Case Fatality Ratio by Admission Diagnosis in Children 1 to 60 Months of Age Admitted to a Tertiary Care Government Hospital in Malawi

Background: Assessments of pediatric hospital mortality in sub-Saharan Africa focus on aggregate mortality rates and diagnoses associated with the largest absolute number of deaths. In contrast, case fatality ratios (CFRs) by diagnosis have been infrequently reported. Differentiating between conditions that cause the most deaths and those that are most deadly will allow health systems to better identify areas for intervention.

Methods: In this study, we investigated hospital mortality by admission diagnosis in a prospective cohort of children aged 1 to 60 months admitted to a tertiary care government referral hospital in Malawi between October 2017 and June 2020. Case fatality ratio (CFR) was calculated as the number of patients with an admission diagnosis who died divided by the number of patients with the admission diagnosis. This calculation represents the risk of death for admitted patients with the diagnosis over the study period. Only diagnoses with a prevalence of at least 0.5% were considered when calculating CFR.

Results: There were 24,588 admitted children eligible for analysis. Of these, 53.0% (n = 13,026) had 1 admission diagnosis, 35.2% (n = 8,664) had 2 diagnoses, 11.2% (n = 2,762) had 3 or more diagnoses, and 0.6% (n = 136) had no recorded diagnoses. Disposition was recorded in 94% of patients and 4% (n = 984) died in the hospital. The most common diagnoses were pneumonia/bronchiolitis, malaria, and sepsis. The diagnoses with the highest absolute numbers of deaths were malaria, pneumonia/bronchiolitis, and sepsis (Table 1). The highest CFRs were found in surgical condition (CFR 16.1%; 95% CI 12.0-20.3), malnutrition (CFR 15.8%; 95% CI 13.6-18.0), and congenital heart disease (CFR 14.5%; 95% CI 9.9-19.2).

Conclusion: Diagnosis-specific mortality has been incompletely studied as an outcome measure of pediatric care in sub-Saharan African hospitals. Our study describes diagnoses associated with the largest numbers of death and highest risk of death in a tertiary care hospital in Malawi. Diagnoses responsible for the largest numbers of death mostly correspond to those of highest prevalence. Diagnoses with the highest CFRs mostly correspond to those requiring resource-intensive care. Decreasing these CFRs will require sustained capacity building – such as training pediatricians, improving nurse-to-patient ratios, and expanding access to critical care resources – in conjunction with targeted quality improvement initiatives against common and deadly diagnoses.