A comparison of the Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) Scores in Predicting Mortality Among Patients with Reduced Level of Consciousness in Uganda

Background: Reduced level of consciousness (LOC) is a common cause of presentation among acutely ill adults in sub-Saharan Africa and is associated with high rates of mortality. Although the Full Outline of Unresponsiveness (FOUR) score is often used in clinical practice, its utility in predicting mortality has not been assessed in the region. Methods: We prospectively enrolled adults presenting with reduced LOC to Mbarara Regional Referral Hospital in Uganda. We recorded clinical and laboratory data and performed the FOUR and Glasgow Coma Scale (GCS) scores at admission. We used survival analysis, fit Cox proportional hazards regression models to assess the predictive properties of the two scores, and compared their performance using area under the receiver operating characteristic curve (AUROC). Results: We enrolled 359 patients, mean (SD) age was 51 (22.2) years, and 58% (210/359) were male. The median (interquartile range) admission FOUR and GCS scores were 13.0 (3.0–16.0) and 10.0 (3.0–14.0), respectively. Subjects with the FOUR score of 0–11 had a 2.6-fold higher hazard of 30-day mortality (HR 2.6, 95% CI 1.9–3.6, p < 0.001) compared to those with the score of 12–16. Those with the GCS score of 3–8 had a 2.7-fold higher hazard of 30-day mortality (HR 2.7, 95% CI 2.0–3.8, p < 0.001) compared to those with the score of 9–15. The AUROC (95% CI) for the FOUR score and GCS score was 0.68 (0.62–0.73) and 0.67 (0.62–0.73), respectively (p = 0.825). Conclusions: The FOUR score is comparable to the GCS score in predicting mortality in Uganda. Our findings support the introduction of the FOUR score in guiding the management of patients with reduced LOC in sub-Saharan Africa.