10 Ways To Empower Patients Using Medical Risk Calculators That Doctors Actually Use

Have you ever wondered your risk for having a heart attack, or a blood clot, or even a brain bleed after a head injury? These questions languish in our minds until we can’t take it any longer and end up heading to the doctor to be checked. But what if there was an answer to this question? What if you did know the general risk of having a medical condition?

Doctors have used decision rules for a number of years. In fact, there is a website called MDCalc that combines these decision rules into easy algorithms to help doctors understand the risk and appropriately counsel patients.

I have always wondered whether patients could use a site like MDCalc to assess their own risk and reassure themselves about their condition.

Don’t get me wrong. I’m not advocating to forgo seeing your doctor or going to the emergency department when you think there could be something seriously wrong with you or your child.

However, I also believe patients have the right to understand their own risk by using these same decision rules to help them make informed decisions about their care.

In a doctor’s office or emergency department, this would fall under the category of shared decision-making. The doctor informs the patient of their risk and the patient shares the responsibility of making decisions about their care.

Some of these decision rules are fairly straight forward and don’t take a rocket scientist (or medical specialist) to understand. Some are a little more complicated.

Let’s look at some of the best rules out there to give you a new understanding of your risk for some major problems and some simpler issues. This is a potpourri guide to show you a number of real world applications that can help inform you. You will learn about your risk of:

1. Heart Attack
2. Blood Clot
3. Brain Bleed After Trauma
4. Broken Neck After Trauma
5. Broken Knee or Ankle After Trauma
6. Strep Throat
7. Appendicitis
8. Type 2 Diabetes
9. Breast Cancer
10. Pain Medicine Misuse

Some of the decision aids require information that you may not have such as blood tests. When this is the case, the rule can help inform you of general risk but would require the tests in a doctor’s office or ER if you are worried enough for that condition.

As you will see, many of these decision aids are ones you can use at home and can certainly help reassure you or give you cause to seek out your physician for further evaluation.

#1 Risk Of Heart Attack

Framingham Risk Score

If you’re looking for a simple score to help you understand your risk for having a heart attack in the next 10 years, the Framingham Coronary Heart Disease Risk Score is one of the best.

This score was developed looking at patients over a lifetime starting in the 1940s and continues today. It takes into account:

• Age
• Gender
• Smoking history
• Cholesterol (can be obtained by blood work with doctor’s order)
• blood pressure

This is easy to do at home on this calculator and gives a percentage score for risk of heart attack or death within 10 years. Needless to say, if your percentage is higher, you should talk with a doctor regarding how to modify your lifestyle to improve your risk.

Remember, if your risk is 10%, that means 10 out of every 100 people with your risk factors could have a heart attack or die in the next 10 years. That’s a considerable amount and there are many things you can do to decrease this risk.

Reynold’s Risk Score

If you’re a woman over 45 years old, the Reynold’s Risk Score can be useful in determining your risk for heart disease.

It is well known in medicine that a woman’s risk can be more difficult to ascertain when it comes to heart disease. We also know that women present atypically when they are having a heart attack so it is sometimes difficult to pick up by story or physical exam.

This risk score does incorporate an extra blood test known as a C-reactive protein, which measures inflammation in the body. This can be obtained with a doctor’s order as well as cholesterol testing.

Not only does this calculator measure for heart risk but also gives you an estimate of stroke risk in the next 10 years. Again, using this score as a measure of your risk can help you find ways to modify your lifestyle to decrease your danger of serious disease.

HEART Score and EDACS

The HEART score and Emergency Department Assessment Of Chest Pain Score (EDACS) are similar in that they are both intended to tell you your risk of a major heart event like a heart attack within 30 days after presenting to the emergency department with chest pain.

If you have chest pain and are concerned about a serious condition, you should certainly go directly to the ER. These scores are meant to help inform you of your risk for serious disease as many causes of chest pain are not dangerous.

Both of these scores ultimately require an EKG and a blood test known as a troponin (a heart enzyme that determines whether there is injury to the heart). This generally can only be done in the ER or a doctor’s office.

For home, probably the best of these two tests to understand your overall risk is the EDACS. This incorporates the following elements, which add or subtract points to get a final score:

• Age
• Gender
• Known heart disease or 3 or more risk factors (previous heart attack, bypass surgery, heart stent, family history of early heart disease, high blood pressure, high cholesterol, diabetes, or a current smoker)
• Sweating with pain
• Movement of pain to the arm, shoulder, neck, or jaw
• Worse pain when breathing in (makes heart attack less likely)
• Can cause pain by pressing on the chest (makes heart attack less likely)

If you have chest pain and your risk is high without even doing an EKG or troponin blood test, then you should be more concerned and go to the ER immediately.

For more information regarding chest pain risk, you can read the article Is That Chest Pain Serious? Tools To Help You Decide When You Should Worry.

#2 Risk Of Blood Clot

Wells’ Score

The Wells’ score was created to help determine risk of having a blood clot. There are two scores, one for a blood clot in the leg (DVT) and one for a blood clot in the lungs (PE). Symptoms that might prompt someone to think they have a blood clot could be pain or swelling in an arm or leg, shortness of breath, or chest pain. The medical calculator at MDCalc can help you see your score and risk based on the following factors.

Criteria for blood clot in the leg:

• Current Cancer
• Bedridden for more than 3 days or surgery within the past 4 weeks
• Calf swelling more than 3cm compared to the other leg
• More prominent veins showing on the skin
• Complete leg swelling
• Tenderness
• Recent paralysis or immobilization of a leg
• Previous history of blood clot
• A different diagnosis is more likely

Criteria for blood clot in the lung:

• Symptoms of blood clot in the leg or arm
• Blood clot looks to be most probable diagnosis
• Heart rate greater than 100
• Bedridden for more than 3 days or surgery within the past 4 weeks
• Previous blood clot
• Coughing up blood
• Treated cancer within 6 months

Use the calculators above to assess your risk.

Pulmonary Embolism Rule Out Criteria (PERC)

If you are worried about having a blood clot in the lung, the PERC rule is probably one of the best. Unfortunately you need to know an oxygen saturation percentage, which is usually available in the doctor’s office, or certainly in an ER. But you can get the idea of whether or not your risk may be lower or higher by using this criteria.

• Age 50 and over
• Heart rate greater than 100
• Oxygen saturation less than 95%
• Swelling in one leg (not both)
• Coughing up blood
• Recent surgery or trauma within 4 weeks
• Hormone use (such as birth control pill or other estrogen use)

If you are interested in learning more about risk when experiencing chest pain or shortness of breath, this article can inform you of a number of risk factors and tools.

#3 Risk Of Brain Bleed After Trauma

PECARN Pediatric Head Injury Algorithm

These are simple rules that give a lot of information to determine whether your child may have a potential serious injury.

Kids younger than 2 years old

Your kid should be evaluated by a physician if:

• They are persistently confused or not acting like themself.
• You think their skull bone may be broken (generally a soft boggy spot on the head).
• They lost consciousness (passed out) for more than 5 seconds.
• They have a large bump (goose egg) anywhere other than their forehead – the forehead is generally ok and normally not anything to worry about.
• The cause of the head injury was high impact like a fall from considerable height (general rule of thumb is greater than 3 feet) or a high speed car accident.

Kids older than 2 years old

Your kid should be evaluated by a physician if:

• They are persistently confused or not acting like themself.
• You think their skull bone may be broken (severe bruising on the skull, around the eyes, or behind the ears, or significant bleeding).
• They lost consciousness (passed out) for any time period.
• They have any vomiting.
• They have a severe headache.
• The cause of the head injury was high impact like a fall from considerable height (general rule of thumb is greater than 3 feet) or a high speed car accident.

Certainly if you are concerned or there is any doubt about whether your child could have a more serious injury, they should be taken to the closest ER for evaluation. If you are interested in more information about this topic, you can read this article for more information.

Canadian Head CT Rules

This rule was created to help doctors decide whether a CAT (CT) scan of the head is needed after an injury to the head in adults. Needless to say, if a CT scan is not needed then the risk of a serious injury is low. Here are the criteria:

• Persistent confusion 2 hours after the injury
• Suspected broken skull bone
• Bruising around the eye, behind the ear, blood coming from the ear, or new significant nasal drainage
• 2 or more episodes of vomiting
• Age 65 and older
• No memory of the event and up to 30 minutes before the event
• High impact injury such as a high speed car accident or fall from a considerable height (like from a ladder)

Using the calculator on MDCalc, you will see whether or not a CT is recommended and thus your risk for serious head injury.

#4 Risk Of Broken Neck After Trauma

NEXUS criteria

Whiplash is extremely common after a car accident. Most of these injuries are simple strains that will resolve on their own. But how do you know whether the injury is just a strain or more serious like a spine fracture. The NEXUS criteria helps physicians to decide whether testing is required and can show you your risk. If you have any of the criteria listed, then an x-ray or CAT could be warranted and you should go to the ER. Here are the criteria:

• Neurological symptom like weakness, numbness, or tingling
• Tenderness in the middle of the back of the neck (not the muscles on the side)
• Confusion
• Intoxication (alcohol or drugs)
• Another serious injury is present (such as a broken arm or leg)

If none are present, the likelihood is that you have simple whiplash. This should improve within a couple of weeks.

Canadian C-Spine Rule

This is another simple rule you can follow to decide whether your neck injury is more serious. It is fairly simple. If you answer yes to any of these questions, then you should seek care immediately. Otherwise, the chances of serious injury are less likely.

• Are you 65 years or older, have tingling in the arms or legs, or was it a high impact accident?
• Are you unable to sit, walk, did your neck pain occur immediately, or is there any pain in the center of the back of the neck?
• Are you unable to rotate your neck fully to the left and to the right?

#5 Risk of Broken Knee or Ankle After Trauma

Have you ever injured your knee or twisted your ankle and you wondered whether it was just a sprain or whether it was broken? I have friends and family call all of the time asking whether they should go get an x-ray right away. Luckily, many of these injuries turn out to be minor. And there are actually some really good rules to help you decide whether you need to get an x-ray at all.

Ottawa Knee

If any of the following answers are yes, then an x-ray could be indicated. Otherwise, waiting to see if there is improvement over the next week or so is certainly an appropriate plan.

• Are you age 55 or older?
• Is there pain right over the kneecap when pressed on? (Point A above)
• Is there pain over the right side lower part of your right knee or left side lower part of your left knee when pressed on? (Point B above)
• Are you unable to bend (flex) your knee more than 90 degrees?
• Are you unable to put weight on the knee (limping is ok)?

I would add, if the knee looks funny (we call that deformed in medicine), this should be an indication to seek care and get an immediate x-ray.

Ottawa Ankle

This rule is similar to the knee and determines whether an x-ray is needed of the ankle or foot. The criteria are based on pain when pressing over certain parts of the ankle. The malleolus is the bone that sticks out on the both sides of the ankle.

Ankle x-ray is necessary if:

• There is pain at point A OR point B
• OR the patient cannot put any weight on that ankle either immediately after the injury or currently

Foot x-ray is necessary if:

• There is pain at point C OR point B
• OR the patient cannot put any weight on that foot either immediately after the injury or currently

#6 Risk Of Strep Throat

Centor Criteria

The Centor criteria have been around for many years and give a pretty good prediction for whether you or your child may have strep throat or whether the sore throat is just a virus that unfortunately takes time to resolve. Generally 2 or more points would prompt at least a rapid strep test to be considered. If 1 point or less, then it is unlikely you have strep throat.

I do have a couple of caveats. First, if you have a friend or family member that has confirmed strep throat (that means a positive rapid strep test or throat culture that shows strep throat), then I believe your risk is likely higher.

Also, my experience has been that if someone has a cough (part of the centor criteria), this is likely to be a virus. Strep throat does not cause cough-like symptoms.

So here are the criteria:

• Age 3-14 years (+1 point)
• Age 15-44 years (0 points)
• Age 45 and older (-1 point)
• White material on tonsils (+1 point)
• Neck lymph nodes under the jaw are swollen (+1 point)
• Temperature over 100.4 degrees F (+1 point)
• No cough (+1 point)

#7 Risk Of Appendicitis

Alvarado Score

Appendicitis is one of the biggest fears when it comes to abdominal pain. Just because the pain is in the right lower area of the abdomen doesn’t mean it’s appendicitis. There are a lot of causes including basic indigestion. But there is a score for this condition as well. The score does incorporate a blood test, which makes it difficult to do at home. But it also incorporates other symptoms of appendicitis that can help you understand your risk better. The elements of the score are as follows:

• Right lower abdominal pain
• Temperature above 99.1 degrees F
• Rebound tenderness (this is pain after you lift up from pressing on the abdomen)
• Pain that started further up in the abdomen (like around the belly button), and over time travelled down to the right lower abdomen.
• Not hungry
• Nausea or vomiting

You can plug in values on the calculator to see your risk but around 5 points or higher starts to increase your risk. This is a great tool to help you decide whether to seek help or not.

#8 Risk of Type 2 Diabetes

Type 2 diabetes is not the type you are born with. This is the type of high blood sugar that you can acquire later in life and there are a number of risk factors associated with developing this condition. Diabetes can cause a lot of long term problems for patients, so understanding your risk now and anything you can do to help with prevention is key. Here are 2 scores that can help predict your risk. If you score high, it would be advisable to see your doctor and be screened for diabetes. If you have a normal blood sugar level, there are a number of lifestyle changes you can make to help prevent yourself from acquiring the condition.

Cambridge Diabetes Risk Score

This score is used to determine whether you could have type 2 diabetes right now based on the following criteria:

• Gender
• On blood pressure medication
• On steroids (i.e. prednisone)
• Age
• Body Mass Index (BMI)
• Family history of diabetes
• Smoking history

This calculator will help you determine your risk.

Finnish Diabetes Risk Score (FINDRISC)

This score identifies patients at high risk for diabetes based on the following criteria:

• Gender
• Age
• Body Mass Index (BMI)
• Use of blood pressure medication
• History of high blood sugar
• Physical activity more or less than 4 hours per week
• Daily consumption of vegetables, fruits, or berries
• Family history of diabetes

This calculator will help you determine your risk.

#9 Risk of Breast Cancer

Gail Model For Breast Cancer Risk

Early identification is very helpful to prevent the spread of the cancer and can improve prognosis. The Gail Model uses a number of criteria to help you understand whether you could be at high risk for breast cancer. The criteria include:

• Age (valid for women 35-80 years old)
• First menstrual period (ages 7-11, 12-13, or over 13)
• Age of first live birth
• First degree relatives with breast cancer
• Previous breast biopsy
• Race/ethnicity

If you are concerned about your chances of having breast cancer or just want to know your risk, this calculator will give you your 5 year and lifetime risk of getting breast cancer.

#10 Risk Of Pain Medicine Abuse

Do you have chronic pain? Are you on opiate medications to control your pain? There is a risk tool that physicians can now use to help identify patients at high risk for misuse (abuse) of these medications.

Now I understand there has become a stigma with patients who are on chronic opiate medications. Many people get labeled “drug seekers” before they’ve even had a chance to explain. There is likely a place for opiate medications in the treatment of chronic pain. I am not here to support or refute this.

However, even if opiate medications have helped you, there can always be a point when a different treatment might be more beneficial. This tool can help and pain specialists around the world have this in their arsenal to discuss with their patients. Now you can have it too.

Opioid Risk Tool For Narcotic Misuse (ORT)

The ORT was created to help identify chronic pain patients at high risk for misuse, and who might benefit more from other modalities of pain control besides narcotics. The criteria ask questions.

• Are you age 16-45?
• Were you abused before puberty?
• Do you have history of depression?
• Do you have history of ADD, OCD, bipolar disorder, or schizophrenia?
• Is there personal history of alcohol abuse?
• Is there personal history of illegal drug abuse?
• Is there personal history of prescription drug abuse?
• Is there family history of alcohol abuse?
• Is there family history of illegal drug abuse?
• Is there family history of prescription drug abuse?

Low risk is 3 points or less. Moderate risk is 4-7 points. And High risk is 8 points and above. Certain questions are higher point values so your best best is to use the calculator to find out your risk. If you are concerned that you may need to stop using opiates, this is a great tool to start with and something you can discuss with your doctor.

Conclusion

There are a number of risk tools available to doctors. They are based on research and have been very helpful to decrease the number of tests we order and the cost of care for patients. Patients have the right to be informed and I hope that this article helps you understand a number of these tools to give you more information about your health.

 

Should patients be able to use these risk calculators? Does this help inform you about your medical risk? Comment below.