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Cited by 16Malaria Research and ControlHemoglobinopathies and Related DisordersSepsis Diagnosis and Treatment

A Competing-Risk Approach for Modeling Length of Stay in Severe Malaria Patients in South-East Asia and the Implications for Planning of Hospital Services

Open access
Keene, Claire M, Dondorp, Arjen, Crawley, Jane, Ohuma, Eric O, Mukaka, Mavuto·2018·Clinical Infectious Diseases
DOI 10.1093/cid/ciy211PMC PMC6137114
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Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

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  • Multivariable models were used to compare periods, adjusting for relevant patient characteristics showing a significant difference between periods at p<0.20.

    “Multivariable models were used to compare periods, adjusting for relevant patient characteristics.”

    From Lab efficiency and improvements in the management of bloodstream infections: a before and after study (2025) · cites this paper as [6]

    The Methods (Statistical Methods; page unavailable) confirm that the paper used multivariable models and adjusted for treatment and country. They describe models for discharge and death, not comparisons between periods, and specify P < .05 rather than P < .20 for selecting factors and assessing significance. (LLM, conf=0.90)

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Research works printed but not linked: 24

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Cited by

Sorted by citations

Authors
Keene, C. M., Dondorp, A., Crawley, J., Ohuma, E. O., & Mukaka, M.
Affiliations
University of Oxford (GB)
Corresponding author
Keene, Claire M
ORCID
Venue
Clinical Infectious Diseases
Publisher
Oxford University Press (OUP)
Published
2018-03-19
Volume
67
Issue
7
Pages
1053-1062
ISSN
  • 1058-4838 (ISSN-L)
  • 1537-6591
DOI
10.1093/cid/ciy211
PMC
PMC6137114
OpenAlex
W2790161816
Cited by
16
References
2
Citations by year
2026: 1 · 2025: 1 · 2024: 1 · 2023: 2 · 2022: 4 · 2021: 2 · 2020: 1 · 2019: 4
FWCI
1.67
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Infectious Diseases (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
  • Greater South Information System
Funders
  • Cancer Research UK
  • University of Oxford
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Malaria Research and Control
  • Health Sciences › Medicine › Genetics › Hemoglobinopathies and Related Disorders
  • Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
Keywords
severe malaria, length of hospital stay, competing risks, discharge, mortality, quinine, artesunate, Glasgow Coma Scale, shock, coma, blood urea nitrogen, hospital service planning, survival analysis, resource-limited settings, malaria treatment outcomes, Southeast Asia
MeSH terms
Artesunate, Adult, Antimalarials, Asia, Southeastern, Female, Humans, Length of Stay, Malaria, Male, Quinine, Retrospective Studies, Young Adult

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