OBJECTIVES: 

Prior research has hypothesized the Sequential Organ Failure Assessment (SOFA) score to be a poor predictor of mortality in mechanically ventilated patients with COVID-19. Yet, several U.S. states have proposed SOFA-based algorithms for ventilator triage during crisis standards of care. Using a large cohort of mechanically ventilated patients with COVID-19, we externally validated the predictive capacity of the preintubation SOFA score for mortality prediction with and without other commonly used algorithm elements.

DESIGN: 

Multicenter, retrospective cohort study using electronic health record data.

SETTING: 

Eighty-six U.S. health systems.

PATIENTS: 

Patients with COVID-19 hospitalized between January 1, 2020, and February 14, 2021, and subsequently initiated on mechanical ventilation.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

Among 15,122 mechanically ventilated patients with COVID-19, SOFA score alone demonstrated poor discriminant accuracy for inhospital mortality in mechanically ventilated patients using the validation cohort (area under the receiver operating characteristic curve [AUC], 0.66; 95% CI, 0.65–0.67). Discriminant accuracy was even poorer using SOFA score categories (AUC, 0.54; 95% CI, 0.54–0.55). Age alone demonstrated greater discriminant accuracy for inhospital mortality than SOFA score (AUC, 0.71; 95% CI, 0.69–0.72). Discriminant accuracy for mortality improved upon addition of age to the continuous SOFA score (AUC, 0.74; 95% CI, 0.73–0.76) and categorized SOFA score (AUC, 0.72; 95% CI, 0.71–0.73) models, respectively. The addition of comorbidities did not substantially increase model discrimination. Of 36 U.S. states with crisis standards of care guidelines containing ventilator triage algorithms, 31 (86%) feature the SOFA score. Of these, 25 (81%) rely heavily on the SOFA score (12 exclusively propose SOFA; 13 place highest weight on SOFA or propose SOFA with one other variable).

CONCLUSIONS: 

In a U.S. cohort of over 15,000 ventilated patients with COVID-19, the SOFA score displayed poor predictive accuracy for short-term mortality. Our findings warrant reappraisal of the SOFA score’s implementation and weightage in existing ventilator triage pathways in current U.S. crisis standards of care guidelines.

中文翻译：

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用于预测 COVID-19 死亡率的插管前序贯器官衰竭评估评分：使用来自 86 个美国医疗保健系统的电子健康记录进行外部验证，以评估当前的呼吸机分类算法*

目标： 

先前的研究假设序贯器官衰竭评估(SOFA) 评分不能很好地预测机械通气的 COVID-19 患者的死亡率。然而，美国的几个州已经提出了基于 SOFA 的算法，用于在危机护理标准期间进行呼吸机分类。我们使用大量机械通气的 COVID-19 患者队列，在外部验证了插管前 SOFA 评分在使用或不使用其他常用算法元素的情况下预测死亡率的能力。

设计： 

使用电子健康记录数据的多中心、回顾性队列研究。

环境： 

美国八十六个卫生系统。

患者： 

2020 年 1 月 1 日至 2021 年 2 月 14 日期间住院的 COVID-19 患者，随后开始机械通气。

干预措施： 

没有任何。

测量和主要结果： 

在 15,122 名患有 COVID-19 的机械通气患者中，使用验证队列，仅 SOFA 评分对机械通气患者的院内死亡率的判别准确性较差（受试者工作特征曲线下面积 [AUC]，0.66；95% CI，0.65-0.67） 。使用 SOFA 评分类别的判别准确性甚至更差（AUC，0.54；95% CI，0.54-0.55）。单独年龄对院内死亡率的判别准确度高于 SOFA 评分（AUC，0.71；95% CI，0.69-0.72）。将年龄分别添加到连续 SOFA 评分（AUC，0.74；95% CI，0.73–0.76）和分类 SOFA 评分（AUC，0.72；95% CI，0.71–0.73）模型后，死亡率的判别准确性得到提高。合并症的增加并没有显着增加模型歧视。美国 36 个州制定了包含呼吸机分类算法的危机护理标准指南，其中 31 个州 (86%) 采用了 SOFA 评分。其中，25 个 (81%) 严重依赖 SOFA 评分（12 个专门提出 SOFA；13 个对 SOFA 给予最高权重或提出 SOFA 与另一个变量）。

结论： 

在美国超过 15,000 名接受机械通气的 COVID-19 患者队列中，SOFA 评分对短期死亡率的预测准确性较差。我们的研究结果需要重新评估 SOFA 评分在当前美国危机护理标准指南中现有呼吸机分类路径中的实施和权重。