Table 1.

Comparison of the patient- and population-level data sets that were used for each phase.

Feature type	Phase 1	Added in phase 2
Demographics	Age, ethnicity, and gender	Insurance (Medicare, Medicaid, self-pay)
Weight and nutrition	None	BMI, hemoglobin A1c
Encounter frequency	Outpatient visits, emergency department encounters, and inpatient admissions	None
Chronic conditions	20 most common chronic conditions [18]	None
Addictions and narcotics use	Tobacco and opioid use	Alcohol abuse, opioid overdose, use disorders
Medications	None	145 categories of medication (categorized by therapeutic and pharmaceutical codes) [19]
Patient-level social risk	None	12 patient-level measures [20]
Population-level social determinants of health	48 social determinants of health measures [11]	60 social determinants of health measures [20]