Predictive Value of an Age-Based Modification of the National Early Warning System in Hospitalized Patients With COVID-19
Authors: Maves Ryan C , Richard Stephanie A , Lindholm David A , Epsi Nusrat , Larson Derek T , Conlon Christian , Everson Kyle , Lis Steffen , Blair Paul W , Chi Sharon , Ganesan Anuradha , Pollett Simon , Burgess Timothy H , Agan Brian K , Colombo Rhonda E , Colombo Christopher J ,   EPICC COVID-19 Cohort Study Group, Cowden J , Lindholm D , Markelz A , Mende K , Merritt S , Merritt T , Walter R , Wellington T , Bazan S , Michel S , Brandon L , Ewers E , Gallagher K , Larson D , Odom M , Colombo C , Colombo R , Conlon C , Everson K , Faestel P , Ferguson T , Gordon L , Grogan S , Lis S , Martin M , Mount C , Musfeldt D , Odineal D , Robb-McGrath W , Sainato R , Schofield C , Skinner C , Stein M , Switzer M , Timlin M , Wood S , Atwood G , Carpenter R , Eickhoff C , Kronmann K , Lalani T , Lee T , Warkentien T , Arnold J , Berjohn C , Husain S , Kirkland N , Lane A , Maves R , Parrish J , Utz G , Chi S , Filan E , Fong K , Hopkinson S , Horseman T , Jones M , Kanis A , Kayatani A , Londeree W , Madar C , Masel J , McMahon M , Miyasato K , Murphy G , Nguay V , O’Connor K , Schmidt P , Schoenman E , Scrivner S , Uyehara C , Villacortalyew R , Agan B , Broder C , Brody D , Burgess T , Byrne C , Chung K , Coles C , Dalgard C , Dumler J S , English C , Haigney M , Hickey P , Laing E , Livezey J , Malloy A , McLeroy R , Millar E , Oliver T , Pollett S , Rajnik M , Richard S , Rozman J , Rusiecki J , Sanchez M , Scher A , Simons M , Snow A , Tribble D , Berry I , Currier J , Darden J , Friberg H , Lanteri C , Peel S , Bhatia P , Ganesan A , Huprikar N , Oyeneyin M , Banda M , Davis B , Hunter T , Ikpekpe-Magege O , Kemp S , Mody R , Resendez R , Farmer A , Hostler D , Maldonado C , Mehrer J , Radcliffe R , Shaha D , Swain M , Weiss J 
Published: August 2021

Abstract

Background
Early recognition of high-risk patients with coronavirus disease 2019 (COVID-19) may improve outcomes. Although many predictive scoring systems exist, their complexity may limit utility in COVID-19. We assessed the prognostic performance of the National Early Warning Score (NEWS) and an age-based modification (NEWS+age) among hospitalized COVID-19 patients enrolled in a prospective, multicenter US Military Health System (MHS) observational cohort study.

Methods
Hospitalized adults with confirmed COVID-19 not requiring invasive mechanical ventilation at admission and with a baseline NEWS were included. We analyzed each scoring system’s ability to predict key clinical outcomes, including progression to invasive ventilation or death, stratified by baseline severity (low [0–3], medium [4–6], and high [≥7]).

Results
Among 184 included participants, those with low baseline NEWS had significantly shorter hospitalizations (P &lt; .01) and lower maximum illness severity (P &lt; .001). Most (80.2%) of low NEWS vs 15.8% of high NEWS participants required no or at most low-flow oxygen supplementation. Low NEWS (≤3) had a negative predictive value of 97.2% for progression to invasive ventilation or death; a high NEWS (≥7) had high specificity (93.1%) but low positive predictive value (42.1%) for such progression. NEWS+age performed similarly to NEWS at predicting invasive ventilation or death (NEWS+age: area under the receiver operating characteristics curve [AUROC], 0.69; 95% CI, 0.65–0.73; NEWS: AUROC, 0.70; 95% CI, 0.66–0.75).

Conclusions
NEWS and NEWS+age showed similar test characteristics in an MHS COVID-19 cohort. Notably, low baseline scores had an excellent negative predictive value. Given their easy applicability, these scoring systems may be useful in resource-limited settings to identify COVID-19 patients who are unlikely to progress to critical illness.