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Discrimination of GutCheckNEC: a clinical risk index for necrotizing enterocolitis

Journal of Perinatology volume 34, pages 468–475 (2014)Cite this article

Subjects

Abstract

Objective:

Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. The objective of this study was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheckNEC. Individual risk factors were weighted to assess composite odds of developing NEC. GutCheckNEC is designed to improve communication about NEC risk and coordination of care among clinicians across an infant’s clinical course.

Study design:

On the basis of a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index, then applied a logistic model building process to derive and validate GutCheckNEC. De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007 to 2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case–control matched validation set and an un-matched calibration set using receiver operating characteristic curves.

Result:

Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n=35 013) revealed nine independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late-onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status and metabolic acidosis) and two risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2:1 matched case–control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n=23 447), GutCheckNEC scores (range 0 to 58) discriminated those infants who developed surgical NEC (area under the curve (AUC)=0.84, 95% confidence interval (CI) 0.82 to 0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81 to 0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70 to 0.74).

Conclusion:

GutCheckNEC represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.

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Acknowledgements

Research was supported by the National Institute of Nursing Research (F31NR012333-A1) and the Friends of Yuma. Content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. We thank Dr Reece Clark for his comments on the initial manuscript; Dr Paula Meek for her advice related to data analysis; and Drs Pamela Reed and Elaine Jones for participating on the first author’s dissertation committee.

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Authors and Affiliations

  1. The University of Arizona College of Nursing, Tucson, AZ, USA

    S M Gephart & J A Effken

  2. The Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, FL, USA

    A R Spitzer & E Dodd

  3. Steele Children’s Research Center, The University of Arizona, Tucson, AZ, USA

    M Halpern

  4. Connecticut Children’s Medical Center, Hartford, CT, USA

    J M McGrath

  5. The University of Connecticut School of Nursing, Hartford, CT, USA

    J M McGrath

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  1. S M Gephart
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Corresponding author

Correspondence to S M Gephart.

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Competing interests

AR Spitzer is the Senior Vice President of Research and Quality for the Mednax/Pediatrix Medical Group. He coordinated the provision of data for the research from the Pediatrix BabySteps Clinical Data Warehouse. No funds were provided to accomplish the research from Pediatrix or Dr Spitzer. E Dodd is also an employee of Pediatrix Medical Group and has no conflict to disclose. The remaining authors declare no conflict of interest.

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Gephart, S., Spitzer, A., Effken, J. et al. Discrimination of GutCheckNEC: a clinical risk index for necrotizing enterocolitis. J Perinatol 34, 468–475 (2014). https://doi.org/10.1038/jp.2014.37

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