Validation of the 4-C mortality score protocol in risk stratification of COVID-19 in patients admitted to a hospital in the Federal District of Brazil
DOI:
https://doi.org/10.11606/issn.1679-9836.v104i1e-229565Keywords:
4-c Mortality Score, Clinical Decision Rules, COVID-19Abstract
The COVID-19 pandemic has imposed challenges on health systems globally, including overloading health services. The aim of this study was to evaluate the accuracy of the 4-C Mortality Score to predict mortality risk in patients with COVID-19 in a public hospital in the Federal District of Brazil. A retrospective study was conducted with 177 patients using the score to predict clinical outcomes, such as hospital discharge or death. The observed mortality rate was 15.25%, with 12.99% of deaths occurring in the high and very high risk groups according to the score. The area under the curve (AUC) for the risk groups was 0.748 (0.641 - 0.855), resulting in a similar performance to that observed in international studies. The results indicate that the 4-C Mortality Score may be useful for estimating prognosis in patients with COVID-19, aiding in clinical decision-making. However, further studies in different regions of Brazil are needed to validate these findings, and immunization of patients against COVID-19 was not considered in this analysis.
Downloads
References
World Health Organization. WHO COVID-19 Dashboard, Geneva, 2021. https://covid19.who.int
Noronha KV, Guedes GR, Turra CM, et al. Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários. Cad Saude Publica. 2020;36(6):e00115320. Doi: 10.1590/0102-311X00115320. https://www.scielo.br/j/csp/a/XMbMhFTGYx5v7LtrTC58TcW/. Acesso em: 2 mar. 2021.
Da Silva MH, Procópio IM. A fragilidade do sistema de saúde brasileiro e a vulnerabilidade social diante da COVID-19. Rev Bras Promoc Saude. 2020;33:e10724. Doi: 10.5020/18061230.2020.10724. https://periodicos.unifor.br/RBPS/article/view/10724.
Xavier AR, Silva JS, Almeida JP, et al. COVID-19: manifestações clínicas e laboratoriais na infecção pelo novo coronavírus. J Bras Patol Med Lab. 2020;56:e3232020. Doi: 10.5935/1676-2444.20200049. http://www.gnresearch.org/doi/10.5935/1676-2444.20200049.
Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res. 2020;7(1):11. Doi: 10.1186/s40779-020-00240-0. https://mmrjournal.biomedcentral.com/articles/10.1186/s40779-020-00240-0.
World Health Organization. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Interim Guidance, 13 Mar 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
Centers for Disease Control and Prevention. Assessing Risk Factors for Severe COVID-19 Illness. COVID-19, 30 Nov 2020. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/assessing-risk-factors.html.
Wynants L, Van Calster B, Collins GS, et al. Prediction models for diagnosis and prognosis of COVID-19: systematic review and critical appraisal. BMJ. 2020;369:m1328. Doi: 10.1136/bmj.m1328. https://www.bmj.com/content/369/bmj.m1328.
Gupta RK, Harrison EM, Ho A, Docherty AB, Knight SR, van Smeden M, et al. Systematic evaluation and external validation of 22 prognostic models among hospitalised adults with COVID-19: An observational cohort study. Eur Respir J. 2020 Sep 25; Doi: 10.1183/13993003.03498-2020. https://erj.ersjournals.com/content/early/2020/09/17/13993003.03498-2020.
Knight SR, Ho A, Pius R, Buchan I, Carson G, Drake TM, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ. 2020;370:m3339. Doi: 10.1136/bmj.m3339. https://www.bmj.com/content/370/bmj.m3339.
Ministério da Saúde. COVID-19: Painel Coronavírus. Brasil, 2021. https://covid.saude.gov.br.
Organização Pan-Americana da Saúde. Histórico da pandemia de COVID-19. 11 mar. 2020. https://www.paho.org/pt/covid19/historico-da-pandemia-covid-19.
Wynants L, Sotgiu G. Improving clinical management of COVID-19: the role of prediction models. Lancet Respir Med. 2021;9(11):1219-21. Doi: 10.1016/S2213-2600(21)00006-0. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00006-0/fulltext.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. Doi: 10.1016/S0140-6736(20)30566-3.
Smits SL, de Lang A, van den Brand JM, Leijten LM, van IJcken WF, Eijkemans MJC, et al. Exacerbated innate host response to SARS-CoV in aged non-human primates. PLoS Pathog. 2010;6(2):e1000756. Doi:10.1371/journal.ppat.1000756. https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1000756.
Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell L, Chernyak Y, et al. Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City. BMJ. 2020;369:m1966. Doi:10.1136/bmj.m1966. https://www.bmj.com/content/369/bmj.m1966.
Földi M, Farkas N, Kiss S, Zádori N, Váncsa S, Szakó L, et al. Obesity is a risk factor for developing critical condition in COVID-19 patients: A systematic review and meta-analysis. Obes Rev. 2020;21(10):e13095. Doi: 10.1111/obr.13095.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analysis. Eur Respir J. 2020;55(5):2000547. Doi:10.1183/13993003.00547-2020.
Knight SR, Gupta RK, Ho A, Pius R, Buchan I, Carson G, et al. Prospective validation of the 4C prognostic models for adults hospitalised with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. Thorax. 2022;77(6):606-15. Doi:10.1136/thoraxjnl-2021-217629.
Wellbelove Z, Walsh C, Perinpanathan T, Lillie P, Barlow G. Comparing the 4C mortality score for COVID-19 to established scores (CURB65, CRB65, qSOFA, NEWS) for respiratory infection patients. J Infect. 2021;82(3):414-51. Doi: 10.1016/j.jinf.2020.10.015.
Fiocruz. Boletim extraordinário 30 de março de 2021. Observatório COVID-19. https://portal.fiocruz.br/observatorio-covid-19.
Lazar Neto F, Marino LO, Torres A, Cilloniz C, Meirelles Marchini JF, Garcia de Alencar JC, et al. Community-acquired pneumonia severity assessment tools in patients hospitalized with COVID-19: a validation and clinical applicability study. Clin Microbiol Infect. 2021;27(7):1037.e1-1037.e8. Doi: 10.1016/j.cmi.2021.03.002.
van Dam PMEL, Zelis N, van Kuijk SMJ, Linkens AEMJH, Brüggemann RAG, Spaetgens B, van der Horst ICC, Stassen PM. Performance of prediction models for short-term outcome in COVID-19 patients in the emergency department: a retrospective study. Ann Med. 2021;53(1):402-9. Doi: 10.1080/07853890.2021.1891453.
Doğanay F, Ak R. Performance of the CURB-65, ISARIC-4C and COVID-GRAM scores in terms of severity for COVID-19 patients. Int J Clin Pract. 2021;75(10):e14759. Doi: 10.1111/ijcp.14759. https://onlinelibrary.wiley.com/doi/full/10.1111/ijcp.14759.
Ong SWX, Sutjipto S, Lee PH, Dugan C, Khoo BY, Ren D, et al. Validation of ISARIC 4C Mortality and Deterioration Scores in a Mixed Vaccination Status Cohort of Hospitalized Coronavirus Disease 2019 (COVID-19) Patients in Singapore. Clin Infect Dis. 2022;75(1):e874-e877. Doi: 10.1093/cid/ciac087.
Kuroda S, Matsumoto S, Sano T, Kitai T, Yonetsu T, Kohsaka S, et al. External validation of the 4C Mortality Score for patients with COVID-19 and pre-existing cardiovascular diseases/risk factors. BMJ Open. 2021;11(9):e052708. Doi: 10.1136/bmjopen-2021-052708.
Ocho K, Hagiya H, Hasegawa K, Fujita K, Otsuka F. Clinical Utility of 4C Mortality Scores among Japanese COVID-19 Patients: A Multicenter Study. J Clin Med. 2022;11(3):821. Doi: 10.3390/jcm11030821.
Morello F, Bima P, Giamello JD, Baricocchi D, Risi F, Vesan M, et al. Study Investigators. A 4C mortality score based dichotomic rule supports Emergency Department discharge of COVID-19 patients. Minerva Med. 2022;113(6):916-26. Doi: 10.23736/S0026-4806.21.07779-X.
Jones A, Pitre T, Junek M, Kapralik J, Patel R, Feng E, et al. Investigators. External validation of the 4C mortality score among COVID-19 patients admitted to hospital in Ontario, Canada: a retrospective study. Sci Rep. 2021;11(1):18638. Doi: 10.1038/s41598-021-97332-1.
Gordon AJ, Govindarajan P, Bennett CL, Matheson L, Kohn MA, Camargo C, et al. External validation of the 4C Mortality Score for hospitalised patients with COVID-19 in the RECOVER network. BMJ Open. 2022;12(4):e054700. Doi: 10.1136/bmjopen-2021-054700.
Riley JM, Moeller PJ, Crawford AG, Schaefer JW, Cheney-Peters DR, Venkataraman CM, Li CJ, et al. External validation of the COVID-19 4C mortality score in an urban United States cohort. Am J Med Sci. 2022;364(4):409-13. Doi: 10.1016/j.amjms.2022.04.030.
Aletreby WT, Mumtaz SA, Shahzad SA, Ahmed I, Alodat MA, Gharba M, et al. External Validation of 4C ISARIC Mortality Score in Critically ill COVID-19 Patients from Saudi Arabia. Saudi J Med Med Sci. 2022;10(1):19-24. Doi: 10.4103/sjmms.sjmms_480_21.
Wirth A, Goetschi A, Held U, Sendoel A, Stuessi-Helbling M, Huber LC. External Validation of the Modified 4C Deterioration Model and 4C Mortality Score for COVID-19 Patients in a Swiss Tertiary Hospital. Diagnostics (Basel). 2022;12(5):1129. Doi: 10.3390/diagnostics12051129.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83. Doi:10.1016/0021-9681(87)90171-8. https://pubmed.ncbi.nlm.nih.gov/3558716/.
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health. www.OpenEpi.com.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Victória Piantino, Leonardo Joaquim Soares de Lima, Tarquino Erastides Gavilanes Sanchez
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
