A fuller picture of COVID-19 prognosis: the added value of vulnerability measures to predict mortality in hospitalised older adults.
ABSTRACT: BACKGROUND:Although COVID-19 disproportionally affects older adults, the use of conventional triage tools in acute care settings ignores the key aspects of vulnerability. OBJECTIVE:This study aimed to determine the usefulness of adding a rapid vulnerability screening to an illness acuity tool to predict mortality in hospitalised COVID-19 patients. DESIGN:Cohort study. SETTING:Large university hospital dedicated to providing COVID-19 care. PARTICIPANTS:Participants included are 1,428 consecutive inpatients aged ?50 years. METHODS:Vulnerability was assessed using the modified version of PRO-AGE score (0-7; higher?=?worse), a validated and easy-to-administer tool that rates physical impairment, recent hospitalisation, acute mental change, weight loss, and fatigue. The baseline covariates included age, sex, Charlson comorbidity score, and the National Early Warning Score (NEWS), a well-known illness acuity tool. Our outcome was time-to-death within 60 days of admission. RESULTS:The patients had a median age of 66 years, and 58% were male. The incidence of 60-day mortality ranged from 22% to 69% across the quartiles of modified PRO-AGE. In adjusted analysis, compared with modified PRO-AGE scores 0-1 ("lowest quartile"), the hazard ratios (95% CI) for 60-day mortality for modified PRO-AGE scores 2-3, 4, and 5-7, were 1.4 (1.1-1.9), 2.0 (1.5-2.7), and 2.8 (2.1-3.8), respectively. The modified PRO-AGE predicted different mortality risk levels within each stratum of NEWS and improved the discrimination of mortality prediction models. CONCLUSIONS:Adding vulnerability to illness acuity improved accuracy of predicting mortality in hospitalised COVID-19 patients. Combining tools such as PRO-AGE and NEWS may help stratify the risk of mortality from COVID-19.
Project description:<h4>Introduction</h4>Older adults with COVID-19 have disproportionately higher rates of severe disease and mortality. It is unclear whether this is attributable to age or attendant age-associated risk factors. This retrospective cohort study aims to characterize hospitalized older adults and examine if comorbidities, frailty and acuity of clinical presentation exert an age-independent effect on COVID-19 severity.<h4>Methods</h4>We studied 275 patients admitted to the National Centre of Infectious Disease, Singapore. We measured: 1)Charlson Comorbidity Index(CCI) as burden of comorbidities; 2)Clinical Frailty Scale(CFS) and Frailty Index(FI); and 3)initial acuity. We studied characteristics and outcomes of critical illness, stratified by age groups (50-59,60-69 and ?70). We conducted hierarchical logistic regression in primary model(N = 262, excluding direct admissions to intensive care unit) and sensitivity analysis(N = 275): age and gender in base model, entering CCI, frailty (CFS or FI) and initial acuity sequentially.<h4>Results</h4>The ?70 age group had highest CCI(p<.001), FI(p<.001) and CFS(p<.001), and prevalence of geriatric syndromes (polypharmacy,53.5%; urinary symptoms,37.5%; chronic pain,23.3% and malnutrition,23.3%). Thirty-two (11.6%) developed critical illness. In the primary regression model, age was not predictive for critical illness when a frailty predictor was added. Significant predictors in the final model (AUC 0.809) included male gender (p=.012), CFS (p=.038), and high initial acuity (p=.021) but not CCI or FI. In sensitivity analysis, FI (p=.028) but not CFS was significant.<h4>Conclusions</h4>In hospitalized older adults with COVID-19, geriatric syndromes are not uncommon. Acuity of clinical presentation and frailty are important age-independent predictors of disease severity. CFS and FI provide complimentary information in predicting interval disease progression and rapid disease progression respectively.
Project description:OBJECTIVES:A simple evaluation tool for patients with novel coronavirus disease 2019 (COVID-19) could assist the physicians to triage COVID-19 patients effectively and rapidly. This study aimed to evaluate the predictive value of 5 early warning scores based on the admission data of critical COVID-19 patients. METHODS:Overall, medical records of 319 COVID-19 patients were included in the study. Demographic and clinical characteristics on admission were used for calculating the Standardized Early Warning Score (SEWS), National Early Warning Score (NEWS), National Early Warning Score2 (NEWS2), Hamilton Early Warning Score (HEWS), and Modified Early Warning Score (MEWS). Data on the outcomes (survival or death) were collected for each case and extracted for overall and subgroup analysis. Receiver operating characteristic curve analyses were performed. RESULTS:The area under the receiver operating characteristic curve for the SEWS, NEWS, NEWS2, HEWS, and MEWS in predicting mortality were 0.841 (95% CI: 0.765-0.916), 0.809 (95% CI: 0.727-0.891), 0.809 (95% CI: 0.727-0.891), 0.821 (95% CI: 0.748-0.895), and 0.670 (95% CI: 0.573-0.767), respectively. CONCLUSIONS:SEWS, NEWS, NEWS2, and HEWS demonstrated moderate discriminatory power and, therefore, offer potential utility as prognostic tools for screening severely ill COVID-19 patients. However, MEWS is not a good prognostic predictor for COVID-19.
Project description:<h4>Introduction</h4>Since the introduction of the UK's National Early Warning Score (NEWS) and its modification, NEWS2, coronavirus disease 2019 (COVID-19), has caused a worldwide pandemic. NEWS and NEWS2 have good predictive abilities in patients with other infections and sepsis, however there is little evidence of their performance in COVID-19.<h4>Methods</h4>Using receiver-operating characteristics analyses, we used the area under the receiver operating characteristic (AUROC) curve to evaluate the performance of NEWS or NEWS2 to discriminate the combined outcome of either death or intensive care unit (ICU) admission within 24?h of a vital sign set in five cohorts (COVID-19 POSITIVE, n?=?405; COVID-19 NOT DETECTED, n?=?1716; COVID-19 NOT TESTED, n?=?2686; CONTROL 2018, n?=?6273; CONTROL 2019, n?=?6523).<h4>Results</h4>The AUROC values for NEWS or NEWS2 for the combined outcome were: COVID-19 POSITIVE, 0.882 (0.868-0.895); COVID-19 NOT DETECTED, 0.875 (0.861-0.89); COVID-19 NOT TESTED, 0.876 (0.85-0.902); CONTROL 2018, 0.894 (0.884-0.904); CONTROL 2019, 0.842 (0.829-0.855).<h4>Conclusions</h4>The finding that NEWS or NEWS2 performance was good and similar in all five cohorts (range?=?0.842-0.894) suggests that amendments to NEWS or NEWS2, such as the addition of new covariates or the need to change the weighting of existing parameters, are unnecessary when evaluating patients with COVID-19. Our results support the national and international recommendations for the use of NEWS or NEWS2 for the assessment of acute-illness severity in patients with COVID-19.
Project description:BACKGROUND:There are scant data regarding the change in volume and acuity of patients presenting to emergency departments (EDs) after Coronavirus Disease 2019 (COVID-19), compared with the pre-COVID-19 era. OBJECTIVE:To determine ED volumes and triage acuity prior to and after COVID-19. METHODS:We determined the volume of patients presenting to four large EDs affiliated with general, cardiac, cancer, and obstetrics hospitals, and the acuity of presenting illness (using the Canadian Triage Acuity Scale [CTAS]) for March and April 2020 and compared them with the same months in 2019 and January 2020. Together, these facilities see over 80% of the ED visits in Qatar. The first COVID-19 patient in Qatar was diagnosed on February 29, 2020. RESULTS:A total of 192,157 ED visits were recorded during the study period. There was a 20-43% overall drop in number of ED visits, with significant variability across hospitals. The Heart Hospital experienced the sharpest decline (33-89%), and the National Center for Cancer Care and Research experienced the least decline in volumes. The decline was observed across all CTAS levels, with the largest decline observed in individuals presenting with CTAS 1 and 2 (26-69% decline month by month). No increase in overall number of deaths or crude mortality rate was observed in the COVID-19 era, according to national statistics. CONCLUSIONS:Sharp declines in ED visits and the triage acuity seen in both general and specialty hospitals raise the concern that severely ill patients may not be seeking timely care, and a surge may be expected once current restrictions on movement are lifted.
Project description:BACKGROUND:We sought to develop an automatable score to predict hospitalization, critical illness, or death for patients at risk for COVID-19 presenting for urgent care. METHODS:We developed the COVID-19 Acuity Score (CoVA) based on a single-center study of adult outpatients seen in respiratory illness clinics (RICs) or the emergency department (ED). Data was extracted from the Partners Enterprise Data Warehouse, and split into development (n = 9381, March 7-May 2) and prospective (n = 2205, May 3-14) cohorts. Outcomes were hospitalization, critical illness (ICU or ventilation), or death within 7 days. Calibration was assessed using the expected-to-observed event ratio (E/O). Discrimination was assessed by area under the receiver operating curve (AUC). RESULTS:In the prospective cohort, 26.1%, 6.3%, and 0.5% of patients experienced hospitalization, critical illness, or death, respectively. CoVA showed excellent performance in prospective validation for hospitalization (expected-to-observed ratio (E/O): 1.01, AUC: 0.76); for critical illness (E/O 1.03, AUC: 0.79); and for death (E/O: 1.63, AUC=0.93). Among 30 predictors, the top five were age, diastolic blood pressure, blood oxygen saturation, COVID-19 testing status, and respiratory rate. CONCLUSIONS:CoVA is a prospectively validated automatable score for the outpatient setting to predict adverse events related to COVID-19 infection.
Project description:BACKGROUND:Severe COVID-19 infection results in a systemic inflammatory response (SIRS). This SIRS response shares similarities to the changes observed during the peri-operative period that are recognised to be associated with the development of multiple organ failure. METHODS:Electronic patient records for patients who were admitted to an urban teaching hospital during the initial 7-week period of the COVID-19 pandemic in Glasgow, U.K. (17th March 2020-1st May 2020) were examined for routine clinical, laboratory and clinical outcome data. Age, sex, BMI and documented evidence of COVID-19 infection at time of discharge or death certification were considered minimal criteria for inclusion. RESULTS:Of the 224 patients who fulfilled the criteria for inclusion, 52 (23%) had died at 30-days following admission. COVID-19 related respiratory failure (75%) and multiorgan failure (12%) were the commonest causes of death recorded. Age???70 years (p?<?0.001), past medical history of cognitive impairment (p???0.001), previous delirium (p?<?0.001), clinical frailty score?>?3 (p?<?0.001), hypertension (p?<?0.05), heart failure (p?<?0.01), national early warning score (NEWS)?>?4 (p?<?0.01), positive CXR (p?<?0.01), and subsequent positive COVID-19 swab (p???0.001) were associated with 30-day mortality. CRP?>?80 mg/L (p?<?0.05), albumin?<?35 g/L (p?<?0.05), peri-operative Glasgow Prognostic Score (poGPS) (p?<?0.05), lymphocytes?<?1.5 109/l (p?<?0.05), neutrophil lymphocyte ratio (p???0.001), haematocrit (<?0.40 L/L (male)/?<?0.37 L/L (female)) (p???0.01), urea?>?7.5 mmol/L (p?<?0.001), creatinine?>?130 mmol/L (p?<?0.05) and elevated urea: albumin ratio (<?0.001) were also associated with 30-day mortality. On multivariate analysis, age???70 years (O.R. 3.9, 95% C.I. 1.4-8.2, p?<?0.001), past medical history of heart failure (O.R. 3.3, 95% C.I. 1.2-19.3, p?<?0.05), NEWS?>?4 (O.R. 2.4, 95% C.I. 1.1-4.4, p?<?0.05), positive initial CXR (O.R. 0.4, 95% C.I. 0.2-0.9, p?<?0.05) and poGPS (O.R. 2.3, 95% C.I. 1.1-4.4, p?<?0.05) remained independently associated with 30-day mortality. Among those patients who tested PCR COVID-19 positive (n?=?122), age???70 years (O.R. 4.7, 95% C.I. 2.0-11.3, p?<?0.001), past medical history of heart failure (O.R. 4.4, 95% C.I. 1.2-20.5, p?<?0.05) and poGPS (O.R. 2.4, 95% C.I. 1.1-5.1, p?<?0.05) remained independently associated with 30-days mortality. CONCLUSION:Age???70 years and severe systemic inflammation as measured by the peri-operative Glasgow Prognostic Score are independently associated with 30-day mortality among patients admitted to hospital with COVID-19 infection.
Project description:BACKGROUND:A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU. METHODS:We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories. RESULTS:1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]). CONCLUSIONS:Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ?5 to guide ICU admission for pneumonia.
Project description:Highlights • Social media, fake news, and COVID-19.• Misinformation on social media has fuelled panic regarding the COVID-19.• Altruism is the strongest predictor of fake news sharing on COVID-19.• Socialization, information seeking and pass time predict fake news sharing.• Entertainment is not associated with sharing fake news on COVID-19. Fake news dissemination on COVID-19 has increased in recent months, and the factors that lead to the sharing of this misinformation is less well studied. Therefore, this paper describes the result of a Nigerian sample (n = 385) regarding the proliferation of fake news on COVID-19. The fake news phenomenon was studied using the Uses and Gratification framework, which was extended by an “altruism” motivation. The data were analysed with Partial Least Squares (PLS) to determine the effects of six variables on the outcome of fake news sharing. Our results showed that altruism was the most significant factor that predicted fake news sharing of COVID-19. We also found that social media users’ motivations for information sharing, socialisation, information seeking and pass time predicted the sharing of false information about COVID-19. In contrast, no significant association was found for entertainment motivation. We concluded with some theoretical and practical implications.
Project description:Italy was the first European nation to be affected by COVID-19. The biggest cluster of cases occurred in Lombardy, the most populous Italian region, and elderly men were the population hit in the hardest way. Besides its high infectivity, COVID-19 causes a severe cytokine storm and old people, especially those with comorbidities, appear to be the most vulnerable, presumably in connection to inflammaging. In centenarians inflammaging is much lower than predicted by their chronological age and females, presenting survival advantage in almost all centenarian populations, outnumber males, a phenomenon particularly evident in Northern Italy. Within this scenario, we wondered if: a) the COVID-19 mortality in centenarians was lower than that in people aged between 50 and 80 and b) the mortality from COVID-19 in nonagenarians and centenarians highlighted gender differences.We checked COVID-19-related vulnerability/mortality at the peak of infection (March 2020), using data on total deaths (i.e. not only confirmed COVID-19 cases). Our conclusion is that excess mortality increases steadily up to very old ages and at the same time men older than 90 years become relatively more resilient than age-matched females.
Project description:BACKGROUND:The aim of this study was to describe outcomes in hospitalised older people with different levels of frailty and COVID-19 infection. METHODS:We undertook a single centre, retrospective cohort study examining COVID-19 related mortality using Electronic Health Records, for older people (65 and over) with frailty, hospitalised with or without COVID-19 infection. Baseline covariates included demographics, Early Warning Scores, Charlson Comorbidity Indices and frailty (Clinical Frailty Scale, CFS), linked to COVID-19 status. FINDINGS:We analysed outcomes on 1,071 patients with COVID-19 test results; 285 (27%) were positive for COVID-19.)The mean age at ED arrival was 79.7 and 49.4% were female. All-cause mortality (by 30 days) rose from 9% (not frail) through to 33% (severely frail) in the COVID negative cohort but was around 60% for all frailty categories in the COVID positive cohort. In adjusted analyses, the hazard ratio for death in those with COVID-19 compared to those without COVID-19 was 7.3, 95% CI: 3.00, 18.0) with age, comorbidities and illness severity making small additional contributions. INTERPRETATION:In this study frailty, measured using the Clinical Frailty Scale, appeared to make little incremental contribution to the hazard of dying in older people hospitalised with COVID-19 infection; illness severity and comorbidity had a modest association with the overall adjusted hazard of death, whereas confirmed COVID-19 infection dominated, with a seven-fold hazard for death.