TY - JOUR
T1 - Incidence and predictors of hospital readmission in children presenting with severe anaemia in Uganda and Malawi: a secondary analysis of TRACT trial data
AU - Connon, Roisin
AU - George, Elizabeth C.
AU - Olupot-Olupot, Peter
AU - Kiguli, Sarah
AU - Chagaluka, George
AU - Alaroker, Florence
AU - Opoka, Robert O.
AU - Mpoya, Ayub
AU - Walsh, Kevin
AU - Engoru, Charles
AU - Nteziyaremye, Julius
AU - Mallewa, Macpherson
AU - Kennedy, Neil
AU - Nakuya, Margaret
AU - Namayanja, Cate
AU - Nabawanuka, Eva
AU - Sennyondo, Tonny
AU - Amorut, Denis
AU - Williams Musika, C.
AU - Bates, Imelda
AU - Boele van Hensbroek, M.
AU - Evans, Jennifer A.
AU - Uyoga, Sophie
AU - Williams, Thomas N.
AU - Frost, Gary
AU - Gibb, Diana M.
AU - Maitland, Kathryn
AU - Walker, A. Sarah
AU - on behalf of the TRACT trial group
AU - Kiguli, S.
AU - Opoka, R. O.
AU - Nabawanuka, E.
AU - Kayaga, J.
AU - Kadama, E.
AU - Mbwali, I.
AU - Nuwabaine, L.
AU - Nakikwaku, R.
AU - Nsubuga, J.
AU - Mpande, K.
AU - Adoo, R.
AU - Ouma, O.
AU - Adia, N. K.
AU - Olupot-Olupot, P.
AU - Nteziyaremye, J.
AU - Namanyanga, C.
AU - Passi, G.
AU - Sennyondo, T.
AU - Adong, R.
AU - Okalebo, C. B.
AU - Atimango, E.
AU - Mwamula, S.
N1 - Funding Information: We thank all the participants and staff from all the centres participating in the TRACT trial. The TRACT trial group consists of: Participating Centres: Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda: S Kiguli, R O Opoka, E Nabawanuka, J Kayaga, C Williams Musika, E Kadama, I Mbwali, L Nuwabaine, R Nakikwaku, J Nsubuga, K Mpande, R Adoo, O Ouma, N K Adia. Mbale Regional Referral Hospital Mbale, Uganda: P Olupot-Olupot, J Nteziyaremye, C Namanyanga, G Passi, T Sennyondo, R Adong, CB Okalebo, E Atimango, S Mwamula, J Kapsindet, G Kiluli, R Muhindo, G Masifa, N Thembo, G Odong. Soroti Regional Referral Hospital Mbale, Uganda: C Engoru, F Aloroker, M Nakuya, D Amorut, M Ariima, M Itipe, MG Atim, M Abeno, B Amede, M Olupot, S Okwi, MG Kulume, G Among, P Onyas, ED Achipa. KEMRI Wellcome Trust Research Programme, Kilifi, Kenya (coordinating centre for the trial and genetics group): K Maitland, A Mpoya, P Maitha, S Uyoga, TN Williams, A Macharia. College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi: M Mallewa, G Chagaluka, Y Chimalizeni, N Kennedy, F Kumwenda, E Nkosi, T Sochera, A Malenga, B Gushu, T Phiri, A Chisale, N Mitole, E Chokani, A Munthali. Imperial College London (Trial Sponsor): K Maitland, TN Williams; Nutritional studies: G Frost, K Walsh. MRC Clinical Trials Unit at UCL, London, UK (oversight): DM Gibb, EC George, M Thomason, D Baptiste, L McCabe, AS Walker. Data Management Systems: A. Ali, K Khamis (Kenya) M Madula, G Abongo (Uganda). Liverpool School of Tropical Medicine, Liverpool, UK: R Heydermann, I Bates, B Urban. Emma Children?s Hospital AMC Amsterdam, The Netherlands: M Boele van Hensbroek. Independent REALITY Trial Monitors: F Kyomuhendo, S Nakalanzi, J Chabuka, N Mkandawire. Endpoint Review Committee: JA Evans, DM Gibb, F Fitzgerald. Trial Steering Committee: E Molyneux (Chair), I Lubega, M Murphy, P Kazembe, J Crawley. Data Monitoring Committee: T Peto (Chair), P Musoke, J Todd, G Mirembe, F Tenu. Funding Information: TRACT was funded by the UK Medical Research Council (MRC) [MR/J012483/1]. The MRC Clinical Trials Unit at UCL receives core support from the MRC [MC_UU_12023/26], through a concordat with the Department for International Development. Cipla Limited donated the cotrimoxazole for the trial. ASW is an NIHR Senior Investigator. The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.
PY - 2021/12/1
Y1 - 2021/12/1
N2 - Background: Severe anaemia (haemoglobin < 6 g/dL) is a leading cause of recurrent hospitalisation in African children. We investigated predictors of readmission in children hospitalised with severe anaemia in the TRACT trial (ISRCTN84086586) in order to identify potential future interventions. Methods: Secondary analyses of the trial examined 3894 children from Uganda and Malawi surviving a hospital episode of severe anaemia. Predictors of all-cause readmission within 180 days of discharge were identified using multivariable regression with death as a competing risk. Groups of children with similar characteristics were identified using hierarchical clustering. Results: Of the 3894 survivors 682 (18%) were readmitted; 403 (10%) had ≥2 re-admissions over 180 days. Three main causes of readmission were identified: severe anaemia (n = 456), malaria (n = 252) and haemoglobinuria/dark urine syndrome (n = 165). Overall, factors increasing risk of readmission included HIV-infection (hazard ratio 2.48 (95% CI 1.63–3.78), p < 0.001); ≥2 hospital admissions in the preceding 12 months (1.44(1.19–1.74), p < 0.001); history of transfusion (1.48(1.13–1.93), p = 0.005); and missing ≥1 trial medication dose (proxy for care quality) (1.43 (1.21–1.69), p < 0.001). Children with uncomplicated severe anaemia (Hb 4-6 g/dL and no severity features), who never received a transfusion (per trial protocol) during the initial admission had a substantially lower risk of readmission (0.67(0.47–0.96), p = 0.04). Malaria (among children with no prior history of transfusion) (0.60(0.47–0.76), p < 0.001); younger-age (1.07 (1.03–1.10) per 1 year younger, p < 0.001) and known sickle cell disease (0.62(0.46–0.82), p = 0.001) also decreased risk of readmission. For anaemia re-admissions, gross splenomegaly and enlarged spleen increased risk by 1.73(1.23–2.44) and 1.46(1.18–1.82) respectively compared to no splenomegaly. Clustering identified four groups of children with readmission rates from 14 to 20%. The cluster with the highest readmission rate was characterised by very low haemoglobin (mean 3.6 g/dL). Sickle Cell Disease (SCD) predominated in two clusters associated with chronic repeated admissions or severe, acute presentations in largely undiagnosed SCD. The final cluster had high rates of malaria (78%), severity signs and very low platelet count, consistent with acute severe malaria. Conclusions: Younger age, HIV infection and history of previous hospital admissions predicted increased risk of readmission. However, no obvious clinical factors for intervention were identified. As missing medication doses was highly predictive, attention to care related factors may be important. Trial registration: ISRCTN ISRCTN84086586.
AB - Background: Severe anaemia (haemoglobin < 6 g/dL) is a leading cause of recurrent hospitalisation in African children. We investigated predictors of readmission in children hospitalised with severe anaemia in the TRACT trial (ISRCTN84086586) in order to identify potential future interventions. Methods: Secondary analyses of the trial examined 3894 children from Uganda and Malawi surviving a hospital episode of severe anaemia. Predictors of all-cause readmission within 180 days of discharge were identified using multivariable regression with death as a competing risk. Groups of children with similar characteristics were identified using hierarchical clustering. Results: Of the 3894 survivors 682 (18%) were readmitted; 403 (10%) had ≥2 re-admissions over 180 days. Three main causes of readmission were identified: severe anaemia (n = 456), malaria (n = 252) and haemoglobinuria/dark urine syndrome (n = 165). Overall, factors increasing risk of readmission included HIV-infection (hazard ratio 2.48 (95% CI 1.63–3.78), p < 0.001); ≥2 hospital admissions in the preceding 12 months (1.44(1.19–1.74), p < 0.001); history of transfusion (1.48(1.13–1.93), p = 0.005); and missing ≥1 trial medication dose (proxy for care quality) (1.43 (1.21–1.69), p < 0.001). Children with uncomplicated severe anaemia (Hb 4-6 g/dL and no severity features), who never received a transfusion (per trial protocol) during the initial admission had a substantially lower risk of readmission (0.67(0.47–0.96), p = 0.04). Malaria (among children with no prior history of transfusion) (0.60(0.47–0.76), p < 0.001); younger-age (1.07 (1.03–1.10) per 1 year younger, p < 0.001) and known sickle cell disease (0.62(0.46–0.82), p = 0.001) also decreased risk of readmission. For anaemia re-admissions, gross splenomegaly and enlarged spleen increased risk by 1.73(1.23–2.44) and 1.46(1.18–1.82) respectively compared to no splenomegaly. Clustering identified four groups of children with readmission rates from 14 to 20%. The cluster with the highest readmission rate was characterised by very low haemoglobin (mean 3.6 g/dL). Sickle Cell Disease (SCD) predominated in two clusters associated with chronic repeated admissions or severe, acute presentations in largely undiagnosed SCD. The final cluster had high rates of malaria (78%), severity signs and very low platelet count, consistent with acute severe malaria. Conclusions: Younger age, HIV infection and history of previous hospital admissions predicted increased risk of readmission. However, no obvious clinical factors for intervention were identified. As missing medication doses was highly predictive, attention to care related factors may be important. Trial registration: ISRCTN ISRCTN84086586.
KW - Readmission
KW - Severe anaemia
UR - http://www.scopus.com/inward/record.url?scp=85112254724&partnerID=8YFLogxK
U2 - https://doi.org/10.1186/s12889-021-11481-6
DO - https://doi.org/10.1186/s12889-021-11481-6
M3 - Article
C2 - 34325680
SN - 1471-2458
VL - 21
JO - BMC public health
JF - BMC public health
IS - 1
M1 - 1480
ER -