Abstract
Management of severe malaria with limited resources requires comprehensive planning. Expected length of stay (LOS) and the factors influencing it are useful in the planning and optimisation of service delivery. A secondary, competing-risk approach to survival analysis was performed for 1217 adult severe malaria patients from the South-East Asia Quinine Artesunate Malaria Trial. Twenty percent of patients died; 95.4% within 7 days compared to 70.3% of those who were discharged. Median time to discharge was 6 days. Compared to quinine, artesunate increased discharge incidence (subdistribution-Hazard ratio, 1.24; [95% confidence interval 1.09-1.40]; P = .001) and decreased incidence of death (0.60; [0.46-0.80]; P < .001). Low Glasgow coma scale (discharge, 1.08 [1.06-1.11], P < .001; death, 0.85 [0.82-0.89], P < .001), high blood urea-nitrogen (discharge, 0.99 [0.99-0.995], P < .001; death, 1.00 [1.00-1.01], P = .012), acidotic base-excess (discharge, 1.05 [1.03-1.06], P < .001; death, 0.90 [0.88-0.93], P < .001), and development of shock (discharge, 0.25 [0.13-0.47], P < .001; death, 2.14 [1.46-3.12], P < .001), or coma (discharge, 0.46 [0.32-0.65], P < .001; death, 2.30 [1.58-3.36], P < .001) decreased cumulative incidence of discharge and increased incidence of death. Conventional Kaplan-Meier survival analysis overestimated cumulative incidence compared to competing-risk model. Clinical factors on admission and during hospitalisation influence LOS in severe malaria, presenting targets to improve health and service efficiency. Artesunate has the potential to increase LOS, which should be accounted for when planning services. In-hospital death is a competing risk for discharge; an important consideration in LOS models to reduce overestimation of risk and misrepresentation of associations.
Highlights
MethodsA secondary, competing-risk approach to survival analysis was performed for 1217 adult severe malaria patients from the South-East Asia Quinine Artesunate Malaria Trial
Management of severe malaria with limited resources requires comprehensive planning
Deaths are censored in a standard survival analysis approach [21], ignoring the influence that time to death has on resource use and the impact deaths have on the cumulative incidence of discharge
Summary
A secondary, competing-risk approach to survival analysis was performed for 1217 adult severe malaria patients from the South-East Asia Quinine Artesunate Malaria Trial. Because more accurate information means better informed decisions on resource allocation [25], we modeled LOS in severe malaria accounting for the competing event of death This was a retrospective, secondary analysis of the South-East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) dataset, modeling LOS as time to discharge or death in-hospital, with competing-risk methodology. Patients from Myanmar, Bangladesh, India, and Indonesia (where 97% of the confirmed malaria cases in the Asia-Pacific region occur [26]) with severe falciparum malaria (diagnosed by clinical criteria and a positive rapid test) were enrolled between June 2003 and May 2005 [18] In this analysis, 234 children aged
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