Predicting high risk of exacerbations in bronchiectasis: the E-FACED score

Abstract

Background: Although the FACED score has demonstrated a great prognostic capacity in bronchiectasis, it does not include the number or severity of exacerbations as a separate variable, which is important in the natural history of these patients.

Objective: Construction and external validation of a new index, the E-FACED, to evaluate the predictive capacity of exacerbations and mortality.

Methods: The new score was constructed on the basis of the complete cohort for the construction of the original FACED score, while the external validation was undertaken with six cohorts from three countries (Brazil, Argentina, and Chile). The main outcome was the number of annual exacerbations/hospitalizations, with all-cause and respiratory-related deaths as the secondary outcomes. A statistical evaluation comprised the relative weight and ideal cut-off point for the number or severity of the exacerbations and was incorporated into the FACED score (E-FACED). The results obtained after the application of FACED and E-FACED were compared in both the cohorts.

Results: A total of 1,470 patients with bronchiectasis (819 from the construction cohorts and 651 from the external validation cohorts) were followed up for 5 years after diagnosis. The best cut-off point was at least two exacerbations in the previous year (two additional points), meaning that the E-FACED has nine points of growing severity. E-FACED presented an excellent prognostic capacity for exacerbations (areas under the receiver operating characteristic curve: 0.82 for at least two exacerbations in 1 year and 0.87 for at least one hospitalization in 1 year) that was statistically better than that of the FACED score (0.72 and 0.78, P<0.05, respectively). The predictive capacities for all-cause and respiratory mortality were 0.87 and 0.86, respectively, with both being similar to those of the FACED.

Conclusion: E-FACED score significantly increases the FACED capacity to predict future yearly exacerbations while maintaining the score's simplicity and prognostic capacity for death.

Keywords: E-FACED score; FACED score; bronchiectasis; exacerbations; mortality.

Figure 1

Flowchart of the study.

Figure 2

Comparative AUC-ROC for the prediction of at least two exacerbations per year. Abbreviation: AUC-ROC, areas under the receiver operating characteristic curve.

Figure 3

Comparison of the prognostic capacity of the FACED and E-FACED scores for (A) all-cause mortality and (B) respiratory mortality in the initial cohort of patients (n=819).

Figure 4

Comparison of the prognostic capacity of the FACED and E-FACED scores for all-cause and respiratory mortality in the validation cohort (n=651). Note: (A) All-cause mortality and (B) respiratory mortality.

Figure 5

Comparison of the discriminatory capacity of the (A) FACED and (B) E-FACED scores in groups of increasing severity in the initial cohort (n=819). Notes: (A) FACED score: mild: 0–2 points, moderate: 3–4 points, and severe: 5–7 points. Log-rank test: mild bronchiectasis versus moderate bronchiectasis 51.2, P<0.0001; mild versus severe 309.9; P<0.0001; and moderate versus severe 64.6, P<0.0001. (B) E-FACED score: mild: 0–3 points, moderate 4–6 points, and severe 7–9 points. Log-rank test: mild bronchiectasis versus moderate bronchiectasis 111.2, P<0.0001; mild versus severe 287.7; P<0.0001; and moderate versus severe 26.5, P<0.0001.

Figure 6

Comparison of the discriminatory capacities of the (A) FACED and (B) E-FACED scores in groups of increasing severity in the validation cohort (n=651). Notes: (A) FACED score: mild: 0–2 points, moderate: 3–4 points, and severe: 5–7 points. Log-rank test: mild bronchiectasis versus moderate bronchiectasis 43.3, P<0.0001; mild versus severe 138.9; P<0.0001; and moderate versus severe 23.4, P<0.0001. (B) E-FACED score: mild: 0–3 points, moderate: 4–6 points; and severe: 7–9 points. Log-rank test: mild bronchiectasis versus moderate bronchiectasis 71.3, P<0.0001; mild versus severe 201.2; P<0.0001; and moderate versus severe 24.1, P<0.0001.