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Use of a Simple Prognostic Model Based on Counting Clinical Signs

Steve Collins, MBBS; Mark Myatt, BA

JAMA. 2000;284:621-626.

Context  In the setting of famine, infection is likely to cause mortality among severely malnourished persons. Although clinical signs are likely to be useful prognostic indicators in this setting, use of a clinical assessment model has not been studied.

Objective  To examine the use of clinical signs in the prediction of short-term mortality in severely malnourished adults and adolescents during famine.

Design  Retrospective cohort study.

Setting  Concern Worldwide Adult Therapeutic Feeding Center in Baidoa, Somalia.

Patients  Data from the clinical records of 383 adult and adolescent inpatients admitted to the center between November 1992 through March 1993 who were aged 15 years or older and had a body mass index (BMI) of 13.5 kg/m² or less or any signs of edematous malnutrition.

Main Outcome Measures  Association of mortality with presence or absence of 8 clinical signs (edema, hydration, ascites, dysentery, diarrhea, anemia, chest infection, and ability to stand) and BMI at admission, and sensitivity and specificity of models including a count of clinical signs and BMI in the prediction of mortality at the center.

Results  Ninety-one patients (23.8%) died, with a median time to death of 8 days from admission. Of the 8 clinical signs, severe edema (unadjusted odds ratio [OR], 2.45; 95% confidence interval [CI], 1.41-4.27), apparent dehydration (unadjusted OR, 2.73; 95% CI, 1.60-4.66), and inability to stand (unadjusted OR, 2.96; 95% CI, 1.40-6.26) were independently associated with mortality. The most useful clinical model was that based on the presence of any 1 of these 3 signs, with a sensitivity of 77% and a specificity of 59%. Ability of admission BMI to predict mortality was less than random.

Conclusions  Models based on clinical signs predicted death better than BMI. Simple counts of clinical signs performed as well as more complex models based on the addition of ORs. Counting relevant clinical signs is an easy and effective prognostic tool in severe adult and adolescent malnutrition during famine; however, it is not sensitive enough for use as a screening tool.

Author Affiliations: Concern Worldwide, Dublin, Ireland (Dr Collins); Center for International Child Health, Institute of Child Health (Dr Collins) and the International Centre for Eye Health, Institute of Ophthalmology, University College London (Mr Myatt), London, England; and Valid International Ltd, Llanidloes, Wales (Dr Collins).

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