The authors have declared that no competing interests exist.
In December 2019, cases of serious illness causing pneumonia and death were first reported in Wuhan, China.
The PIRO (predisposition, insult, response, and organ dysfunction) scoring was developed for use in the emergency department to risk stratify sepsis cases.
To validate PIRO score as an assessment tool for COVID-19 mortality risk among patients with confirmed COVID-19 RT-PCR test among patients aged 19 and above admitted in World Citi Medical Center from March 2020 to August 2020
This study included 93 patients aged 19 and above admitted in World Citi Medical Center with a primary diagnosis of COVID-19 Confirmed with pneumonia between March 2020 to August 2020. The patients’ charts were retrieved from the hospital medical records and case notes were reviewed. A severity assessment score was developed based on PIRO score (Predisposition comorbidities and age; Insult multilobar opacities and viremia; Response shock and hypoxemia; Organ Dysfunciton) were extracted. The patients were stratified in four levels of risk: a)Low,0-2 points; b)Mild,3 points; c)High,4 points; d)Very High,5-8 points. The PIRO score and the clinical outcome were compared. The discriminative ability of PIRO score to predict mortality risk was evaluated under receiver operating characteristic curve (AUC).
The PIRO score had an excellent predictive ability for in-hospital mortality (AUC0.9197). Analysis of variance showed that higher levels of PIRO scores were significantly associated with higher mortality (p<0.001). Patients with Mild PIRO risk category were 98.65% less likely to expire (p<0.001, 95%CI 0.0015) and High PIRO risk category were 94.47% less likely to expire (p<0.001, 95%CI 0.0124), both compared to patients with Very high PIRO risk category. Finally, Very High PIRO risk category were more than 44 times likely to expire compared to patients with Low, Mild and High PIRO risk category (p<0.001, 95%CI 11.738).
The PIRO score is a valid risk model that can be used to predict in-hospital mortality, that can help clinicians provide timely and accurate assessment, and hence appropriate management to patients with COVID-19 Pneumonia.
In December 2019, cases of serious illness causing pneumonia and death were first reported in Wuhan, the capital of Hubei, China. Soon after, the number of cases soared dramatically, spreading across China and worldwide
The clinical features of Corona Virus Disease 2019 (COVID-19) are varied, ranging from asymptomatic state to acute respiratory distress syndrome and multi organ dysfunction. The common clinical features include fever (not in all), cough, sore throat, headache, fatigue, headache, myalgia and breathlessness. Thus, they are indistinguishable from other respiratory infections. In a subset of patients, by the end of the first week, the disease can progress to pneumonia, respiratory failure and death.
Originally, PIRO (predisposition, insult, response, and organ dysfunction) scoring was developed for use in the emergency department (ED) to risk stratify sepsis cases,
COVID-19 pneumonia does not have any objective measurement or tool to help identify its mortality risk.
To be clinically useful, the assessment tool or risk model should be simple, readily measurable, easily accessible, reliable, non-invasive and most of all in expensive. This study aims to provide an objective measure in determining the in-hospital mortality risk of COVID-19 Pneumonia in adult patients, aged 19 and above, with confirmed diagnosis of COVID-19 Pneumonia using the PIRO score.
The purpose of this study is to validate PIRO score as an assessment tool for COVID-19 mortality risk among patients with confirmed COVID-19 Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR) test among patients aged 19 and above admitted in World Citi Medical Center from March 2020 to August 2020.
To determine the PIRO score of admitted patients, aged 19 and above, with pneumonia and COVID-19 Confirmed RT PCR test
To correlate the PIRO score of admitted patients, aged 19 and above, with pneumonia and COVID-19 Confirmed RT PCR test with the clinical outcome
This is a retrospective observational cohort study of adult patients, aged 19 and above, admitted at World Citi Medical Center with a primary diagnosis of Coronavirus Disease-19 Pneumonia between March 01, 2020 to August 31, 2020.
The study was performed in World Citi Medical Center, an adult urban tertiary hospital with 150 bed capacity. The Emergency Department (ED) has approximately 12,000 non-trauma patients per year, and 20% seek medical care for respiratory symptoms.
All the consecutive adult patients (age 19 and above) admitted to hospital through the ER with a final diagnosis of COVID-19 Pneumonia (International Classification of Diseases, 10th revision, Clinical Modification, ICD-10 CM code UO7) Confirmed by RT-PCR and chest radiograph or high resolution chest CT-scan, between 01 March–31 August 2020 were included.
The patients’ charts were retrieved from the hospital medical records and case notes were reviewed by the investigators. The variables required for PIRO score (predisposition, insult, response, and organ dysfunction) including the presence of the following: comorbidities (COPD, immunocompromise); age >70 years; multilobar opacities in chest radiograph or chest CT-scan; shock, severe hypoxemia; acute renal failure; viremia and acute respiratory distress syndrome were extracted. The patients were stratified in four levels of risk: a) Low, 0-2 points; b) Mild, 3 points; c) High, 4 points; d) Very High, 5-8 points. The PIRO score and the clinical outcome was compared. The discriminative ability of PIRO score to predict mortality risk was evaluated under receiver operating characteristic curve (AUC).
In this study, COVID-19 Confirmed Pneumonia were cases with RT-PCR result of positive for RNA Corona Virus Disease 19 with evidence of Pneumonia either via chest radiograph or chest CT-scan.
Patients were aged 19 and above, who were admitted in World Citi Medical Center from March 01, 2020-August 31, 2020, with RT-PCR confirmed COVID-19 and pneumonia via chest radiograph or chest CT scan.
Patients with confirmed COVID-19 RT-PCR test but with no evidence of pneumonia either via chest radiograph or chest CT-scan, aged 18 years and 364 days and younger and patients admitted outside the inclusion dates of March 2020 to August 2020 were all excluded.
The PIRO score was obtained from the data extracted from patients’ chart
A minimum of 41 patients were required for this study based on 0.88 AUC of PIRO score to predict 28-day mortality among patients with community-acquired pneumonia
Descriptive statistics was used to summarize the demographic and clinical characteristics of the patients. Frequency and proportion was used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and SD for normally distributed continuous variables. Independent Sample
There were 277 subjects admitted as either COVID-19 Suspect or Confirmed. 159 subjects were excluded for testing negative for COVID-19 RT-PCR and 25 subjects were excluded for having no evidence of pneumonia either by chest radiograph or chest CT-scan. A total of 93 patients met the inclusion criteria.
This study included 93 patients with a primary discharged diagnosis of COVID-19 pneumonia at World Citi Medical Center from March 01, 2020 to August 31, 2020.
Total (n=93) | Expired (n=24, 26%) | Recovered (n=69, 74%) | P-value | |
Frequency (%); Mean + SD; Median (IQR) | ||||
Age | 56.7 ± 18.08 | 67.42 ± 18.12 | 52.97 ± 16.63 |
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Sex | 0.634 | |||
Male | 53 (56.99) | 15 (62.5) | 38 (55.07) | |
Female | 40 (43.01) | 9 (37.5) | 31 (44.93) | |
Comorbidities | ||||
Hypertension | 46 (49.46) | 16 (66.67) | 30 (43.48) |
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Diabetes Mellitus | 27 (29.03) | 9 (37.5) | 18 (26.09) | 0.289 |
COPD | 4 (4.30) | 3 (12.5) | 1 (1.45) |
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Cardiovascular | 20 (21.51) | 8 (33.33) | 12 (17.39) | 0.147 |
Cerebrovascular | 1 (1.08) | 0 | 1 (1.45) | 1.000 |
CA | 3 (3.23) | 2 (8.33) | 1 (1.45) | 0.162 |
BA | 9 (9.68) | 3 (12.5) | 6 (8.7) | 0.690 |
PTB | 4 (4.30) | 1 (4.17) | 3 (4.35) | 1.000 |
Immunodeficiency | 1 (1.08) | 1 (4.17) | 0 | 0.258 |
Chronic Kidney Disease | 12 (12.9) | 4 (16.67) | 8 (11.59) | 0.499 |
Liver Pathology | 1 (1.08) | 0 | 1 (1.45) | 1.000 |
PIRO score | 4 (3 to 5) | 7 (5 to 8) | 3 (3 to 4) |
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Low | 17 (18.28) | 0 | 17 (24.64) |
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Mild | 27 (29.03) | 1 (4.17) | 26 (37.68) | |
High | 22 (23.66) | 3 (12.5) | 19 (27.54) | |
Very high | 27 (29.03) | 20 (83.33) | 7 (10.14) |
The mean age of patients with confirmed COVID-19 pneumonia was 56 years old. There was statistical difference between the mean age of those who expired was 67 and mean age of recovered was 52. In terms of gender, there were more males (56.99%) than females (43.01%) who got infected with COVID-19. Among the co-morbidities in patients with COVID-19 Pneumonia, Hypertension (49.46%) and Diabetes mellitus (29.03%) are the two most common. The two most statistically significant comorbidities that may have contributed to mortality risk are hypertension and COPD with P-value of 0.049 and 0.022, respectively.
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Low riska | |||
Mild riska | 0.0135 | 0.0015 to 0.1185 | <0.001 |
High riska | 0.0553 | 0.0124 to 0.2455 | <0.001 |
Very high riskb, | 44.2857 | 11.738 to 167.09 | <0.001 |
Note: a - Very high risk as reference category; b - Low, Mild and High risk as reference categories
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20 (83.33) | 7(10.14) | 27 (29.03) |
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62 (89.86) | 66 (70.97) | |
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24 (100) | 69 (100) | 93 (100) |
Sensitivity | 83.33%(62.62 to 95.26) | Positive LR | 8.21 (3.98 to 16.95) |
Specificity | 89.86%(80.21 to 95.82) | Negative LR | 0.19 (0.08 to 0.46) |
PPV | 74.07%(58.06 to 85.50) | Prevalence | 25.81% (17.29 to 35.92) |
NPV | 93.94%(86.33 to 97.44) | Accuracy | 88.17% (79.82 to 93.95) |
COVID-19 Pneumonia is caused by novel Coronavirus. The clinical features of COVID-19 are varied, ranging from asymptomatic state to acute respiratory distress syndrome and multi organ dysfunction. They are indistinguishable from other respiratory infections. In a subset of patients, by the end of the first week the disease can progress to pneumonia, respiratory failure and death.
To our knowledge, this is the first study to objectively measure the mortality risk of COVID-19 pneumonia on the basis of risk category of PIRO scoring. Many other models have been developed, some of which are designed to predict mortality. The diversity of scoring tools may pose difficulties for clinicians who are attempting to choose a tool for use in their daily practice.
There were 277 subjects admitted as either COVID-19 Suspect or Confirmed. 159 subjects were excluded for testing negative for COVID-19 RT-PCR and 25 subjects were excluded for having no evidence of pneumonia either by chest radiograph or chest CT-scan. A total of 93 patients met the inclusion criteria and among these patients, 24 (26%) of which expired and 69 (74%) were recovered and discharged. There was statistical difference between recovered and expired patients in terms of Age, Hypertension, COPD, PIRO score and PIRO category.
The mean age of subjects infected was 56.7 and mean age of subjects who expired is 67. Analysis showed that the older the age were significantly associated with higher mortality (p<0.001). Likewise in the study of Farha et al (September 2020), a significant association were found between mortality among COVID-19 infected patients and older age (>65 years vs <65 years) (RR 3.59, 95% CI (1.87-6.90), p<0.001).
The two most statistically significant comorbidities that may have contributed to mortality risk are hypertension and COPD with P-value of 0.049 and 0.022, respectively. It is parallel with the recent study of Farha et al (September 2020) shows that a significant association were found between mortality among COVID-19 infected patients and hypertension (RR 2.08, 95% CI (1.79-2.43), p<0.001).
This tool can be used as an initial risk assessment and stratification that predicts not only the severity of COVID-19 Pneumonia but also in-hospital mortality
These results showed that higher levels of PIRO score were significantly associated with higher mortality. (p<0.001) Further, the calculated AUC for predicting in-hospital mortality of COVID-19 Pneumonia is 0.9197, which shows that the tool has excellent discriminative ability. These findings were also parallel with the recent studies, by Pinera et al (2016),
The PIRO score can be used as an assessment tool to identify the severity and in-hospital mortality risk of COVID-19 pneumonia among patients, aged 19 and above. It is simple, readily measurable, easily accessible, reliable, non-invasive and most of all inexpensive.
A larger retrospective cohort study may be done in the future to assess the predictive capacity of PIRO for COVID-19 Pneumonia. A prospective cohort study could also be done to observe the subjects while admitted and to identify other possible factors affecting the clinical outcome. Lastly, we would like to recommend using PIRO score in a prospective study with COVID-19 pneumonia to possibly lower its mortality by aggressively managing affected systems before its failure and stabilizing comorbidities such as hypertension and COPD that may alter the clinical outcome.
Our study was limited by being a retrospective and single-center study. This study also had a relatively small sample size with limited age of 19 and above only. The study setting was limited to a 150 bed capacity tertiary hospital which may influence the generalizability of the study. The risk scoring was not calculated in real time during hospital admission and not used to guide clinical care.