Risk calculators—methods,development, implementation,and validation

Introduction

A surgical risk calculator (SRC) estimates the probabilities of unfavorable outcomes such as complications or death after a specific surgery. The risk estimates are based on information regarding the patient’s medical history and his current status. They are calculated using risk models derived from the analysis of data from a large number of previous patients in a similar clinical situation.

Methods

This paper discusses several aspects of the SRC development and its implementation into clinical practice: the development of the statistical risk models, their validation and software implementation, the use of the SRC output for shared decision making in clinical settings, and the evaluation of the SRC’s impact on individual patient outcomes as well as on the institution’s quality of care of the clinical institution.

Results

Probably the most elaborate SRC is the ACS NSQIP SRC. A comparable project was started by the German Society for Visceral and General Surgery (DGAV) in the framework of its Study, Documentation, and Quality Center (StuDoQ). It is relevant to consider that the transportability of a SRC from a US American to a German setting is not straightforward.

Conclusions

Risk calculators are important instruments for shared decision making between patients and doctor. Their implementation into clinical practice has to solve technical issues, and it is related to appropriate training of clinicians. There are specific study designs to evaluate the clinical impact of a SCR.

     

Maternal HIV Serostatus, Mother–Daughter Sexual Risk Communication and Adolescent HIV Risk Beliefs and Intentions

Daughters of HIV-positive women are often exposed to the same factors that placed their mothers at risk. This cross-sectional study (N = 176 dyads) examined HIV status, parent-teen sexual risk communication (PTSRC), and daughters’ abstinence and condom use beliefs and intentions. Maternal HIV status was not associated with PTSRC. Path analyses show that maternal depression was associated with PTSRC behavioral and normative beliefs; relationship satisfaction was associated with PTSRC normative and control beliefs. Control beliefs were solely predictive of maternal PTSRC intention. PTSRC was associated with adolescent behavioral and normative beliefs. Abstinence beliefs were associated with abstinence intentions; condom beliefs were associated with condom use intentions. Relationship satisfaction was associated with adolescent control beliefs about both abstinence and condom use. There is a need for interventions that help HIV-positive mothers recognize their daughter’s HIV risk and provide them with relationship building and parent process skills to help reduce these risks.     

Metabolic Syndrome and Heart Failure—The Risk,Paradox, and Treatment

The constellation of obesity, hypertension, dyslipidemia, and insulin resistance—together referred to as metabolic syndrome (MetS)—is increasing in prevalence in the American population and also worldwide. The individual components of MetS and MetS as a whole increase the risk of heart failure, cardiovascular mortality, and all-cause mortality. Despite this adverse association, numerous studies have documented an obesity paradox, in which overweight and obese people with established cardiovascular disease, including hypertension, coronary heart disease, heart failure, and peripheral arterial disease, have a better prognosis than patients who are not overweight or obese. Current treatment strategies for these patients include weight loss, control of blood pressure and cholesterol levels, and treatment of hyperglycemia. Because of increasing evidence for the obesity paradox, some physicians question whether obesity should be treated when it is associated with heart failure. Several studies have shown improvement in left ventricular function and decreased mortality and morbidity from heart failure with weight loss and treatment of elevated blood pressure, cholesterol, and hyperglycemia. The most reasonable approach at this time appears to be weight loss and exercise, lowering blood pressure to less than 130/80 mm Hg, low-density lipoprotein (LDL) cholesterol to less than 100 mg/dL, and glycosylated hemoglobin levels to less than 7%.     

Small,dense low-density lipoprotein: Risk or myth?

Based on the particle diameter of the major subpopulation of low-density lipoprotein (LDL) in plasma, an individual may be classified either as having phenotype A (desirable phenotype; large, buoyant LDL) or phenotype B (high risk; small, dense LDL). This article reviews the clinical significance of LDL particle diameter determination and proposes a strategy for incorporating this information in the new guidelines of the National Cholesterol Education Program’s Adult Treatment Panel III.     

Motivated Reasoning and HIV Risk? Views on Relationships,Trust, and Risk from Young Women in Cape Town,South Africa,and Implications for Oral PrEP

In high prevalence environments relationship characteristics are likely to be associated with HIV risk, yet evidence indicates general underestimation of risk. Furthermore uncertainty about partner‘s risk may challenge PrEP demand among young African women. We conducted quantitative and qualitative interviews with women before and after HIV discussions with partners, to explore how partner’s behavior affected risk perceptions and interest in PrEP. Twenty-three women were interviewed once; twelve had a follow-up interview after speaking to their partners. Fourteen women were willing to have their partner contacted; yet two men participated. Several themes related to relationships and risk were identified. These highlighted that young women’s romantic feelings and expectations influenced their perceptions of risk within their relationships, consistent with the concept of motivated reasoning. Findings emphasize challenges in using risk to promote HIV prevention among young women. Framing PrEP in a positive empowering way that avoids linking it to relationship risk may ultimately encourage greater uptake.     

Fibromyalgia and Risk of Dementia—A Nationwide,Population-Based,Cohort Study

Background

Fibromyalgia is a syndrome of chronic pain and other symptoms and is associated with patient discomfort and other diseases. This nationwide matched-cohort population-based study aimed to investigate the association between fibromyalgia and the risk of developing dementia, and to clarify the association between fibromyalgia and dementia.

Scaling Sexual Behavior or “Sexual Risk Propensity” Among Men at Risk for HIV in Kisumu,Kenya

We present a scale to measure sexual risk behavior or “sexual risk propensity” to evaluate risk compensation among men engaged in a randomized clinical trial of male circumcision. This statistical approach can be used to represent each respondent’s level of sexual risk behavior as the sum of his responses on multiple dichotomous and rating scale (i.e. ordinal) items. This summary “score” can be used to summarize information on many sexual behaviors or to evaluate changes in sexual behavior with respect to an intervention. Our 18 item scale demonstrated very good reliability (Cronbach’s alpha of 0.87) and produced a logical, unidimensional continuum to represent sexual risk behavior. We found no evidence of differential item function at different time points (except for reporting a concurrent partners when comparing 6 and 12 month follow-up visits) or with respect to the language with which the instrument was administered. Further, we established criterion validity by demonstrating a statistically significant association between the risk scale and the acquisition of incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV at the 12 month follow-up visits. This method has broad applicability to evaluate sexual risk behavior in the context of other HIV and STI prevention interventions (e.g. microbicide or vaccine trials), or in response to treatment provision (e.g., anti-retroviral therapy).     

Endoscopy in GERD: Boondoggle, Diagnostic Test, or Risk Management Tool?

The role of endoscopy in reflux disease is debated. Diagnostic certainty is attractive to patients and physicians, to affirm health and to ensure the absence of serious disease, but it is expensive and the majority of patients will have no endoscopic abnormalities. Empirical treatment with acid suppression in patients with symptoms of gastroesophageal reflux disease (GERD) is now widely practiced in primary care in many countries but in others, endoscopy is mandatory to receive approval from the payors for proton pump inhibitor therapy. In patients with dysphagia, endoscopy has a role in ruling out an obstructing lesion. A "once-in-a-lifetime" endoscopy has been proposed as a way to improve our ability to diagnose Barrett's esophagus, but cost-models suggest that this strategy is not cost-effective if current surveillance guidelines are followed after the diagnosis of Barrett's esophagus is made. The role of routine endoscopic examination in GERD is therefore questionable and needs better definition in carefully designed trials.     

Lipids,Lipoproteins, and Metabolites and Risk of Myocardial Infarction and Stroke

Background

Blood lipids are established risk factors for myocardial infarction (MI), but uncertainty persists about the relevance of lipids, lipoprotein particles, and circulating metabolites for MI and stroke subtypes.

Risk of fracture in celiac disease： Gender,dietary compliance,or both？

AIM:To determine the incidence of peripheral fractures in patients with celiac disease (CD) and the effect of treatment on fracture risk.METHODS:We compared the incidence and risk of peripheral fractures before and after diagnosis between a cohort of 265 patients who had been diagnosed with CD at least 5 years before study entry and a cohort of 530 age-and sex-matched controls who had been diagnosed with functional gastrointestinal disorders.Data were collected through in-person interviews with an investiga...