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Abtahi et al. | Journal of Clinical and Translational Research 2024; 10(2): 119-140 123
In the second step, the factors were validated concerning Table 1. General characteristics (i.e., type of clinical decision and
each outcome via CVI calculation, and the critical factors were country) of the evaluated articles
determined. Characteristic Number of articles
(relative to all articles [%])
3.1. Literature review to identify the effective factors Type of clinical decision
Overall, 273 articles were obtained from the literature search. Length of stay 12 (8.89)
Fifty duplicate studies were removed accordingly. After assessing Ward referrals 9 (6.67)
the title, abstract, and full text of the articles and excluding Home referrals 4 (2.96)
the irrelevant studies, the remaining 136 articles were further Deterioration 98 (72.59)
evaluated. The articles were evaluated for the relevant factors (e.g., Discharge 15 (11.11)
effective factors and clinical tests in COVID-19 management) ICU referrals 30 (22.22)
based on predefined categories regarding decision-making. The Country
general characteristics of the evaluated articles are displayed in China 53 (39.26)
Table 1. United States of America 22 (16.30)
From the literature review, a total of 293 demographic and Italy 17 (12.59)
clinical factors, considered effective in clinical decision-making France 9 (6.67)
at different stages of COVID-19, were identified. Among them, 51 Turkey 6 (4.44)
factors were related to the length of stay, 50 factors were related to Iran 4 (2.96)
ward referrals, 24 factors were related to home referrals, 63 factors Belgium 2 (1.48)
were related to deterioration diagnosis, 43 factors were related to Canada 3 (1.48)
discharge, and 62 factors were related to ICU referrals. It should Germany 4 (1.48)
also be noted that several factors are common in various areas.
Greece 5 (1.48)
3.2. Clinical expert panel data analysis Japan 6 (1.48)
Pakistan 7 (1.48)
The clinical expert panel included one subspecialist, six Spain 8 (1.48)
specialists, and three general practitioners with experience United Kingdom 9 (1.48)
working in COVID-19 wards or ICUs in referral academic Australia and New Zealand 1 (0.74)
hospitals in Iran. Six of the participants worked in Tehran, while Israel 1 (0.74)
the others worked in Kerman, Varamin, Yasuj, and Dehdasht. Korea 1 (0.74)
Table 2 summarizes the characteristics of these clinical experts
based on gender, medical specialty, clinical experience, and Netherlands 1 (0.74)
Singapore
1 (0.74)
the number of COVID-19 patients visited from March 2020 to
December 2022. Abbreviation: ICU: Intensive care unit.
3.3. Essential and critical factors of cancer or malignancy, history of any cardiovascular disease,
history of renal function impairment or chronic kidney disease,
Based on the calculated CVRs of 258 items, 159 items were history of respiratory diseases (e.g., asthma and COPD), RR,
identified as essential factors, and 28 items were identified as SpO at admission, and arterial oxygen pressure (PaO ). A total
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critical factors in the six outcome categories. A total of 71 items of 24 factors were reported for home referrals or home isolation,
were rejected based on our criteria described in Section 2.3.5. The of which one factor (i.e., SpO ) was considered critical, while the
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full results are displayed in Tables A2-A7. other 23 factors were deemed essential (Table A4).
The first category of factors was associated with decision- The fourth category of decision-making was related to the
making regarding the length of stay in the hospital (Table A2). factors in deterioration diagnosis (Table A5). This category reported
From a total of 51 factors, 10 were considered critical and 41 63 factors, including six critical factors and 57 essential factors.
were considered essential. The critical factors were the history The critical factors for this decision-making were the history of
of cancer or malignancy, history of any cardiovascular disease, respiratory disease (e.g., asthma, COPD, and other similar diseases),
history of renal function impairment or chronic kidney disease, RR, D-dimers, SpO at admission, venous blood pH, and PaO .
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history of respiratory disease (e.g., asthma and chronic obstructive The discharge category (with a total of 43 factors) reported two
pulmonary diseases [COPD]), history of using immunosuppressive critical elements, including RR and GFR (Table A6).
drugs, respiratory rate (RR), C-reactive protein, glomerular The sixth category was ICU referrals with 57 factors in total
filtration rate (GFR), oxygen saturation (SpO ) at admission, and (Table A7). Among them, there were 47 essential factors and
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the sequential organ failure assessment score. 10 critical factors. The critical factors were body mass index or
The second category (i.e., ward referrals) included 49 factors obesity, history of cancer or malignancy, history of renal function
(Table A3), of which eight factors were considered critical. The impairment or chronic kidney disease, history of respiratory
accepted factors were the history of diabetes mellitus, history disease (e.g., asthma, COPD, and other similar diseases), RR,
DOI: https://doi.org/10.36922/jctr.22.00226