Deshpande K, Tripathi D. Predictive accuracy of 4C Mortality Score and Acute Physiology and Chronic Health Evaluation scores for mortality in COVID-19 patients admitted to intensive care unit. World J Crit Care Med 2025; 14(4): 108907 [DOI: 10.5492/wjccm.v14.i4.108907]
Corresponding Author of This Article
Kush Deshpande, MD, Consultant, Department of Intensive Care, St George Hospital, Gray Street, Kogarah, NSW 2217, Sydney 2217, New South Wales, Australia. kush.deshpande@health.nsw.gov.au
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Critical Care Medicine
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Retrospective Cohort Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Dec 9, 2025 (publication date) through Dec 8, 2025
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World Journal of Critical Care Medicine
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2220-3141
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Deshpande K, Tripathi D. Predictive accuracy of 4C Mortality Score and Acute Physiology and Chronic Health Evaluation scores for mortality in COVID-19 patients admitted to intensive care unit. World J Crit Care Med 2025; 14(4): 108907 [DOI: 10.5492/wjccm.v14.i4.108907]
World J Crit Care Med. Dec 9, 2025; 14(4): 108907 Published online Dec 9, 2025. doi: 10.5492/wjccm.v14.i4.108907
Predictive accuracy of 4C Mortality Score and Acute Physiology and Chronic Health Evaluation scores for mortality in COVID-19 patients admitted to intensive care unit
Kush Deshpande, Dushyant Tripathi
Kush Deshpande, Department of Intensive Care, St George Hospital, Sydney 2217, New South Wales, Australia
Kush Deshpande, School of Medicine, University of New South Wales, Sydney 2033, New South Wales, Australia
Dushyant Tripathi, Intensive Care Unit, Maitland Hospital, Maitland 2323, New South Wales, Australia
Co-first authors: Kush Deshpande and Dushyant Tripathi.
Author contributions: Deshpande K and Tripathi D contributed to conceptualisation, literature review, writing original draft, review and editing; Deshpande K contributed to statistical analysis, validation, supervision; Tripathi D contributed to data collection.
Institutional review board statement: The ethics approval was obtained from the Human Research Ethics Committee, South Eastern Sydney Local Health District.
Informed consent statement: Not applicable.
Conflict-of-interest statement: There are no disclosures or conflicts of interest to declare.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Data sharing statement: The data supporting the findings of this study will be made available upon request by the authors.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kush Deshpande, MD, Consultant, Department of Intensive Care, St George Hospital, Gray Street, Kogarah, NSW 2217, Sydney 2217, New South Wales, Australia. kush.deshpande@health.nsw.gov.au
Received: April 27, 2025 Revised: June 2, 2025 Accepted: August 29, 2025 Published online: December 9, 2025 Processing time: 217 Days and 12 Hours
Abstract
BACKGROUND
Previous studies have reported the high predictive accuracy of 4C Mortality Score derived at hospital admission in coronavirus disease 2019 (COVID-19) patients. Very few studies have assessed it at intensive care unit (ICU) admission and compared it with the Acute Physiology and Chronic Health Evaluation (APACHE) II score. There are no studies comparing its accuracy with APACHE III score.
AIM
To describe the characteristics and outcomes of patients admitted to ICU with COVID-19 infection and to compare the accuracy of 4C score and APACHE score in predicting mortality in these patients.
METHODS
We conducted this retrospective cohort study using an electronic database in a tertiary ICU in Sydney. We included all adult patients (age > 16 years) admitted to ICU with COVID-19 infection over a 5-month period (July 1, 2021 to November 30, 2021). We collected the data on demographics, clinical characteristics, interventions and outcomes for all patients. We calculated the 4C Mortality Score for each patient using eight variables as described previously. We compared the predictive accuracy of 4C Mortality Score at hospital and ICU admission and APACHE II and III scores by area under the receiver operating characteristic curve (AUROC). We determined the optimal cut-off value for each of these scores using the ‘nearest’ method and its 95% confidence interval by bootstrapping.
RESULTS
A total of 140 patients (62% males, mean age 56 ± 17 years, mean APACHE II score 13 ± 57) were included in the study. Nineteen (13.6%) of 140 patients died in the hospital. Compared to survivors, the non-survivors were older, males, had more comorbidities, higher rate of mechanical ventilation and vasopressor use. The AUROC for the 4C Mortality Score at hospital and ICU admission and APACHE II and II score was 0.75, 0.80. 0.75 and 0.79 respectively. The optimal cut-off value for these four scores was 9, 10, 14 and 56 respectively. The cut-point for all the scores had higher sensitivity than specificity.
CONCLUSION
The 4C score at ICU admission had a higher accuracy in predicting mortality than the 4C score at hospital admission. The predictive accuracy was similar to that for APACHE III score. The 4C score at ICU admission needs to be validated in future studies.
Core Tip: This retrospective cohort study compared the predictive accuracy of the 4c Mortality Score and Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores for coronavirus disease 2019 patients admitted to intensive care unit (ICU). The 4C score at ICU admission showed an area under the receiver operating characteristic curve of 0.80, higher than at hospital admission (0.75) and comparable to APACHE III (0.79) and II (0.75). Non-survivors were older, predominantly male, with more comorbidities and higher intervention rates. The study suggests that the 4C score at ICU admission is a reliable predictor of mortality and is easier to calculate. These findings warrant further validation in a larger study.
