Developing and validating an explainable digital mortality prediction tool for extremely preterm infants

Decision-making in perinatal management of extremely preterm infants is challenging. Mortality prediction tools may support decision-making. We used population-based routinely entered electronic patient record data from 25,902 infants born between 23+0–27+6 weeks’ gestation and admitted to 185 English and Welsh neonatal units from 2010–2020 to develop and internally validate an online tool to predict mortality before neonatal discharge. Comparing nine machine learning approaches, we developed an explainable tool based on stepwise backward logistic regression (https://premoutcome.shinyapps.io/Death/). The tool demonstrated good discrimination (area under the receiver operating characteristics curve (95% confidence interval) of 0.746 (0.729–0.762)) and calibration with superior net benefit across probability thresholds of 10%–70%. Our tool also demonstrated superior calibration and utility performance than previously published models. Acceptable performance was demonstrated in a multinational, external validation cohort of preterm infants. This tool may be useful to support high-risk perinatal decision-making following further evaluation.Author summary: Increasingly, more premature babies are being born even earlier and surviving. Each premature baby is unique, with different combinations of factors affecting their chances of survival. An individualised approach is needed to support discussions with parents in creating a care plan for the baby before birth. Prediction tools can help support this discussion and reduce variation in the care delivered by providing an objective measure after considering important risk factors. We used artificial intelligence to analyse the electronic health records of 25,902 premature babies born between 23 and 27 completed weeks of pregnancy from 2010 to 2020 in England and Wales. We worked with parent groups to use the data pattern identified by artificial intelligence to develop an online tool (https://premoutcome.shinyapps.io/Death/) to predict the risk of premature babies dying. The tool demonstrated how the risk factors contributed to the prediction, explaining how the predicted risk was derived. The tool developed demonstrated better performance than previously developed tools in our cohort of babies in England and Wales. The tool also showed good performance when tested in a separate cohort of babies in Australasia. The tool developed could support parental discussion and decision-making following further evaluation.