Table 2.
Characteristics of the study population for the development of the social risk score using electronic health record data at Johns Hopkins Health System between 2016 and 2021: overall and by 2-year enrollment cohorts (all characteristics are reported based on the first year of each cohort unless otherwise indicated).
| Variables | Study cohort | Overall (N=1,852,228) | |||||
|
|
2016-2017 (n=448,666) | 2017-2018 (n=442,366) | 2018-2019 (n=450,426) | 2019-2020 (n=510,770) |
|
||
| Age (years), mean (SD) | 53.76 (17.65) | 54.63 (17.43) | 55.18 (17.25) | 55.95 (17.34) | 54.92 (17.43) | ||
| Gender (female), n (%) | 278,488 (62.07) | 274,330 (62.01) | 278,574 (61.85) | 314,741 (61.62) | 1,146,133 (61.88) | ||
| Race, n (%) | |||||||
|
|
White | 290,688 (64.79) | 285,558 (64.55) | 289,611 (64.30) | 324,279 (63.49) | 1,190,136 (64.25) | |
|
|
Black | 105,746 (23.57) | 103,879 (23.48) | 105,156 (23.35) | 118,989 (23.3) | 433,770 (23.42) | |
|
|
Other | 52,232 (11.64) | 52,929 (11.97) | 55,659 (12.35) | 67,502 (13.21) | 228,322 (12.33) | |
| Preferred language (English), n (%) | 430,331 (95.91) | 423,396 (95.71) | 430,024 (95.47) | 465,173 (91.07) | 1,748,924 (94.42) | ||
| Interpreter needed (yes), n (%) | 9,356 (2.09) | 9,715 (2.20) | 10,632 (2.36) | 12,928 (2.53) | 42,631 (2.30) | ||
| Area deprivation index national rank, mean (SD)a | 30.31 (23.6) | 29.93 (23.46) | 29.65 (23.24) | 28.76 (22.81) | 29.63 (23.27) | ||
| Health care use, n (%) | |||||||
|
|
Any in-patient admission | 39,364 (8.77) | 37,154 (8.4) | 38,407 (8.53) | 41,149 (8.06) | 156,074 (8.43) | |
|
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Any emergency department visits | 71,737 (15.99) | 69,436 (15.70) | 69,649 (15.46) | 77,308 (15.14) | 288,130 (15.56) | |
| Previous social needs, n (%) | |||||||
|
|
Year 1: ICD-10b codes | 37,137 (8.28) | 50,332 (11.38) | 52,037 (11.55) | 57,170 (10.21) | 191,693 (10.35) | |
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Year 1: EPIC Wellness Registry | 0 (0) | 0 (0) | 2 (0) | 6,663 (1.3) | 6,665 (0.36) | |
|
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Year 2: ICD-10 codes | 45,272 (10.09) | 46,587 (10.53) | 42,475 (9.43) | 42,902 (8.40) | 177,236 (9.57) | |
|
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Year 2: EPIC Wellness Registry | 0 (0) | 3 (0) | 5,596 (1.24) | 11,079 (2.17) | 16,678 (0.90) | |
| Clinical characteristics, mean (SD)c | |||||||
|
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Number of Chronic Conditions | 2.3 (2.7) | 2.4 (2.8) | 2.4 (2.8) | 2.2 (2.7) | 2.3 (2.7) | |
|
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Number of Medication Active Ingredients | 2.2 (6.1) | 2.2 (6.1) | 2.3 (6.3) | 2.1 (5.9) | 2.2 (6.1) | |
| Resource Utilization Band, n (%)c | |||||||
|
|
No or only invalid diagnosis | 2,2507 (5.02) | 20,273 (4.58) | 16,897 (3.75) | 35,288 (6.91) | 94,965 (5.13) | |
|
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Healthy users | 44,731 (9.97) | 43,408 (9.81) | 40,996 (9.1) | 53,142 (10.4) | 182,277 (9.84) | |
|
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Low resource use | 59,400 (13.24) | 55,221 (12.48) | 57,667 (12.8) | 69,566 (13.62) | 241,854 (13.06) | |
|
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Moderate resource use | 232,748 (51.88) | 231,680 (52.37) | 239,473 (53.17) | 257,424 (50.4) | 961,325 (51.9) | |
|
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High resource use | 59,979 (13.37) | 60,841 (13.75) | 62,740 (13.93) | 63,338 (12.4) | 246,898 (13.33) | |
|
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Very high resource use | 29,301 (6.53) | 30,943 (6.99) | 32,653 (7.25) | 32,012 (6.27) | 124,909 (6.74) | |
aNeighborhood characteristics for the person’s residence of the longest duration are reported as a percentile of national rank [30].
bICD-10: International Classification of Diseases, Tenth Revision.
cThese clinical measures are derived from the Johns Hopkins Adjusted Clinical Group (ACG) System version 12.0. The Resource Utilization Band represents expected future use based on current morbidities [29].