Dear Editor
The article by Sijia Liu et al. is meaningful [1]. We agree that Sequential Organ Failure Assessment (SOFA) scoring systems at admission have high performance in predicting the mortality risk of coronavirus disease (COVID-19) patients. Quick Sequential Organ Failure Assessment (qSOFA) is accepted as well, though it is inferior to that of SOFA, it's quick which could greatly shorten research time to get initial results. Due to some limitations, only two scoring systems as SOFA and qSOFA are mentioned in this article, while other studies suggest that scoring systems such as Rapid Emergency Medicine Score (REMS) can also be used in this area. The evidence for putting these scores together is extremely limited, therefore, we used the data from a tertiary hospital in China from March 7 to April 7 to evaluate its effectiveness of some other rapid predictive methods at admission that are also used in our clinic practice for the prediction of mortality risk in COVID-19 patients. Severe COVID-19 illness can be predicted with demographics, symptoms and medical history [2], and a rapid and accurate method is needed to assess the severity of the disease at admission such as Modified Early Warning Score (MEWS) [3], Rapid Emergency Medicine Score (REMS), Hamilton Early Warning Score (HEWS), National Early Warning Score (NEWS), which need less parameters than SOFA, are also widely used for the mortality prediction of COVID-19 patients [4] In addition, although there are many indicators of REMS, they are very simple and easy to be obtained in the emergency department. We collected demographics, clinical manifestations, and laboratory results, to calculate these scoring systems together [5], record the patient outcomes. And then we used SPSS to perform a Receiver Operating Characteristic curve (ROC curve) analysis to determine their predictive ability and performed an area under the curve (AUC) comparison among these methods. There were a total of 137 cases enrolled in the study, after excluding 3 patients with missing data. 21 people were dead, in total, the mean age of the survivor and non-survivor in this study population were 58.62 ± 14.68 and 75.36 ± 12.14 years, respectively.
The ROC curve and AUC of the five scores were shown in Fig. 1 . From our research, we found that SOFA is most accuracy but complex. In rapid scoring systems, the result shows that the maximum area under the curve (AUC) was REMS, followed by NEWS, HEWS, qSOFA. qSOFA, mentioned in the original text, is indeed effective, but it is worse than several other rapid scoring systems (Table 1 ).
Fig. 1.
The ROC curves of several scoring systems for predicting the mortality of COVID-19 patients.
qSOFA = Quick Sequential Organ Failure Assessment; REMS = Rapid Emergency Medicine Score; MEWS = Modified Early Warning Score; NEWS=National Early Warning Score; HEWS=Hamilton Early Warning Score; SOFA = Sequential Organ Failure Assessment;
Table 1.
The AUC of six scoring systems in predicting in-hospital mortality.
| Scoring systems | AUC | SE | p value | 95%CI |
|---|---|---|---|---|
| qSOFA | 0.734 | 0.063 | 0.001⁎ | 0.610–0.858 |
| REMS | 0.831 | 0.045 | 0.000⁎ | 0.742–0.920 |
| MEWS | 0.660 | 0.063 | 0.020⁎ | 0.536–0.784 |
| NEWS | 0.793 | 0.046 | 0.000⁎ | 0.702–0.883 |
| HEWS | 0.766 | 0.056 | 0.000⁎ | 0.656–0.876 |
| SOFA | 0.908 | 0.028 | 0.000⁎ | 0.854–0.962 |
AUC = area under the curve of the Receiver Operating Characteristic; SE = standard error; 95%CI = 95% confidence interval.
p<0.05.
We completely approve of the view that SOFA could function as an effective tool for critical COVID-19 patients. Additionally, we can draw another conclusion that REMS was rapid ideal for predicting mortality in COVID-19 patients. The performance in predicting mortality such patients of HEWS, NEWS, MEWS is accepted as well but less effective to that of REMS.
In conclusion, as stated in the original article, qSOFA is effective in assessing COVID-19 in-hospital deaths, but it's not as accurate as REMS, thus we hold the view that REMS has the potential for rapid evaluation of COVID-19.
Declaration of Competing Interest
The authors declare they have no competing conflict.
Acknowledgements
And this work was financially supported by the Novel Coronavirus Research Fund of West China Hospital (HX2019nCoV063) and the Strategic Priority Research Program of the Chinese Academy of Science (XDA23090502).
References
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