1. Todd A. Kawecki, D.C. VA Connecticut
VACS Index Calculator
Todd A. Kawecki, D.C.
VA Connecticut

2. Risk Assessment (Decision Support) Tools
Many computerized tools
Available for many health risks including:
Diabetes
Heart disease, MI
Breast Cancer
Colorectal Cancer
HIV Transmission
The concept of developing a web-based risk assessment tool is certainly not new.
If you ‘google’: health risk assessment tools, you get over 20 million hits
The spectrum of what you might find is very broad.
As a sampling, this list includes a number of these.
Many of which are from large organizations: American Diabetes Association, American Heart Association, National Cancer Institute, etc.
There are also many tools to assess risk of HIV transmission

3. Framingham Risk Assessment
Results View:
Risk score results:
Age: 60
Gender:
male
Total Cholesterol:
280 mg/dL
HDL Cholesterol:
100 mg/dL
Smoker:
Yes
Systolic Blood Pressure:
120 mm/Hg
On medication for HBP:      No
Risk Score*
10%
* The risk score shown was derived on the basis of an equation. Other NCEP materials, such as ATP III print products, use a point-based system to calculate a risk score that approximates the equation-based one.
To interpret the risk score and for specific information about CHD risk assessment as part of detection, evaluation, and treatment of high blood cholesterol, see ATP III Executive Summary and ATP III At-a-Glance.
Tool based on the Framingham Heart Study
It assesses for “hard” coronary heart disease outcomes like MI and coronary death

4. Tool Based on Framingham Study
National Heart Lung and Blood Institute
National Institutes of Health
Calculates 10 year risk of “hard” coronary heart disease outcomes like MI
Result is a score with link to explanation

5. Cleveland Clinic
Wells BJ, Jain A, Arrigain S, Yu C, Rosenkrans JR WA, Kattan MW. Predicting Six-year Mortality Risk in Patients with Type 2 Diabetes. Diabetes Care 2008;31:

6. Cleveland Clinic
6-year mortality risk for patients with Type 2 Diabetes
Input demographic and clinical data
Result is a probability

7. Survival Probability http://www.mayoclinic.org/gi-rst/mayomodel1.html
This give the survival probability of a patient with untreated biliary cirrhosis

8. Mayo Clinic Risk Tools Mayo Clinic mortality risk models
This tool is for risk of mortality in patients with untreated primary biliary cirrhosis
Computes a risk score and gives an estimated probability of survival up to 7 years

9. Acute Coronary Syndrome
Global Registry of Acute Coronary Events
UMASS Medical School
Center for Outcomes Research

10. GRACE Center for Outcomes Research, UMASS Medical School
International database
30 countries
247 hospitals
102, 341 patients
Gives probability of death or death/MI at admission or discharge

11. Diabetes Risk Test
This is the first of several screen shots of risk assessment tools. They cover a number of common, health conditions. A few deal with very serious health problems (ie: MI, coronary death, Cancer), which I think is critical to point out. It may help those that are a bit squeamish about the content of this site. Also, they are from ‘high profile’ organizations.
American Diabetes Association
This is a tool to assess risk of Type-2 diabetes

12. Heart Attack Risk Calculator
American Heart Association
Full Name of Tool: Heart Attack-Coronary Heart Disease-Metabolic Syndrome Risk Assessment
Some of this repetition is to reinforce the notion that there are many tools out there and some of them address very serious health outcomes. This may enlighten some of the those concerned about the content of our site.

13. Colorectal Cancer Risk Assessment
National Cancer Institute
Yet another example….

14. HIV Risk http://www.thebody.com/surveys/sexsurvey.html
Risk of HIV transmission

15. VACS Index Calculator
Brief overview of the development of the prototype
Brief overview of the project.
What we developed
It is a portal through which people may get their VACS Index score
Built as a prototype
This allows for incremental building with feedback and revision
The main features
It is developed around functional requirements

16. Prototype Development
Goals:
Identify the basic requirements
Development of a user interface
Gather feedback from users
Revise and enhance the tool
Explain the development process for a prototype:
What the goals are and where we stand
You find out what the functional requirements are, then build a prototype. It may or may not be close to the final product, but you test it, get feedback, and enhance the next generation.
Sit in between 1 and 2

17. Functional Requirements: What it Should Do
Calculate the VACS Index
Provide unique patient-specific feedback based on an individual score
Provide a risk estimate
Be used for online research recruitment
The functional requirements define the function(s) of the site.
Specifically, what the tool or site must be able to do
This input is essential for the development of the tool

18. Workflow Patients/Providers access the site Information entered
Score calculated
Explanation of tests and score
Option to register for online research
Evaluate end-user experience through survey
This slide highlights the use or flow of the site.
Who can access it
How it will be used
Allows you to develop the navigational features, ie links, the various pages and how they should interact
Helps the developer maximize the user experience

19. This is an overview of the various pages and how they might interact.
For example:
From the calculator tool itself, you should be able to access the results and a description of the lab values associated with calculating the score.

20. Technical Specifications
Website will be ASP.NET pages
Database will be SQL Server relational database
Secure VA Intranet Environment
Behind the firewall
Must obtain informed consent, HIPAA, patient de-identification
Possibility of hosting outside of VA
This is technical information. It also briefly mentions the security issues.
According to Mike R., the site may be hosted behind the VA firewall, or an outside source. The latter is something we have to find out more about, as there is a group in Boston that has a patient-accessible home care portal hosted on the outside that communicates with VistA.

21. The Calculator
This is a screen shot of the calculator. Users can enter information and calculate their risk index score.

22. Results
Your score is XX. Among 100 veterans in VA care with HIV infection with this score, we would expect that YY would be alive at five years and ZZ would have died. The figures in grey represent those expected to live 5 years and the figures in black represent those expected to have died.
This is how results will be displayed. There will be an explanation as well as a 100 faces diagram, depicting the results

23. Issues to Address #1 Discrepancies in internet access
Concerns have been voiced. One of those being discrepancies in internet access. This is a table highlighting the data gathered on variation in Veteran’s access to the internet.
Variation in Veterans’ Access to Internet and . Kirsha S. Gordon, et al. 3/2010. (under review)
Discrepancies in internet access
Solution: Provide training and internet access

24. Issues to Address #2: Calibration
Tool is VERY accurate at ranking within a sample of individuals with HIV infection in every sample studied (discrimination)
Tool is VERY accurate at estimating mortality rates within VA (calibration)
But…

25. Calibration (continued)
Observed vs. predicted mortality for a given score depends upon
Overall mortality within the sample (may be artifact due to incomplete death ascertainment in Non North American cohorts
Interval over which the mortality is predicted (short term is more accurate than long term)
Solution: Test index in SMART, NA-ACCORD, and ACTG (groups with good mortality ascertainment)

26. Research Recruitment We are planning a link for online recruitment
Idea is to create a “virtual laboratory” of VA and non-VA patients willing to help us develop the tool
This slide is incomplete. We were also discussing dissemination….[I wasn’t sure what else to put here]

27. Groups Who Might Disseminate Tool
Gay Men’s Health Crisis
ACRIA (NYC)
VA Public Health Strategic Health Care Group?
NIAAA?
NHLBI?
NA-ACCORD
ART-CC

28. Future Work Quality of decision support for Research screening
Patient education
Doctor/Patient communication
Research screening
As a template for other risk assessment tools
The possibilities are endless…
As the prototype evolves, data will be collected
Usability of the site
Research recruitment