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Predictive Accuracy of Quick Sequential Organ Failure Assessment for Hospital Mortality Decreases With Increasing Comorbidity Burden Among Patients Admitted for Suspected Infection*

Parks Taylor, Stephanie MD1; McWilliams, Andrew MD2; Taylor, Brice T. MD3; Heffner, Alan C. MD3; Chou, Shih-Hsiung PhD2; Runyon, Michael MD4; Cunningham, Kyle MD5; Evans, Susan L. MD5; Gibbs, Michael MD6; Russo, Mark MD7; Rossman, Whitney MS2; Murphy, Stephanie E. DO8; Kowalkowski, Marc A. PhD2; Atrium Health Acute Care Outcomes Research Network Investigators

doi: 10.1097/CCM.0000000000003815
Clinical Investigations
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Objectives: Evaluate the accuracy of the quick Sequential Organ Failure Assessment tool to predict mortality across increasing levels of comorbidity burden.

Design: Retrospective observational cohort study.

Setting: Twelve acute care hospitals in the Southeastern United States.

Patients: A total of 52,187 patients with suspected infection presenting to the Emergency Department between January 2014 and September 2017.

Interventions: None.

Measurements and Main Results: The primary outcome was hospital mortality. We used electronic health record data to calculate quick Sequential Organ Failure Assessment risk scores from vital signs and laboratory values documented during the first 24 hours. We calculated Charlson Comorbidity Index scores to quantify comorbidity burden. We constructed logistic regression models to evaluate differences in the performance of quick Sequential Organ Failure Assessment greater than or equal to 2 to predict hospital mortality in patients with no documented (Charlson Comorbidity Index = 0), low (Charlson Comorbidity Index = 1–2), moderate (Charlson Comorbidity Index = 3–4), or high (Charlson Comorbidity Index ≥ 5) comorbidity burden. Among the cohort, 2,030 patients died in the hospital (4%). No comorbidities were documented for 5,038 patients (10%), 9,235 patients (18%) had low comorbidity burden, 12,649 patients (24%) had moderate comorbidity burden, and 25,265 patients (48%) had high comorbidity burden. Overall model discrimination for quick Sequential Organ Failure Assessment greater than or equal to 2 was the area under the receiver operating characteristic curve of 0.71 (95% CI, 0.69–0.72). A model including both quick Sequential Organ Failure Assessment and Charlson Comorbidity Index had improved discrimination compared with Charlson Comorbidity Index alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.76–0.78 vs area under the curve, 0.61; 95% CI, 0.59–0.62). Discrimination was highest among patients with no documented comorbidities (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.84; 95% CI; 0.79–0.89) and lowest among high comorbidity patients (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.67; 95% CI, 0.65–0.68). The strength of association between quick Sequential Organ Failure Assessment and mortality ranged from 30.5-fold increased likelihood in patients with no comorbidities to 4.7-fold increased likelihood in patients with high comorbidity.

Conclusions: The accuracy of quick Sequential Organ Failure Assessment to predict hospital mortality diminishes with increasing comorbidity burden. Patients with comorbidities may have baseline abnormalities in quick Sequential Organ Failure Assessment variables that reduce predictive accuracy. Additional research is needed to better understand quick Sequential Organ Failure Assessment performance across different comorbid conditions with modification that incorporates the context of changes to baseline variables.

1Department of Internal Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC.

2Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC.

3Division of Pulmonary and Critical Care, Department of Internal Medicine, Atrium Health, Charlotte, NC.

4Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC.

5Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC.

6Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC.

7Division of Hepatology, Department of Internal Medicine, Atrium Health, Charlotte, NC.

8Atrium Health Transition Services, Charlotte, NC.

*See also p. 1159.

Atrium Health Acute Care Outcomes Research Network Investigators (listed in alphabetical order) are as follows: Ryan Brown, MD; Larry Burke, MD; Shih-Hsiung Chou, PhD; Kyle Cunningham, MD; Susan L. Evans, MD; Scott Furney, MD; Michael Gibbs, MD; Alan Heffner, MD; Timothy Hetherington, MS; Daniel Howard, MD; Marc Kowalkowski, PhD; Scott Lindblom, MD; Andrea McCall; Lewis McCurdy, MD; Andrew McWilliams, MD, MPH; Stephanie Murphy, DO; Alfred Papali, MD; Christopher Polk, MD; Whitney Rossman, MS; Michael Runyon, MD; Mark Russo, MD; Melanie Spencer, PhD; Brice Taylor, MD; Stephanie Taylor, MD, MS.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/ccmjournal).

Preliminary study findings were presented at the Society of Critical Care Medicine’s 47th Critical Care Congress, February 25–28, 2018.

Dr. McWilliams’ institution received funding from the National Institutes of Health (NIH), Patient Centered Outcomes Research Institute, and American Cancer Society. Dr. Heffner received funding from Edwards Lifesciences. Dr. Runyon’s institution received funding from the NIH, Centers for Disease Control and Prevention, and National Association of State Emergency Medical Services Officials and received funding from Academic Emergency Medicine (Editorial Board Member) and UpToDate (royalties), and his institution received funding for his effort on research contracts with the following companies: Medevac Foundation, Ortho Clinical Diagnostics, Emergency MCG USA, Janssen Pharmaceutical Companies, Siemens Healthcare Diagnostics, Boehringer Ingelheim Pharmaceuticals, Trinity Biotech, Durata Therapeutics International, and BRAHMS GmbH. Dr. Russo received funding from Gilead, Dova, and Intercept. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, Email: stephanie.p.taylor@atriumhealth.org

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