Relevance of prediction scores derived from the SARS-CoV-2 first wave, in the UK COVID-19 second wave, for early discharge, severity and mortality: a PREDICT COVID UK prospective observational cohort study

  1. Hakim Ghani
  2. Alessio Navarra
  3. Phyoe K Pyae
  4. Harry Mitchell
  5. William Evans
  6. Rigers Cama
  7. Michael Shaw
  8. Ben Critchlow
  9. Tejal Vaghela
  10. Miriam Schechter
  11. Nazril Nordin
  12. Andrew Barlow
  13. Rama Vancheeswaran

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Abstract

Objective

Prospectively validate two prognostic scores, pre-hospitalisation (SOARS) and hospitalised mortality prediction (4C Mortality Score), derived from the coronavirus disease 2019 (COVID-19) first wave, in the evolving second wave with prevalent B.1.1.7 and parent D614 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, in two large United Kingdom (UK) cohorts.

Design

Prospective observational cohort study of SOARS and 4C Mortality Score in PREDICT (single site) and multi-site ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts.

Setting

Protocol-based data collection in UK COVID-19 second wave, between October 2020 and January 2021, from PREDICT and ISARIC cohorts.

Participants

1383 from single site PREDICT cohort and 20,595 from multi-site ISARIC cohort.

Main outcome measures

Relevance of SOARS and 4C Mortality Score derived from the COVID-19 first wave, determining in-hospital mortality and safe discharge in the UK COVID-19 second wave.

Results

Data from 1383 patients (median age 67y, IQR 52-82; mortality 24.7%) in the PREDICT and 20,595 patients from the ISARIC (mortality 19.4%) cohorts showed both SOARS and 4C Mortality Score remained relevant despite the B.1.1.7 variant and treatment advances. SOARS had AUC of 0.8 and 0.74, while 4C Mortality Score had an AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore effective in evaluating both safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with a SOARS of 0-1 were potential candidates for home discharge to a virtual hospital (VH) model. SOARS score implementation resulted in low re-admission rates, 11.8% (27/229), and low mortality, 0.9% (2/229), in the VH pathway. Use is still suboptimal to prevent admission, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1.

Conclusion

SOARS and 4C Mortality Score remains valid, providing accurate prognostication despite evolving viral subtype and treatment advances, which have altered mortality. Both scores are easily implemented within urgent care pathways with a scope for admission avoidance. They remain safe and relevant to their purpose, transforming complex clinical presentations into tangible numbers, aiding objective decision making.

Trial registration

NHS HRA registration and REC approval (20/HRA/2344, IRAS ID 283888).

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  1. ScreenIT

    SciScore for 10.1101/2021.06.09.21258602: (What is this?)

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

    Table 1: Rigor

    EthicsIRB: Baseline clinical characteristics and investigations were collected according to a pre-specified protocol in a National Health Service Health Research Authority (NHS HRA) and Research Ethics Committee (REC) approved study (20/HRA/2344, IRAS ID 283888)25.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All statistical analyses including risk modelling calculations were performed using GraphPad PRISM statistics software (GraphPad, San Diego, USA) and R statistical language.
    GraphPad
    suggested: (GraphPad Prism, RRID:SCR_002798)
    PRISM
    suggested: (PRISM, RRID:SCR_005375)

    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:
    One of the main limitations of the SOARS score is its dependance on age. Older patients automatically trigger a higher mortality score regardless of their comorbidities and clinical presentation, a limitation in all COVID-19 severity scores due to high weighting for age. This may change with vaccination and will require review in post-vaccination waves. If viral subtypes evade vaccination or boosters are delayed, age may still be relevant to scoring7. Additionally, multivariate analysis from the second wave revealed that pre-morbid CVA (OR 0.78), despite affecting a similar proportion of SARS-CoV-2 cases in both waves (Table 1), was no longer associated with mortality, an observation difficult to explain. Another limitation of this study is the absence of SARS-CoV-2 serotyping of individual patients which would help assess the contribution of B.1.1.7 variant in presentations and outcomes. This may have provided some clarity to the differential contribution of the variant to treatment, public health measures and host characteristics resulting in the reduced mortality in the second wave. The contribution of Remdesivir and Tocilizumab were also not discussed in view of the small number of patients treated with these agents and as it was not the primary objective of this study. Effects of vaccination did not contribute significantly to the second wave, a limitation that requires further review in future. SOARS, a clinical score developed to enable safe discharge to the community ...

    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.

    Results from scite Reference Check: We found no unreliable references.

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  2. Version published to 10.1101/2021.06.09.21258602v1 on medRxiv