Clinician prognostic scoring system reveals COVID-19 patients' prognosis more likely to be limited by acute illness relative to traditional ICU patients

ABSTRACT

Introduction: There has been substantial lay press interest in whether patients who die of COVID-19 are dying of COVID-19 or other underlying illnesses. We have previously described a clinician scoring system that delineates whether a patient's prognosis is driven by acute illness vs comorbidities. In this study we compared this clinician phenotyping system in patients with COVID-19 to ICU biobank patients enrolled prior to 2020. Methods: Clinician phenotyping was performed on patients enrolled into 2 Stanford ICU biobanks (1) Patients admitted to Stanford ICU before 2020 with at least one ARDS risk factor (non-COVID-19 cohort) and (2) Patients admitted to the ICU with confirmed COVID-19 infection (COVID-19 cohort). The roles of each of the following categories in determining prognosis at time of enrollment were scored from 1-5 (1 being non-contributory and 5 being highly contributory) goals of care, comorbidities, baseline functional status, acute multi-system organ failure (MSOF), ARDS, acute neurologic injury, and terminal illness. Each patient's primary determinant of mortality was then grouped into one of four categories (1) MSOF or ARDS (>=4 for ARDS or multi-organ failure), (2) Comorbidities (>=4 for goals of care, comorbidities, acute neurologic injury, or baseline functional status), (3) Mixed (>= 4 for both of the above), or (4) None (<4 for all categories). The odds ratio for prognostic subgroupings was compared between patient cohorts.Results: Clinician phenotyping was performed on 70 non-COVID-19 patients admitted to the ICU with at least one risk factor for ARDS, and 28 patients with COVID-19 admitted to the ICU. Compared to the general ICU population, COVID-19 patients were younger (median age 53 vs 71), more likely to be male (71% vs 54%), and more likely to identify as Hispanic (64% vs 13%). 60-day mortality was higher in the COVID-19 group (29% vs 20%). ARDS or MSOF was the primary determinant of prognosis in 64% of patients with COVID-19 compared to 31% of traditional ICU patients (OR 3.9, 95% CI 1.6-9.9, Figure 1). Only 11% of COVID-19 patients' primary determinant of prognosis was comorbidities or goals of care relative to 31% in the traditional ICU population (OR 0.26, 95% CI 0.07-0.9).Conclusion: In this study, ARDS or MSOF is far more likely to be the main risk factor for death in patients with COVID-19 than in a traditional ICU population. This suggests that most COVID-19 fatalities are attributable to acute infection with SARS-CoV-2 rather than progression of underlying disease.