Validity of pneumonia severity assessment scores in low- and middle-income countries : a systematic review and meta-analysis

Hussain, Sarah and Kurdi, Amanj and Abutheraa, Nouf and Al Dawsari, Asma and Sneddon, Jacqueline and Seaton, Andrew and Godman, Brian (2020) Validity of pneumonia severity assessment scores in low- and middle-income countries : a systematic review and meta-analysis. In: Medicine Utilisation Research In Africa (MURIA), 2020-10-13 - 2020-10-14, Kenya (Virtual).

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    Background: Pneumonia treatment decisions are often guided by the use of severity assessment scores, such as the well-known and validated pneumonia severity index and CURB-65. Several pneumonia severity scoring systems have been developed, but the evidence of their utilisation in low- and middle-income countries (LMICs) remains limited. Objective: In this review, we sought to systematically investigate the evidence around the validity and performance of the existing pneumonia severity scores in adult patients diagnosed with community-acquired pneumonia in LMICs. Methods: Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials, Scopus, and Web of Science were searched for eligible articles up to May 2020. Relevant data were extracted from the included studies. The association between high severity scores and the studied outcome was tested. Pooled estimates of the severity scores performance (sensitivity and specificity) at their high-risk cutoffs in predicting the reported outcome were estimated using the bivariate meta-analysis model. Heterogeneity was assessed using the I² index. Results: Overall, 11 studies met our inclusion criteria, of which, only six with sufficient data were included in the final meta-analysis that involved examining CURB-65 and CRB-65 scores. Both scores at a threshold ≥3 were related to an increased mortality risk, with pooled relative risks of 8.58 (95%CI: 3.48-21.18) and 4.83 (95%CI: 2.52-9.28) for CURB-65 and CRB-65, respectively. The predictive performance of CURB-65 and CRB-65 at their high-risk cutoffs, respectively, were as follows: the pooled sensitivity, 0.69 (95%CI: 0.25-0.94) and 0.04 (95%CI: 0.00-0.40); the pooled specificity, 0.89 (95%CI: 0.72-0.96) and 0.99 (95%C%: 0.95-1.00); and the area under the summary receiver operator characteristic curves, 0.90 (95%CI: 0.87-0.92) and 0.86 (95%CI: 0.83-0.89). Conclusion: CURB-65 and CRB-65 at a cutoff ≥3 are strongly associated with mortality and appear to be valid scores for mortality prediction in LMICs. CURB-65 exhibited higher sensitivity and overall accuracy, compared to CRB-65.