Development and validation of COEWS (COVID-19 Early Warning Score) for hospitalized COVID-19 with laboratory features: a multicontinental retrospective study
- University of Turku, Finland
- Hospital Italiano de Buenos Aires, Argentina
- Hospital Universitario 12 De Octubre, Spain
- Vélez Sarsfield Hospital, Argentina
- Hospital Municipal de Agudos Dr Leónidas Lucero, Argentina
- University of Malaga, Spain
- Infanta Cristina University Hospital, Spain
- University of Vienna, Austria
Abstract
Background: The emergence of new SARS-CoV-2 variants with significant immune-evasiveness, the relaxation of measures for reducing the number of infections, the waning of immune protection (particularly in high-risk population groups), and the low uptake of new vaccine boosters, forecast new waves of hospitalizations and admission to intensive care units (ICUs). There is an urgent need for easily implementable and clinically effective early warning scores (EWSs) that can predict the risk of complications within the next 24 to 48 hours. Although EWSs have been used in the evaluation of COVID-19 patients, there are several clinical limitations to their use. Moreover, no models have been tested on geographically distinct populations or population groups with varying levels of immune protection.
Methods: We developed and validated COEWS, an EWS that is automatically calculated solely from laboratory parameters that are widely available and affordable. We benchmarked COEWS against the widely used NEWS2. We also evaluated the predictive performance of vaccinated and unvaccinated patients.
Results: The variables of the COEWS predictive model were selected based on their predictive coefficients and on the wide availability of these laboratory variables. The final model included complete blood count, blood glucose, and oxygen saturation features. To make COEWS more actionable in real clinical situations, we transformed the predictive coefficients of the COEWS model into individual scores for each selected feature. The global score serves as an easy-to-calculate measure indicating the risk of a patient developing the combined outcome of mechanical ventilation or death within the next 48 hours. The discrimination in the external validation cohort was 0.743 (95% confidence interval [CI]: 0.703-0.784) for the COEWS score performed with coefficients and 0.700 (95% CI: 0.654-0.745) for the COEWS performed with scores. The area under the receiver operating characteristic curve (AUROC) was similar in vaccinated and unvaccinated patients. Additionally, we observed that the AUROC of the NEWS2 was 0.677 (95% CI: 0.601-0.752) in vaccinated patients and 0.648 (95% CI: 0.608-0.689) in unvaccinated patients.
Conclusions: The COEWS score predicts death or mechanical ventilation within the next 48 hours based on routine and widely available laboratory measurements. The extensive external validation, its high performance, its ease of use, and its positive benchmark in comparison with the widely used NEWS2 position COEWS as a new reference tool for assisting clinical decisions and improving patient care in the upcoming pandemic waves.
Funding: University of Vienna.
Data availability
The databases used in this article are not freely available because they are the property of the '12 de Octubre University Hospital' from Spain and the 'Sociedad Argentina de Medicina' from Argentina. If any researcher wants to use this data, please send a message to either Dr. Antonio Lalueza (lalueza@hotmail.com) or to Dr. Ivan Alfredo Huespe (ivan.huespe@hospitalitaliano.org.ar) including a project proposal. The data will be only available for non-commercial proposals. The dataset used for Figure 2 can be found in the Supplementary data tables.
Article and author information
Author details
Felipe Aníbal Gregalio
Juan Miguel Antón-Santos
David Gómez-Varela
Funding
University of Vienna
- David Gómez-Varela
The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.
Reviewing Editor
- Evangelos J Giamarellos-Bourboulis, National and Kapodistrian University of Athens, Medical School, Greece
Ethics
Human subjects: The SEMI-COVID-19 Registry and the COVID registries of 12 de Octubre and the Costa del Sol hospitals have been approved by the Provincial Research Ethics Committee of Malaga (Spain; C.I.F. number: 0-9150013-B). Institutional review boards approved each participating site in the Argentinian COVID-19 Network study (approval numbers: 1575, 5562, and 5606).
Version history
- Received: February 2, 2023
- Accepted: August 23, 2023
- Accepted Manuscript published: August 24, 2023 (version 1)
- Version of Record published: September 5, 2023 (version 2)
Copyright
© 2023, Klén et al.
This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.
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Development and validation of COEWS (COVID-19 Early Warning Score) for hospitalized COVID-19 with laboratory features: a multicontinental retrospective study
eLife 12:e85618.
https://doi.org/10.7554/eLife.85618
Further reading
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- Epidemiology and Global Health
Paxlovid, a SARS-CoV-2 antiviral, not only prevents severe illness but also curtails viral shedding, lowering transmission risks from treated patients. By fitting a mathematical model of within-host Omicron viral dynamics to electronic health records data from 208 hospitalized patients in Hong Kong, we estimate that Paxlovid can inhibit over 90% of viral replication. However, its effectiveness critically depends on the timing of treatment. If treatment is initiated three days after symptoms first appear, we estimate a 17% chance of a post-treatment viral rebound and a 12% (95% CI: 0–16%) reduction in overall infectiousness for non-rebound cases. Earlier treatment significantly elevates the risk of rebound without further reducing infectiousness, whereas starting beyond five days reduces its efficacy in curbing peak viral shedding. Among the 104 patients who received Paxlovid, 62% began treatment within an optimal three-to-five-day day window after symptoms appeared. Our findings indicate that broader global access to Paxlovid, coupled with appropriately timed treatment, can mitigate the severity and transmission of SARS-Cov-2.
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- Cancer Biology
- Epidemiology and Global Health
Background:
Age is the most important risk factor for cancer, but aging rates are heterogeneous across individuals. We explored a new measure of aging-Phenotypic Age (PhenoAge)-in the risk prediction of site-specific and overall cancer.
Methods:
Using Cox regression models, we examined the association of Phenotypic Age Acceleration (PhenoAgeAccel) with cancer incidence by genetic risk group among 374,463 participants from the UK Biobank. We generated PhenoAge using chronological age and nine biomarkers, PhenoAgeAccel after subtracting the effect of chronological age by regression residual, and an incidence-weighted overall cancer polygenic risk score (CPRS) based on 20 cancer site-specific polygenic risk scores (PRSs).
Results:
Compared with biologically younger participants, those older had a significantly higher risk of overall cancer, with hazard ratios (HRs) of 1.22 (95% confidence interval, 1.18–1.27) in men, and 1.26 (1.22–1.31) in women, respectively. A joint effect of genetic risk and PhenoAgeAccel was observed on overall cancer risk, with HRs of 2.29 (2.10–2.51) for men and 1.94 (1.78–2.11) for women with high genetic risk and older PhenoAge compared with those with low genetic risk and younger PhenoAge. PhenoAgeAccel was negatively associated with the number of healthy lifestyle factors (Beta = –1.01 in men, p<0.001; Beta = –0.98 in women, p<0.001).
Conclusions:
Within and across genetic risk groups, older PhenoAge was consistently related to an increased risk of incident cancer with adjustment for chronological age and the aging process could be retarded by adherence to a healthy lifestyle.
Funding:
This work was supported by the National Natural Science Foundation of China (82230110, 82125033, 82388102 to GJ; 82273714 to MZ); and the Excellent Youth Foundation of Jiangsu Province (BK20220100 to MZ).
