
Abstract
  • Introduction Length of hospital stay (LOS), defined as the time from inpatient admission to discharge, death, referral, or abscondment, is one of the key indicators of quality in patient care. Reduced LOS lowers health care expenditure and minimizes the chance of in-hospital acquired infections. Conventional methods for estimating LOS such as the Kaplan-Meier survival curve and the Cox proportional hazards regression for time to discharge cannot account for competing risks such as death, referral, and abscondment. This study applied competing risk methods to investigate factors important for risk-stratifying patients based on LOS in order to enhance patient care. Methods This study analyzed data from ongoing safety surveillance of the malaria vaccine implementation program in Malawi's four district hospitals of Balaka, Machinga, Mchinji, and Ntchisi. Children aged 1–59 months who were hospitalized (spending at least one night in hospital) with a medical illness were consecutively enrolled between 1 November 2019 and 31 July 2021. Sub-distribution-hazard (SDH) ratios for the cumulative incidence of discharge were estimated using the Fine-Gray competing risk model. Results Among the 15,463 children hospitalized, 8,607 (55.7%) were male and 6,856 (44.3%) were female. The median age was 22 months [interquartile range (IQR): 12–33 months]. The cumulative incidence of discharge was 40% lower among HIV-positive children compared to HIV-negative (sub-distribution-hazard ratio [SDHR]: 0.60; [95% CI: 0.46–0.76]; P < 0.001); lower among children with severe and cerebral malaria [SDHR: 0.94; (95% CI: 0.86–0.97); P = 0.04], sepsis or septicemia [SDHR: 0.90; (95% CI: 0.82–0.98); P = 0.027], severe anemia related to malaria [SDHR: 0.54; (95% CI: 0.48–0.61); P < 0.001], and meningitis [SDHR: 0.18; (95% CI: 0.09–0.37); P < 0.001] when compared to non-severe malaria; and also 39% lower among malnourished children compared to those that were well-nourished [SDHR: 0.61; (95% CI: 0.55–0.68); P < 0.001]. Conclusions This study applied the Fine-Gray competing risk approach to more accurately model LOS as the time to discharge when there were significant rates of in-hospital mortality, referrals, and abscondment. Patient care can be enhanced by risk-stratifying by LOS based on children's age, HIV status, diagnosis, and nutritional status.
Date of publication
Keyword
DOI
Identifier
Resource type
  • Article
Rights statement
  • In Copyright
License
  • Attribution 4.0 International
Journal title
  • Frontiers in Epidemiology
Journal volume
  • 3
Language
  • English
Version
  • Publisher
ISSN
  • 2674-1199
Publisher
  • Frontiers Media SA

Relations

Parents:

This work has no parents.

In Collection:

Items

Thumbnail Title Date Uploaded Visibility Actions
file details fepid-03-1274776.pdf 2023-12-05 Public Download