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Annals of Medicine and Medical Sciences
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  3. Comparative Evaluation of the Glasgow and FOUR Scores for Prognostic S…
Original Article Open Access

Comparative Evaluation of the Glasgow and FOUR Scores for Prognostic Stratification of Comatose Patients in Hospital Settings: Multicenter observational cohort study in Kinshasa

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Annals of Medicine and Medical SciencesVol. 05, (2026) May 7, 2026pp. 638 - 645
178 135
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Abstract
Introduction: Assessment of the level of consciousness is essential for prognostic stratification in comatose patients. The Glasgow Coma Scale (GCS) is widely used but has recognized limitations. The Full Outline of UnResponsiveness (FOUR) score has been proposed as a more comprehensive alternative; however, comparative data from African settings remain limited, which hinders its validation and potential implementation in these regions Objective: To compare the prognostic performance of the GCS and FOUR scores in predicting in-hospital mortality among comatose patients in the Democratic Republic of the Congo. Methods: We conducted a multicenter observational cohort study including 538 adult patients admitted to intensive care units in Kinshasa between October 2024 and October 2025. GCS and FOUR scores were assessed at admission. Pearson correlation analysis was performed to evaluate the relationship between both scores. Multivariable logistic regression models were used to assess associations with in-hospital mortality, including separate and combined score-based models adjusted for relevant clinical covariates. Model performance was evaluated using accuracy, precision, recall (sensitivity), and the area under the receiver operating characteristic curve (AUC), with comparisons performed using DeLong’s test. Results: Both GCS and FOUR scores were significantly associated with in-hospital mortality. A strong positive correlation was observed between GCS and FOUR scores (r = 0.75, p < 0.001). The GCS-based model exhibited commendable discriminative performance (AUC = 0.866; accuracy = 0.878; recall = 0.951), whereas the FOUR-based model displayed marginally superior discrimination (AUC = 0.883; accuracy = 0.896) but diminished sensitivity (recall = 0.633). In the combined model, both scores remained associated with mortality; however, no significant improvement in predictive performance was observed (AUC = 0.883), suggesting partial redundancy between the two scales. Conclusion: In this multicenter cohort, both GCS and FOUR scores showed excellent prognostic performance for in-hospital mortality. The FOUR score demonstrated slightly higher discrimination, whereas the GCS showed higher sensitivity. The strong correlation between both scales and the absence of improvement in the combined model suggests overlapping but not identical prognostic information.
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Comparative Evaluation of the Glasgow and FOUR Scores for Prognostic Stratification of Comatose Patients in Hospital Settings: Multicenter observational cohort study in Kinshasa