ACP risk grade: a simple mortality index for patients with confirmed or suspected severe acute respiratory syndrome coronavirus 2 disease (COVID-19) during the early stage of outbreak in Wuhan, China

  1. Jiatao Lu
  2. Shufang Hu
  3. Rong Fan
  4. Zhihong Liu
  5. Xueru Yin
  6. Qiongya Wang
  7. Qingquan Lv
  8. Zhifang Cai
  9. Haijun Li
  10. Yuhai Hu
  11. Ying Han
  12. Hongping Hu
  13. Wenyong Gao
  14. Shibo Feng
  15. Qiongfang Liu
  16. Hui Li
  17. Jian Sun
  18. Jie Peng
  19. Xuefeng Yi
  20. Zixiao Zhou
  21. Yabing Guo
  22. Jinlin Hou

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Abstract

Background

Since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) outbreaks in Wuhan, China, healthcare systems capacities in highly endemic areas have been overwhelmed. Approaches to efficient management are urgently needed and key to a quicker control of the outbreaks and casualties. We aimed to characterize the clinical features of hospitalized patients with confirmed or suspected COVID-19, and develop a mortality risk index for COVID-19 patients.

Methods

In this retrospective one-centre cohort study, we included all the confirmed or suspected COVID-19 patients hospitalized in a COVID-19-designated hospital from January 21 to February 5, 2020. Demographic, clinical, laboratory, radiological and clinical outcome data were collected from the hospital information system, nursing records and laboratory reports.

Results

Of 577 patients with at least one post-admission evaluation, the median age was 55 years (interquartile range [IQR], 39 - 66); 254 (44.0%) were men; 22.8% (100/438) were severe pneumonia on admission, and 37.7% (75/199) patients were SARS-CoV-2 positive. The clinical, laboratory and radiological data were comparable between positive and negative SARS-CoV-2 patients. During a median follow-up of 8.4 days (IQR, 5.8 - 12.0), 39 patients died with a 12-day cumulative mortality of 8.7% (95% CI, 5.9% to 11.5%). A simple mortality risk index (called ACP index), composed of Age and C-reactive Protein, was developed. By applying the ACP index, patients were categorized into three grades. The 12-day cumulative mortality in grade three (age ≥ 60 years and CRP ≥ 34 mg/L) was 33.2% (95% CI, 19.8% to 44.3%), which was significantly higher than those of grade two (age ≥ 60 years and CRP < 34 mg/L; age < 60 years and CRP ≥ 34 mg/L; 5.6% [95% CI, 0 to 11.3%]) and grade one (age < 60 years and CRP < 34 mg/L, 0%) (P <0.001), respectively.

Conclusion

The ACP index can predict COVID-19 related short-term mortality, which may be a useful and convenient tool for quickly establishing a COVID-19 hierarchical management system that can greatly reduce the medical burden and therefore mortality in highly endemic areas.

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    SciScore for 10.1101/2020.02.20.20025510: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The study was conducted in accordance with the guidelines of the Declaration of Helsinki and the principles of good clinical practice, and was approved by the Nanfang Hospital Ethics Committee (NFEC-2020-026).
    Consent: Written informed consent was waived in light of the urgent need to collect clinical data.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical analysis was performed by Statistical Package for Social Science (SPSS version 20.0, Chicago, IL, USA) and R (Version 3.5.1).
    SPSS
    suggested: (SPSS, RRID:SCR_002865)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    The traditional RT-PCR assay has its limitations. The assay results could be influenced by specimen sources (from upper respiratory tract or lower respiratory tract) and the quality of the specimen collection. In addition, the process of virus inactivation and extraction might confer risk of viral RNA degradation in some extent and PCR inhibitors could interfere the PCR reaction, causing false-negative result.10 Therefore, we strongly believed that SARS-CoV-2 infections should not be ruled out on the patients with negative results of RT-PCR assay for SARS-CoV-2 when there are similar clinical presentations to COVID-19, especially in highly endemic area. Additionally, negative RT-PCR assay results for SARS-CoV-2 should not be used as a criterion to discharge seemingly improved patients after treatment from quarantine. Considering the false-negative SARS-CoV-2 assay results, a sensitive and specific as well as fast and convenient diagnostic method needs to be developed with urgency. At present, we are conducting another promising study on the evaluation of the antibodies (immunoglobulin [Ig] G and IgM) to SARS-CoV-2 among patients in the current cohort. It is believed that the combination of detection of the pathogen and antibodies to it would improve the accuracy of SARS-CoV-2 infection diagnosis. With the increasing number of confirmed cases and deaths from SARS-CoV-2 infection, the city of Wuhan is facing a big challenge with the overwhelmed medical capacity to provide essen...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2020.02.20.20025510v1 on medRxiv