{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T05:36:48Z","timestamp":1782452208709,"version":"3.54.5"},"reference-count":36,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2024,11,19]],"date-time":"2024-11-19T00:00:00Z","timestamp":1731974400000},"content-version":"unspecified","delay-in-days":18,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004889","name":"Fondation du CHU de Qu\u00e9bec","doi-asserted-by":"crossref","award":["4007"],"award-info":[{"award-number":["4007"]}],"id":[{"id":"10.13039\/501100004889","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100000106","name":"Saskatchewan Health Research Foundation","doi-asserted-by":"publisher","award":["5357"],"award-info":[{"award-number":["5357"]}],"id":[{"id":"10.13039\/501100000106","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000233","name":"Genome British Columbia","doi-asserted-by":"publisher","award":["COV024"],"award-info":[{"award-number":["COV024"]}],"id":[{"id":"10.13039\/501100000233","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000233","name":"Genome British Columbia","doi-asserted-by":"publisher","award":["VAC007"],"award-info":[{"award-number":["VAC007"]}],"id":[{"id":"10.13039\/501100000233","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Fonds de recherche du Qu\u00e9bec \u2013 Sant\u00e9","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]},{"name":"Ontario Ministry of Colleges and Universities","award":["C-655-2129"],"award-info":[{"award-number":["C-655-2129"]}]},{"DOI":"10.13039\/501100000024","name":"Canadian Institutes of Health Research","doi-asserted-by":"publisher","award":["447679"],"award-info":[{"award-number":["447679"]}],"id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"publisher"}]},{"name":"BC Academic Health Science Network","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]},{"DOI":"10.13039\/501100024843","name":"BioTalent Canada","doi-asserted-by":"crossref","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}],"id":[{"id":"10.13039\/501100024843","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Public Health Agency of Canada\/COVID-19 Immunity Task Force","award":["2122-HQ-000054"],"award-info":[{"award-number":["2122-HQ-000054"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2024,10,24]]},"published-print":{"date-parts":[[2024,11]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>The objective is to externally validate and assess the opportunity to update the Canadian COVID-19 Mortality Score (CCMS) to predict in-hospital mortality among consecutive non-palliative COVID-19 patients infected with Omicron subvariants at a time when vaccinations were widespread.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>\n                      This observational study validated the CCMS in an external cohort at a time when Omicron variants were dominant. We assessed the potential to update the rule and improve its performance by recalibrating and adding vaccination status in a subset of patients from provinces with access to vaccination data and created the adjusted CCMS (CCMS\n                      <jats:sup>adj<\/jats:sup>\n                      ). We followed discharged patients for 30 days after their index emergency department visit or for their entire hospital stay if admitted.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>\n                      External validation cohort for CCMS: 36 hospitals participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). Update cohort for CCMS\n                      <jats:sup>adj<\/jats:sup>\n                      : 14 hospitals in CCEDRRN in provinces with vaccination data.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Consecutive non-palliative COVID-19 patients presenting to emergency departments.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>In-hospital mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Of 39\u2009682 eligible patients, 1654 (4.2%) patients died. The CCMS included age, sex, residence type, arrival mode, chest pain, severe liver disease, respiratory rate and level of respiratory support and predicted in-hospital mortality with an area under the curve (AUC) of 0.88 (95% CI 0.87 to 0.88) in external validation. Updating the rule by recalibrating and adding vaccination status to create the CCMS\n                      <jats:sup>adj<\/jats:sup>\n                      changed the weights for age, respiratory status and homelessness, but only marginally improved its performance, while vaccination status did not. The CCMS\n                      <jats:sup>adj<\/jats:sup>\n                      had an AUC of 0.91 (95% CI 0.89 to 0.92) in validation. CCMS\n                      <jats:sup>adj<\/jats:sup>\n                      scores of &lt;10 categorised patients as low risk with an in-hospital mortality of &lt;1.6%. A score&gt;15 had observed mortality of &gt;56.8%.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The CCMS remained highly accurate in predicting mortality from Omicron and improved marginally through recalibration. Adding vaccination status did not improve the performance. The CCMS can be used to inform patient prognosis, goals of care conversations and guide clinical decision-making for emergency department patients with COVID-19.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-083280","type":"journal-article","created":{"date-parts":[[2024,11,20]],"date-time":"2024-11-20T01:25:23Z","timestamp":1732065923000},"page":"e083280","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Accuracy of the Canadian COVID-19 Mortality Score (CCMS) to predict in-hospital mortality among vaccinated and unvaccinated patients infected with Omicron: a cohort study"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9210-7838","authenticated-orcid":false,"given":"Corinne M","family":"Hohl","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada"},{"name":"Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David S","family":"Yeom","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin","family":"Yan","sequence":"additional","affiliation":[{"name":"Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada"},{"name":"Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick M","family":"Archambault","sequence":"additional","affiliation":[{"name":"Department of Family Medicine and Emergency Medicine, Universit\u00e9 Laval, Qu\u00e9bec City, Qu\u00e9bec, Canada"},{"name":"Centre de recherche du Centre int\u00e9gr\u00e9 de sant\u00e9 et de services sociaux de Chaudi\u00e8re-Appalaches, L\u00e9vis, Qu\u00e9bec, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven C","family":"Brooks","sequence":"additional","affiliation":[{"name":"Departments of Emergency Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurie J","family":"Morrison","sequence":"additional","affiliation":[{"name":"Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada"},{"name":"Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Perry","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada"},{"name":"Ottawa Hospital Research Institute, Ottawa, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rhonda","family":"Rosychuk","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2024,11,19]]},"reference":[{"key":"2025121410413052000_14.11.e083280.1","doi-asserted-by":"publisher","DOI":"10.9778\/cmajo.20210243"},{"key":"2025121410413052000_14.11.e083280.2","doi-asserted-by":"publisher","DOI":"10.1016\/s1473-3099(22)00801-5"},{"key":"2025121410413052000_14.11.e083280.3","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s43678-022-00275-3","article-title":"Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)","volume":"24","author":"Hohl","year":"2022","journal-title":"CJEM"},{"key":"2025121410413052000_14.11.e083280.4","doi-asserted-by":"publisher","DOI":"10.7326\/M14-0698"},{"key":"2025121410413052000_14.11.e083280.5","doi-asserted-by":"publisher","DOI":"10.9778\/cmajo.20200290"},{"key":"2025121410413052000_14.11.e083280.6","doi-asserted-by":"crossref","DOI":"10.1002\/emp2.12868","article-title":"Derivation and validation of a clinical decision rule to risk-stratify COVID-19 patients discharged from the emergency department: The CCEDRRN COVID discharge score","volume":"3","author":"Brooks","year":"2022","journal-title":"J Am Coll Emerg Physicians Open"},{"key":"2025121410413052000_14.11.e083280.7","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-055832","article-title":"CCEDRRN COVID-19 Infection Score (CCIS): development and validation in a Canadian cohort of a clinical risk score to predict SARS-CoV-2 infection in patients presenting to the emergency department with suspected COVID-19","volume":"11","author":"McRae","year":"2021","journal-title":"BMJ Open"},{"key":"2025121410413052000_14.11.e083280.8","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2022.36288","article-title":"Sensitivity and Diagnostic Yield of the First SARS-CoV-2 Nucleic Acid Amplification Test Performed for Patients Presenting to the Hospital","volume":"5","author":"Hohl","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2025121410413052000_14.11.e083280.9","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-057852","article-title":"Diagnostic yield of screening for SARS-CoV-2 among patients admitted to hospital for alternate diagnoses: an observational cohort study","volume":"12","author":"Davis","year":"2022","journal-title":"BMJ Open"},{"key":"2025121410413052000_14.11.e083280.10","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1007\/s43678-022-00440-8","article-title":"Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study","volume":"25","author":"Lin","year":"2023","journal-title":"CJEM"},{"key":"2025121410413052000_14.11.e083280.11","doi-asserted-by":"crossref","DOI":"10.2196\/44465","article-title":"Accuracy of Self-Reported COVID-19 Vaccination Status Compared With a Public Health Vaccination Registry in Qu\u00e9bec: Observational Diagnostic Study","volume":"9","author":"Archambault","year":"2023","journal-title":"JMIR Public Health Surveill"},{"key":"2025121410413052000_14.11.e083280.12","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.puhe.2022.11.016","article-title":"Patient-reported health outcomes of SARS-CoV-2-tested patients presenting to emergency departments: a propensity score-matched prospective cohort study","volume":"215","author":"Bola","year":"2023","journal-title":"Pub Health (Fairfax)"},{"key":"2025121410413052000_14.11.e083280.13","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.101786"},{"key":"2025121410413052000_14.11.e083280.14","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2035389"},{"key":"2025121410413052000_14.11.e083280.15","doi-asserted-by":"publisher","DOI":"10.1002\/sim.6787"},{"key":"2025121410413052000_14.11.e083280.16","doi-asserted-by":"publisher","DOI":"10.1016\/S0895-4356(96)00236-3"},{"key":"2025121410413052000_14.11.e083280.17","doi-asserted-by":"crossref","unstructured":"Harrell FE . Regression Modeling Strategies With Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis. 2nd edn. New York: Springer, 2015.","DOI":"10.1007\/978-3-319-19425-7"},{"key":"2025121410413052000_14.11.e083280.18","unstructured":"R Core Team . R: A Language and Environment for Statistical Computing. Vienna,Austria: R Foundation for Statistical Computing, 2021."},{"key":"2025121410413052000_14.11.e083280.19","unstructured":"Harrell F . Rms: regression modeling strategies. r package version 6.3-0. 2022. Available: https:\/\/CRAN.R-project.org\/package=rms"},{"key":"2025121410413052000_14.11.e083280.20","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2105-12-77","article-title":"pROC: an open-source package for R and S+ to analyze and compare ROC curves","volume":"12","author":"Robin","year":"2011","journal-title":"BMC Bioinformatics"},{"key":"2025121410413052000_14.11.e083280.21","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.m1328","article-title":"Prediction models for diagnosis and prognosis of covid-19: systematic review and critical appraisal","volume":"369","author":"Wynants","year":"2020","journal-title":"BMJ"},{"key":"2025121410413052000_14.11.e083280.22","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1007\/s10654-023-00973-x","article-title":"Prognostic models in COVID-19 infection that predict severity: a systematic review","volume":"38","author":"Buttia","year":"2023","journal-title":"Eur J Epidemiol"},{"key":"2025121410413052000_14.11.e083280.23","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.m3339","article-title":"Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score","volume":"370","author":"Knight","year":"2020","journal-title":"BMJ"},{"key":"2025121410413052000_14.11.e083280.24","doi-asserted-by":"publisher","DOI":"10.1186\/s12916-020-01893-3"},{"key":"2025121410413052000_14.11.e083280.25","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2022-072976","article-title":"Risk prediction of covid-19 related death or hospital admission in adults testing positive for SARS-CoV-2 infection during the omicron wave in England (QCOVID4): cohort study","volume":"381","author":"Hippisley-Cox","year":"2023","journal-title":"BMJ"},{"key":"2025121410413052000_14.11.e083280.26","doi-asserted-by":"crossref","first-page":"105039","DOI":"10.1016\/j.ijmedinf.2023.105039","article-title":"Clinical prediction rules for adverse evolution in patients with COVID-19 by the Omicron variant","volume":"173","author":"Portuondo-Jim\u00e9nez","year":"2023","journal-title":"Int J Med Inform"},{"key":"2025121410413052000_14.11.e083280.27","doi-asserted-by":"crossref","DOI":"10.3390\/biomedicines11030767","article-title":"Risk Stratification Model for Severe COVID-19 Disease: A Retrospective Cohort Study","volume":"11","author":"Mizrahi Reuveni","year":"2023","journal-title":"Biomedicines"},{"key":"2025121410413052000_14.11.e083280.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0245840","article-title":"Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19: The PRIEST observational cohort study","volume":"16","author":"Goodacre","year":"2021","journal-title":"PLoS ONE"},{"key":"2025121410413052000_14.11.e083280.29","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0287091","article-title":"LMIC-PRIEST: Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19 in a middle-income setting","volume":"18","author":"Marincowitz","year":"2023","journal-title":"PLoS ONE"},{"key":"2025121410413052000_14.11.e083280.30","article-title":"Do Neuroprognostic Studies Account for Self-Fulfilling Prophecy Bias in Their Methodology? The SPIN Protocol for a Systematic Review","volume":"5","author":"Teixeira","year":"2023","journal-title":"Crit Care Explor"},{"key":"2025121410413052000_14.11.e083280.31","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2110362"},{"key":"2025121410413052000_14.11.e083280.32","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(22)00152-0"},{"key":"2025121410413052000_14.11.e083280.33","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(21)02226-1"},{"key":"2025121410413052000_14.11.e083280.34","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.230249"},{"key":"2025121410413052000_14.11.e083280.35","doi-asserted-by":"publisher","DOI":"10.1016\/S0196-0644(99)70309-4"},{"key":"2025121410413052000_14.11.e083280.36","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.211712"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2023-083280","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,14]],"date-time":"2025-12-14T18:41:43Z","timestamp":1765737703000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2023-083280"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,11]]},"references-count":36,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2024,11,19]]},"published-print":{"date-parts":[[2024,11]]}},"alternative-id":["10.1136\/bmjopen-2023-083280"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2023-083280","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,11]]}}}