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Mapping Community Risk: The Nashville Cardiovascular Burden Score

Integrating clinical data with social vulnerability to identify priority "hotspot" communities.

PHASE 1: CALCULATING CARDIOVASCULAR BURDEN

High Blood Pressure (HBP)

Diabetes (DIA)

Obesity (OBE)

CLINICAL DATA INTEGRATION: HBP

High prevalence areas

CLINICAL DATA INTEGRATION:

Diabetes Prevalence

CLINICAL DATA INTEGRATION:

Obesity

HBP + DIA + OBE

3

=

Cardiovascular Burden Score

Averaged clinical layers capture comprehensive risk across the community.

Metric: CVD Burden Score

Calculation: (HBP + DIA + OBE) / S

Goal: Measure clinical disease density

60%

Weight

40%

Weight

PHASE 2: THE FINAL BURDEN SCORE

Cardiovascular Burden Score

Averaged clinical layers capture comprehensive risk across the community.

Social Vulnerability Index (SVI)

Accounts for economic, housing, and transportation barriers.

PHASE 3: THE FINAL BURDEN SCORE

FINAL BURDEN SCORE

(CVD * 0.6) + (SVI * 0.4)

Weighted formula integrates

social barriers with health.

Metric: Final Burden Score

Calculation: (CVD * 0.6) + (SVI * 0.4)

Goal: integrate social barriers with health

HOTSPOT IDENTIFICATION

High Burden Areas (Top 20%)

Priority neighborhoods where health

needs and structural barriers are

most severe.

Metric: Hotspot Priority

Calculation: Top 20th Percentile

Goal: Identify areas for urgent intervention

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Source: BRFSS 2021-2022

% High Blood Pressure (2023)

Nashville, TN

3 of 16

Source: BRFSS 2021-2022

% Diabetes (2023)

Nashville, TN

4 of 16

Source: BRFSS 2021-2022

% Obesity (2023)

Nashville, TN

5 of 16

Source: (HBP+DIA+OBE)/3

Clinical Burden Score (2023)

Nashville, TN

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Source: Overall SVI score (0 to 1)

Overall SVI (2022)

Nashville, TN

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Source: CVD Burden *.6 + SVI * .4

HEART Priority Score

Nashville, TN

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Source: Areas more than 80% of FBP

High Risk Area (Top 20%)

Nashville, TN

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Mapping Community Risk: Detroit Cardiovascular Burden Score

Integrating clinical data with social vulnerability to identify priority "hotspot" communities.

PHASE 1: CALCULATING CARDIOVASCULAR BURDEN

High Blood Pressure (HBP)

Diabetes (DIA)

Obesity (OBE)

CLINICAL DATA INTEGRATION: HBP

High prevalence areas

CLINICAL DATA INTEGRATION:

Diabetes Prevalence

CLINICAL DATA INTEGRATION:

Obesity

HBP + DIA + OBE

3

=

Cardiovascular Burden Score

Averaged clinical layers capture comprehensive risk across the community.

Metric: CVD Burden Score

Calculation: (HBP + DIA + OBE) / S

Goal: Measure clinical disease density

60%

Weight

40%

Weight

PHASE 2: THE FINAL BURDEN SCORE

Cardiovascular Burden Score

Averaged clinical layers capture comprehensive risk across the community.

Social Vulnerability Index (SVI)

Accounts for economic, housing, and transportation barriers.

PHASE 3: THE FINAL BURDEN SCORE

FINAL BURDEN SCORE

(CVD * 0.6) + (SVI * 0.4)

Weighted formula integrates

social barriers with health.

Metric: Final Burden Score

Calculation: (CVD * 0.6) + (SVI * 0.4)

Goal: integrate social barriers with health

HOTSPOT IDENTIFICATION

High Burden Areas (Top 20%)

Priority neighborhoods where health

needs and structural barriers are

most severe.

Metric: Hotspot Priority

Calculation: Top 20th Percentile

Goal: Identify areas for urgent intervention

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Source: BRFSS 2021-2022

% High Blood Pressure (2023)

Detroit, MI

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Source: BRFSS 2021-2022

% Diabetes (2023)

Detroit, MI

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Source: BRFSS 2021-2022

% Obesity (2023)

Detroit, MI

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Source: (HBP+DIA+OBE)/3

Clinical Burden Score (2023)

Detroit, MI

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Source: Overall SVI score (0 to 1)

Overall SVI (2022)

Detroit, MI

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Source: CVD Burden *.6 + SVI * .4

Heart Priority Score

Detroit, MI

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Source: Areas more than 80% of FBP

High Burden Area (Top 20%)

Detroit, MI