In Reply We agree with Dr Lewis and colleagues that missing data can be an important limitation in clinical research, including our analysis of the predictive validity of the qSOFA score and SIRS criteria.1 There are 2 issues related to missing data: (1) why missing data are present and (2) the approach to missing data during analysis. First, missing data were present in all 9 cohorts included in the study. Many sites lacked electronic health record systems, had limited medical staff available to collect and record serial vital signs, and were unable to routinely perform laboratory testing for every patient with suspected infection because of limited laboratory and financial resources. Given this reality, the diagnosis of sepsis in LMICs will not always be informed by complete data. Therefore, it is useful for clinicians in low-resource settings to understand the performance of alternative scoring systems in situations in which some variables, though important predictors of clinical outcome, may be missing.
Rudd KE, Seymour CW, Angus DC. Validity of the qSOFA Score in Low- and Middle-Income Countries—Reply. JAMA. 2018;320(19):2039–2040. doi:10.1001/jama.2018.14477
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