Accuracy of qSOFA for the diagnosis of sepsis-3: a secondary analysis of a population-based cohort study

Abstract

Background: We aimed to evaluate the accuracy of quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) for the diagnosis of sepsis-3, and to analyze the prognosis of infected patients in wards over-diagnosed with qSOFA but missed by sepsis-3, and those missed by qSOFA but in accordance with sepsis-3 criteria. We also intended to validate the performance of qSOFA as one predictor of outcome in patients with suspicion of infection.

Methods: We reviewed the medical records of 1,716 adult patients with infection who were hospitalized from July 1^st, 2012 to June 30^th, 2014 in the Yuetan subdistrict of Beijing, China. Based on the sepsis-3 criteria and qSOFA score proposed by the Third International Consensus Definitions for Sepsis and Septic Shock, these patients were categorized into four groups: qSOFA(-)sepsis(-), qSOFA(+)sepsis(-), qSOFA(-)sepsis(+), and qSOFA(+)sepsis(+). Multivariate logistic regression analysis was used to determine the independent risk factors for in-hospital mortality. The area under the receiver operating characteristic curves (AUROCs) of the qSOFA(+) group were compared with the sepsis(+) group for in-hospital mortality, ICU admission, and invasive ventilation.

Results: Among the 1,716 patients with infection, there were 935 patients (54.5%) with sepsis, and 640 patients (37.3%) with qSOFA ≥2. There were 610 patients in the qSOFA(-)sepsis(-) group, 171 in the qSOFA(+)sepsis(-) group, 466 in the qSOFA(-)sepsis(+) group, and 469 in the qSOFA(+)sepsis(+) group. In the logistic regression analysis, increasing age, bedridden status, and malignancy were all independent risk factors of hospital mortality. Sepsis and qSOFA ≥2 were also independent risk factors of hospital mortality, with an adjusted OR of 3.85 (95% CI: 2.70-5.50) and 13.92 (95% CI: 9.87-16.93) respectively. qSOFA had a sensitivity of 50.2% and a specificity of 78.1% for sepsis-3. The false-positive [qSOFA(+)sepsis(-)] group had 38 patients (22.2%) die during hospitalization, and an adjusted OR of 9.20 (95% CI: 4.86-17.38). In addition, the false-negative [qSOFA(-)sepsis(+)] group had a hospital mortality rate of 7.3% (34/466) and an adjusted OR of 2.59 (95% CI: 1.39-4.83). In comparison, patients meeting neither qSOFA nor sepsis criteria had the lowest hospital mortality [2.6% (16/610)], whereas patients with both qSOFA ≥2 and sepsis had the highest hospital mortality [56.5% (265/469)], with an adjusted OR of 42.02 (95% CI: 24.31-72.64). The discrimination of in-hospital mortality using qSOFA (AUROC, 0.846; 95% CI, 0.824-0.868) was greater compared with sepsis-3 criteria (AUROC, 0.834; 95% CI, 0.805-0.863; P<0.001).

Conclusions: In our analysis, the sensitivity(Se) of qSOFA for the diagnosis of sepsis was lower, and qSOFA score ≥2 might identify a group of patients at a higher risk of mortality, regardless of being septic or not.

Keywords: Sequential (sepsis-related) Organ Failure Assessment (SOFA); mortality; quick Sequential Organ Failure Assessment (qSOFA) score; sepsis-3; the area under the receiver operating characteristic curves (AUROCs).