Table 3.
Generalized estimating equation model predicting prospective social needs for patients at Johns Hopkins Health System using electronic health record data between 2016 and 2021: overall model and models for selected subpopulations.
| Variable | Overall Population | Population aged ≥65 years | Racial groups | Neighborhood characteristics | ||||
|
|
|
|
White | Black | Most disadvantaged | Least disadvantaged | ||
| Area under the curve (95% CI) | 0.702 (0.699-0.705) | 0.701 (0.696-0.706) | 0.689 (0.685-0.693) | 0.711 (0.706-0.716) | 0.711 (0.708-0.714) | 0.667 (0.663-0.677) | ||
| Age (years), ORa (95% CI) | 0.994 (0.993-0.994) | 1.002 (1.001-1.004) | 0.994 (0.994-0.995) | 0.993 (0.992-0.994) | 0.991 (0.991-0.992) | 1.002 (1.001-1.002) | ||
| Gender (male; reference: female), OR (95% CI) | 0.993 (0.981-1.004) | 0.922 (0.903-0.941) | 0.964 (0.95-0.979) | 1.068 (1.046-1.092) | 1.004 (0.991-1.017) | 0.952 (0.927-0.977) | ||
| Race (Black; reference: White), OR (95% CI) | 1.125 (1.11-1.141) | 1.149 (1.118-1.182) | —b | — | 1.127 (1.111-1.144) | 1.137 (1.087-1.190) | ||
| Preferred language (English; reference: missing, others, or sign language), OR (95% CI) | 1.061 (1.026-1.097) | 1.293 (1.221-1.371) | 1.034 (0.991-1.08) | 1.112 (1.043-1.187) | 1.030 (0.993-1.069) | 1.217 (1.125-1.317) | ||
| Interpreter needed (yes; reference: no or missing), OR (95% CI) | 1.179 (1.122-1.238) | 1.266 (1.156-1.386) | 1.006 (0.908-1.114) | 0.816 (0.679-0.981) | 1.148 (1.089-1.211) | 1.085 (0.944-1.247) | ||
| Area deprivation index national rank (percentile), OR (95% CI)c | 1.005 (1.005-1.005) | 1.001 (1.001-1.002) | 1.003 (1.003-1.004) | 1.007 (1.006-1.007) | 1.006 (1.006-1.006) | 0.983 (0.979-0.988) | ||
| Health care use, OR (95% CI) | ||||||||
|
|
Any in-patient admission | 1.017 (0.993-1.042) | 1.077 (1.03-1.126) | 1.064 (1.03-1.1) | 0.987 (0.947-1.029) | 0.986 (0.960-1.013) | 1.131 (1.071-1.194) | |
|
|
Any emergency department visits | 1.659 (1.634-1.684) | 1.539 (1.495-1.584) | 1.691 (1.656-1.728) | 1.627 (1.587-1.668) | 1.636 (1.608-1.664) | 1.555 (1.503-1.608) | |
| Previous social needs, OR (95% CI) | 3.285 (3.237-3.335) | 3.043 (2.96-3.128) | 3.459 (3.391-3.529) | 2.9 (2.824-2.977) | 3.390 (3.334-3.447) | 2.775 (2.677-2.877) | ||
| Clinical characteristics, OR (95% CI)d | ||||||||
|
|
Number of chronic conditions | 1.066 (1.064-1.069) | 1.08 (1.07-1.08) | 1.070 (1.067-1.074) | 1.063 (1.058-1.068) | 1.070 (1.067-1.073) | 1.066 (1.058-1.073) | |
|
|
Number of medication active ingredients | 0.997 (0.996-0.998) | 0.99 (0.99-1.00) | 0.997 (0.995-0.998) | 0.997 (0.995-0.999) | 0.996 (0.995-0.997) | 1.001 (0.999-1.004) | |
| Resource Utilization Band (reference: no or only invalid diagnosis), OR (95% CI)d | ||||||||
|
|
Healthy users | 0.838 (0.808-0.869) | 0.792 (0.734-0.854) | 0.836 (0.798-0.876) | 0.785 (0.729-0.844) | 0.837 (0.802-0.872) | 0.787 (0.729-0.850) | |
|
|
Low resource use | 0.855 (0.826-0.885) | 0.837 (0.778-0.9) | 0.856 (0.819-0.895) | 0.846 (0.792-0.904) | 0.849 (0.816-0.882) | 0.847 (0.787-0.911) | |
|
|
Moderate resource use | 0.964 (0.935-0.994) | 0.935 (0.876-0.997) | 0.942 (0.906-0.981) | 1.008 (0.952-1.069) | 0.978 (0.945-1.012) | 0.908 (0.848-0.972) | |
|
|
High resource use | 1.259 (1.217-1.302) | 1.226 (1.144-1.314) | 1.238 (1.184-1.294) | 1.328 (1.246-1.415) | 1.285 (1.238-1.335) | 1.113 (1.030-1.204) | |
|
|
Very high resource use | 1.371 (1.317-1.427) | 1.218 (1.128-1.315) | 1.291 (1.225-1.361) | 1.514 (1.408-1.629) | 1.420 (1.359-1.485) | 1.136 (1.034-1.249) | |
aOR: odds ratio.
bNot available.
cNeighborhood characteristics for the person’s residence of longest duration are reported as a percentile of national rank [30].
dThese 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].