Utility of conventional clinical risk scores in a low-risk COVID-19 cohort

Abstract Background Several specific risk scores for Coronavirus disease 2019 (COVID-19) involving clinical and biochemical parameters have been developed from higher-risk patients, in addition to validating well-established pneumonia risk scores. We compared multiple risk scores in predicting more severe disease in a cohort of young patients with few comorbid illnesses. Accurately predicting the progression of COVID-19 may guide triage and therapy. Methods We retrospectively examined 554 hospitalised COVID-19 patients in Singapore. The CURB-65 score, Pneumonia Severity Index (PSI), ISARIC 4C prognostic score (4C), CHA2DS2-VASc score, COVID-GRAM Critical Illness risk score (COVID-GRAM), Veterans Health Administration COVID-19 index for COVID-19 Mortality (VACO), and the “rule-of-6” score were compared for three performance characteristics: the need for supplemental oxygen, intensive care admission and mechanical ventilation. Results A majority of patients were young (≤ 40 years, n = 372, 67.1%). 57 (10.3%) developed pneumonia, with 16 (2.9% of study population) requiring supplemental oxygen. 19 patients (3.4%) required intensive care and 2 patients (0.5%) died. The clinical risk scores predicted patients who required supplemental oxygenation and intensive care well. Adding the presence of fever to the CHA2DS2-VASc score and 4C score improved the ability to predict patients who required supplemental oxygen (c-statistic 0.81, 95% CI 0.68–0.94; and 0.84, 95% CI 0.75–0.94 respectively). Conclusion Simple scores including well established pneumonia risk scores can help predict progression of COVID-19. Adding the presence of fever as a parameter to the CHA2DS2-VASc or the 4C score improved the performance of these scores in a young population with few comorbidities.

Download Full-text

Intensive Care Services in the Veterans Health Administration

CHEST Journal ◽

10.1378/chest.06-3083 ◽

2007 ◽

Vol 132 (5) ◽

pp. 1455-1462 ◽

Cited By ~ 18

Author(s):

Peter Almenoff ◽

Anne Sales ◽

Sharon Rounds ◽

Michael Miller ◽

Kelly Schroeder ◽

...

Keyword(s):

Intensive Care ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Care Services

Download Full-text

Complications of Hospital-Onset Healthcare Facility–Associated Clostridium difficile Infections Among Veterans

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2016.33 ◽

2016 ◽

Vol 37 (6) ◽

pp. 717-719 ◽

Cited By ~ 3

Author(s):

Martin E. Evans ◽

Stephen M. Kralovic ◽

Loretta A. Simbartl ◽

Judith L. Whitlock ◽

Rajiv Jain ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Clostridium Difficile ◽

Acute Care ◽

Healthcare Facility ◽

Veterans Health Administration ◽

Infect Control Hosp ◽

Veterans Health ◽

Health Administration ◽

Infection Diagnosis

Complications within 30 days of a clinically confirmed hospital-onset Clostridium difficile infection diagnosis from July 1, 2012, through June 30, 2015, in 127 acute care Veterans Health Administration facilities were evaluated. Pooled rates for attributable intensive care unit admissions, colectomies, and deaths were 2.7%, 0.5%, and 0.4%, respectively.Infect Control Hosp Epidemiol 2016;37:717–719

Download Full-text

Preexisting Comorbid Psychiatric Conditions and Mortality in Nonsurgical Intensive Care Patients

American Journal of Critical Care ◽

10.4037/ajcc2010967 ◽

2010 ◽

Vol 19 (3) ◽

pp. 241-249 ◽

Cited By ~ 14

Author(s):

Thad E. Abrams ◽

Mary Vaughan-Sarrazin ◽

Gary E. Rosenthal

Keyword(s):

Intensive Care ◽

Confidence Interval ◽

Odds Ratio ◽

Bipolar Disorders ◽

Inhospital Mortality ◽

Veterans Health ◽

Medical Conditions ◽

Health Administration ◽

Intensive Care Patients ◽

Psychiatric Conditions

Purpose To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit. Methods This retrospective cohort study involved 66 672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of inhospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission. Results Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted inhospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01–1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94–1.08; P = .70) were no longer significant. Conclusion Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.

Download Full-text

Pulse oximetry and supplemental oxygen use in nationwide Veterans Health Administration hospitals, 2013–2017: a Veterans Affairs Patient Database validation study

BMJ Open ◽

10.1136/bmjopen-2021-051978 ◽

2021 ◽

Vol 11 (10) ◽

pp. e051978

Author(s):

Xiao Qing Wang ◽

Theodore Iwashyna ◽

Hallie Prescott ◽

Valeria Valbuena ◽

Sarah Seelye

Keyword(s):

Pulse Oximetry ◽

Oxygen Therapy ◽

Supplemental Oxygen ◽

Face Validity ◽

Veterans Health ◽

Health Administration ◽

Electronic Health Record Data ◽

Patient Database ◽

Electronic Health ◽

Veteran's Affairs

ObjectiveExtraction and standardisation of pulse oximetry and supplemental oxygen data from electronic health records has the potential to improve risk-adjustment, quality assessment and prognostication. We develop an approach to standardisation and report on its use for benchmarking purposes.Materials and methodsUsing electronic health record data from the nationwide Veteran’s Affairs healthcare system (2013–2017), we extracted, standardised and validated pulse oximetry and supplemental oxygen data for 2 765 446 hospitalisations in the Veteran’s Affairs Patient Database (VAPD) cohort study. We assessed face, concurrent and predictive validities using the following approaches, respectively: (1) evaluating the stability of patients’ pulse oximetry values during a 24-hour period, (2) testing for greater amounts of supplemental oxygen use in patients likely to need oxygen therapy and (3) examining the association between supplemental oxygen and subsequent mortality.ResultsWe found that 2 700 922 (98%) hospitalisations had at least one pulse oximetry reading, and 864 605 (31%) hospitalisations received oxygen therapy. Patients monitored by pulse oximetry had a reading on average every 6 hours (median 4; IQR 3–7). Patients on supplemental oxygen were older, white and male compared with patients not receiving oxygen therapy (p<0.001) and were more likely to have diagnoses of heart failure and chronic pulmonary diseases (p<0.001). The amount of supplemental oxygen for patients with at least three consecutive values recorded during a 24-hour period fluctuated by median 2 L/min (IQR: 2–3), and 81% of such triplets showed the same level of oxygen receipt.ConclusionOur approach to standardising pulse oximetry and supplemental oxygen data shows face, concurrent and predictive validities as the following: supplemental oxygen clusters in the range consistent with hospital wall-dispensed oxygen supplies (face validity); there are greater amounts of supplemental oxygen for certain clinical conditions (concurrent validity) and there is an association of supplemental oxygen with in-hospital and postdischarge mortality (predictive validity).

Download Full-text

Gene Expression Risk Scores for COVID-19 Illness Severity

10.1101/2021.08.24.457521 ◽

2021 ◽

Author(s):

Derick R Peterson ◽

Andrea M Baran ◽

Soumyaroop Bhattacharya ◽

Angela Ramona Branche ◽

Daniel P Croft ◽

...

Keyword(s):

Gene Expression ◽

Intensive Care ◽

Severe Disease ◽

Expression Patterns ◽

Illness Severity ◽

Risk Scores ◽

Severe Illness ◽

T Cell Signaling ◽

Training Cohort ◽

Peripheral Blood Gene Expression

Background: The correlates of COVID-19 illness severity following infection with SARS-Coronavirus 2 (SARS-CoV-2) are incompletely understood. Methods: We assessed peripheral blood gene expression in 53 adults with confirmed SARS-CoV-2-infection clinically adjudicated as having mild, moderate or severe disease. Supervised principal components analysis was used to build a weighted gene expression risk score (WGERS) to discriminate between severe and non-severe COVID. Results: Gene expression patterns in participants with mild and moderate illness were similar, but significantly different from severe illness. When comparing severe versus non-severe illness, we identified >4000 genes differentially expressed (FDR<0.05). Biological pathways increased in severe COVID-19 were associated with platelet activation and coagulation, and those significantly decreased with T cell signaling and differentiation. A WGERS based on 18 genes distinguished severe illness in our training cohort (cross-validated ROC-AUC=0.98), and need for intensive care in an independent cohort (ROC-AUC=0.85). Dichotomizing the WGERS yielded 100% sensitivity and 85% specificity for classifying severe illness in our training cohort, and 84% sensitivity and 74% specificity for defining the need for intensive care in the validation cohort. Conclusion: These data suggest that gene expression classifiers may provide clinical utility as predictors of COVID-19 illness severity.

Download Full-text

Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration

MDM Policy & Practice ◽

10.1177/23814683211057902 ◽

2021 ◽

Vol 6 (2) ◽

pp. 238146832110579

Author(s):

Todd H. Wagner ◽

Jeanie Lo ◽

Erin Beilstein-Wedel ◽

Megan E. Vanneman ◽

Michael Shwartz ◽

...

Keyword(s):

Average Cost ◽

Surgical Care ◽

Risk Scores ◽

Fiscal Year ◽

Veterans Health ◽

Health Administration ◽

Complex Patients ◽

Risk Patients ◽

Community Providers ◽

The Cost

Background. Veterans’ access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.

Download Full-text

Early warning scores to assess the probability of critical illness in patients with COVID-19

Emergency Medicine Journal ◽

10.1136/emermed-2020-211054 ◽

2021 ◽

pp. emermed-2020-211054

Author(s):

Lars Veldhuis ◽

Milan L Ridderikhof ◽

Michiel Schinkel ◽

Joop van den Bergh ◽

Martijn Beudel ◽

...

Keyword(s):

Early Warning ◽

Severe Disease ◽

Early Warning Score ◽

Risk Scores ◽

Operating Characteristics ◽

Icu Patients ◽

Icu Admission ◽

Clinical Risk ◽

High Flow Oxygen ◽

Early Warning Scores

ObjectiveValidated clinical risk scores are needed to identify patients with COVID-19 at risk of severe disease and to guide triage decision-making during the COVID-19 pandemic. The objective of the current study was to evaluate the performance of early warning scores (EWS) in the ED when identifying patients with COVID-19 who will require intensive care unit (ICU) admission for high-flow-oxygen usage or mechanical ventilation.MethodsPatients with a proven SARS-CoV-2 infection with complete resuscitate orders treated in nine hospitals between 27 February and 30 July 2020 needing hospital admission were included. Primary outcome was the performance of EWS in identifying patients needing ICU admission within 24 hours after ED presentation.ResultsIn total, 1501 patients were included. Median age was 71 (range 19–99) years and 60.3% were male. Of all patients, 86.9% were admitted to the general ward and 13.1% to the ICU within 24 hours after ED admission. ICU patients had lower peripheral oxygen saturation (86.7% vs 93.7, p≤0.001) and had a higher body mass index (29.2 vs 27.9 p=0.043) compared with non-ICU patients. National Early Warning Score 2 (NEWS2) ≥ 6 and q-COVID Score were superior to all other studied clinical risk scores in predicting ICU admission with a fair area under the receiver operating characteristics curve of 0.740 (95% CI 0.696 to 0.783) and 0.760 (95% CI 0.712 to 0.800), respectively. NEWS2 ≥6 and q-COVID Score ≥3 discriminated patients admitted to the ICU with a sensitivity of 78.1% and 75.9%, and specificity of 56.3% and 61.8%, respectively.ConclusionIn this multicentre study, the best performing models to predict ICU admittance were the NEWS2 and the Quick COVID-19 Severity Index Score, with fair diagnostic performance. However, due to the moderate performance, these models cannot be clinically used to adequately predict the need for ICU admission within 24 hours in patients with SARS-CoV-2 infection presenting at the ED.

Download Full-text

Robust prognostic signatures derived from proteomic panel profiling of plasma from patients with severe COVID-19 complications

10.21203/rs.3.rs-126482/v1 ◽

2021 ◽

Author(s):

Maryam Al-Nesf ◽

Houari Abdesselem ◽

Ilham Bensmail ◽

Shahd Ibrahim ◽

Walaa Saeed ◽

...

Keyword(s):

Severity Score ◽

Plasma Proteins ◽

Risk Model ◽

Severe Disease ◽

Healthcare Systems ◽

Risk Scores ◽

Clinical Risk ◽

Predictive Risk ◽

Approved Drugs ◽

Fda Approved Drugs

Abstract COVID-19 complications present a huge burden on healthcare systems and warrant a predictive risk model for disease severity of SARS-CoV-2 infection to enable early intervention, prospective decision-making and triaging of patients. We profiled plasma proteins from COVID-19 patients (severe n=50, and mild n=50) and controls (n=50) using function- and pathway-based panels developed with the highly specific proximity extension assays. Several biological pathways were specific for patients with severe complications. Based on these dysregulated profiles, we propose candidate FDA-approved drugs that target multiple upregulated proteins to treat severe complications. In addition, the set of differentially expressed plasma proteins in severe disease contained a robust 46-protein signature, the COVID-19 molecular severity score, which predicts the risk of severe complications. We cross-validated this molecular severity score in an independent cohort and found it useful within three days after hospital admission to predict COVID-19 severity and outcomes. Associated with the molecular severity score, we identified a set of clinical parameters available at admission, that act as a clinical risk score for complications. The molecular and clinical risk scores described in our study may be prognostic tools for severe COVID-19 disease and help alleviate the pressure on healthcare systems during infection peaks.

Download Full-text

Clinical characteristics of COVID-19 in young patients differ from middle-aged and elderly patients

Archives of Medical Science ◽

10.5114/aoms/133090 ◽

2021 ◽

Author(s):

Keqiang Wan ◽

Chang Su ◽

Lingxi Kong ◽

Juan Liao ◽

Wenguang Tian ◽

...

Keyword(s):

Clinical Characteristics ◽

Smoking Status ◽

Severe Disease ◽

Young Patients ◽

Clinical Manifestations ◽

Pneumonia Severity Index ◽

Education Level ◽

The Other ◽

Middle Aged ◽

Youth Group

IntroductionCoronavirus disease-2019 (COVID-19) spreads worldwide. The study Aimed to understand the clinical characteristics of young COVID-19 patients.Material and methods90 patients with severe COVID-19 infection in western Chongqing were collected from 21 January to 14 March 2020. They were divided into 4 groups based on age: youth (<39 years), middle-aged (39-48 years), middle-elderly aged (49-60 years), and elderly (> 60 years). The clinical symptoms, laboratory findings, imaging findings, and treatment effects were compared among the groups.ResultsThere were 22, 27, 19, and 22 cases in the youth, middle-aged, middle-elderly, and elderly groups, respectively. There were no significant differences with respect to gender or smoking status among the four groups. The clinical indicators of severe disease in the youth group were significantly different from the other three groups, and included the lymphocyte count (P = 0.00), C-reactive protein level (P = 0.03), interleukin-6 level (P = 0.01), chest computed tomography (CT) findings (P = 0.00), number of mild cases (P = 0.02), the education level (P = 0.00), and the CD4 + T lymphocyte level (P = 0.02) at the time of admission, and the pneumonia severity index (PSI) at the time of discharge (P = 0.00). The complications (P = 0.00) among the youth group were also significantly different from the other groups.ConclusionsYoung patients have milder clinical manifestations, which may be related to higher education level, higher awareness and higher acceptance of the prevention and control of the COVID-19 epidemic, as well as their good immune function.

Download Full-text