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Predictive validity of daily sequential organ failure assessment (SOFA)-2 score for 30-day mortality
Johan Helleberg1,2, Anna Sundelin3,4, Navid Soltani1,5
1Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
Purpose:
The sequential organ failure assessment (SOFA) score was recently updated to better reflect contemporary intensive care. This study compares the predictive validity of the updated SOFA-2 and the previous SOFA-1 for 30-day mortality over the first week in ICU, overall and in subgroups with distinct age and comorbidity profiles.
Methods:
We conducted a retrospective observational study of adult patients admitted to four ICUs in Sweden from 2010 to 2021. Predictive validity for 30-day mortality was assessed on day 1-7 using the area under the receiver operating characteristic curve (AUROC).
Results:
We included 29,820 admissions (mean age 60 years, 64.8% males, median Charlson comorbidity index [CCI] 1). Reclassification between SOFA-1 and SOFA-2 occurred in 75-79% of admissions across days 1-7. On day 1, the AUROC for 30-day mortality was 0.81 (95% CI 0.80-0.81) for SOFA-2 and 0.80 (95% CI 0.79-0.81) for SOFA-1 (p < 0.001). From day 2 onward, AUROCs declined for both scores and were largely similar. Among trauma patients (mean age 50 years; median CCI 0), day-1 AUROC for SOFA-2 was 0.81 (95% CI 0.79-0.83), while among sepsis patients (mean age 61 years; median CCI 3) it was 0.72 (95% CI 0.70-0.74), with comparable performance for SOFA-1.
Conclusions:
SOFA-2 provided modestly better discrimination for 30-day mortality on ICU-day 1 compared with SOFA-1. Predictive validity diminished over subsequent days for both scores and varied across subgroups with different age and comorbidity distributions, underscoring the context-dependence of organ dysfunction scoring.
Trial Registration:
https://doi.org/10.5281/zenodo.17651826 , registration date November 19, 2025.
Insights
The updated Sequential Organ Failure Assessment (SOFA) score, SOFA-2, showed slightly better prediction of 30-day mortality on day 1 in the ICU compared to SOFA-1. Predictive accuracy decreased over time and varied by patient characteristics.
Area of Science:
- Intensive care medicine
- Clinical epidemiology
- Health informatics
Background:
- The Sequential Organ Failure Assessment (SOFA) score is a key tool for assessing organ dysfunction in intensive care units (ICUs).
- Recent updates led to the development of SOFA-2, necessitating a comparison with the previous SOFA-1.
- Understanding the predictive performance of SOFA-2 is crucial for contemporary critical care practice.
Purpose of the Study:
- To compare the predictive validity of the updated SOFA-2 and the previous SOFA-1 for 30-day mortality.
- To evaluate performance over the first week in the ICU, considering overall patient populations and specific age/comorbidity subgroups.
Main Methods:
- A retrospective observational study included 29,820 adult ICU admissions in Sweden (2010-2021).
- Predictive validity for 30-day mortality was assessed using the area under the receiver operating characteristic curve (AUROC) from day 1 to day 7.
- Analyses were conducted overall and within subgroups defined by age and Charlson Comorbidity Index (CCI).
Main Results:
- SOFA-2 demonstrated a modestly higher AUROC (0.81) for 30-day mortality on ICU day 1 compared to SOFA-1 (0.80) (p < 0.001).
- AUROCs for both scores declined from day 2 onwards and showed largely similar performance.
- In specific subgroups like trauma patients, SOFA-2 showed good predictive validity (AUROC 0.81 on day 1), while sepsis patients had lower AUROCs (0.72 on day 1) for both scores.
Conclusions:
- SOFA-2 offers a slight improvement in discriminating 30-day mortality on the first day of ICU admission compared to SOFA-1.
- The predictive validity of both scores diminishes over the ICU stay and is influenced by patient age and comorbidity profiles.
- These findings highlight the context-dependent nature of organ dysfunction scoring in critical care settings.
