Development and validation of a 30-day mortality index based on pre-existing medical administrative data from 13,323 COVID-19 patients: The Veterans Health Administration COVID-19 (VACO) Index.
Development and validation of a 30-day mortality index based on pre-existing medical administrative data from 13,323 COVID-19 patients: The Veterans Health Administration COVID-19 (VACO) Index.
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DOI：
10.1371/journal.pone.0241825
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发表时间：
2020
期刊：
影响因子：
3.7
通讯作者：
Justice AC
中科院分区：
文献类型：
--
作者：
King JT Jr;Yoon JS;Rentsch CT;Tate JP;Park LS;Kidwai-Khan F;Skanderson M;Hauser RG;Jacobson DA;Erdos J;Cho K;Ramoni R;Gagnon DR;Justice AC
可用的COVID-19死亡率指数仅限于急性住院数据。利用美国退伍军人健康管理局（VA）在SARS-CoV-2感染前提供的全国医疗管理数据，我们开发了VA COVID-19（VACO）30天死亡率指数，并在两个独立的前瞻性样本中验证了该指数。我们审查了2020年2月8日至8月18日期间VA内的SARS-CoV-2检测结果。该样本被分为开发队列（2020年3月2日至4月15日期间检测呈阳性）、早期验证队列（2020年4月16日至5月18日期间检测呈阳性）和晚期验证队列（2020年5月19日至7月19日期间检测呈阳性）。我们在发展队列中的逻辑回归模型考虑了人口统计学（年龄，性别，种族/民族），预先存在的医疗条件和来自ICD-10诊断代码的Charlson合并症指数（CCI）。固定权重以创建VACO指数，然后通过比较早期和晚期验证队列以及按性别、人种/种族和地理区域定义的重要验证队列亚组中的受试者工作特征曲线下面积（AUC）进行验证。我们还评估了校准曲线和年龄类别内产生的预测范围。13，323人对SARS-CoV-2检测呈阳性（中位年龄：63岁; 91%为男性; 42%为非西班牙裔黑人）。我们观察到开发中有480/3，681（13%）例死亡，早期验证队列中有253/2，151（12%）例死亡，晚期验证队列中有403/7，491（5%）例死亡。年龄、CCI描述的多发病、心肌梗死或外周血管疾病史与死亡率独立相关，没有其他个体共病诊断提供额外信息。VACO指数区分了发育（AUC = 0.79，95% CI：0.77-0.81）、早期（AUC = 0.81，95% CI：0.78-0.83）和晚期（AUC = 0.84，95% CI：0.78-0.86）验证中的死亡率。VACO指数允许对COVID-19感染后30天的死亡率进行个性化估计。例如，在60-64岁的人群中，总死亡率估计为9%（95% CI：6-11%）。该指数进一步区分了该年龄层的风险，从4%（95%CI：3-7%）到21%（95%CI：12-31%），取决于性别和共病。在感染前，人口统计学和共病状况可以区分COVID-19死亡风险的整体和年龄层。尽管州和地方指导方针有所放宽，但VACO指数可重复地识别出面临COVID-19死亡风险的个人，他们可能会考虑继续保持社交距离。
Available COVID-19 mortality indices are limited to acute inpatient data. Using nationwide medical administrative data available prior to SARS-CoV-2 infection from the US Veterans Health Administration (VA), we developed the VA COVID-19 (VACO) 30-day mortality index and validated the index in two independent, prospective samples. We reviewed SARS-CoV-2 testing results within the VA between February 8 and August 18, 2020. The sample was split into a development cohort (test positive between March 2 and April 15, 2020), an early validation cohort (test positive between April 16 and May 18, 2020), and a late validation cohort (test positive between May 19 and July 19, 2020). Our logistic regression model in the development cohort considered demographics (age, sex, race/ethnicity), and pre-existing medical conditions and the Charlson Comorbidity Index (CCI) derived from ICD-10 diagnosis codes. Weights were fixed to create the VACO Index that was then validated by comparing area under receiver operating characteristic curves (AUC) in the early and late validation cohorts and among important validation cohort subgroups defined by sex, race/ethnicity, and geographic region. We also evaluated calibration curves and the range of predictions generated within age categories. 13,323 individuals tested positive for SARS-CoV-2 (median age: 63 years; 91% male; 42% non-Hispanic Black). We observed 480/3,681 (13%) deaths in development, 253/2,151 (12%) deaths in the early validation cohort, and 403/7,491 (5%) deaths in the late validation cohort. Age, multimorbidity described with CCI, and a history of myocardial infarction or peripheral vascular disease were independently associated with mortality–no other individual comorbid diagnosis provided additional information. The VACO Index discriminated mortality in development (AUC = 0.79, 95% CI: 0.77–0.81), and in early (AUC = 0.81 95% CI: 0.78–0.83) and late (AUC = 0.84, 95% CI: 0.78–0.86) validation. The VACO Index allows personalized estimates of 30-day mortality after COVID-19 infection. For example, among those aged 60–64 years, overall mortality was estimated at 9% (95% CI: 6–11%). The Index further discriminated risk in this age stratum from 4% (95% CI: 3–7%) to 21% (95% CI: 12–31%), depending on sex and comorbid disease. Prior to infection, demographics and comorbid conditions can discriminate COVID-19 mortality risk overall and within age strata. The VACO Index reproducibly identified individuals at substantial risk of COVID-19 mortality who might consider continuing social distancing, despite relaxed state and local guidelines.
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