Table 1.
Participant Characteristics
| Demographics | |
| Age (years), median [IQR] | 53.00 [33.00, 67.00] |
| Gender, n (%) | |
| Male | 13,427 (36.2) |
| Female | 23,678 (63.8) |
| Race, n (%) | |
| Black/African-American | 29,797 (80.3) |
| White | 5424 (14.6) |
| Other | 1884 (5.1) |
| Ethnicity, n (%) | |
| Hispanic or Latino | 1758 (4.7) |
| Not Hispanic or Latino | 34,871 (94.0) |
| Unknown | 476 (1.3) |
| Vital Signs, median [IQR] | |
| Systolic blood pressure, mmHg | 123.00 [110.00, 137.00] |
| Diastolic blood pressure, mmHg | 70.00 [61.00, 79.00] |
| Heart rate, beats per minute | 80.00 [71.00, 90.00] |
| BMI | 27.46 [23.19, 33.30] |
| Laboratories, median [IQR] | |
| Hemoglobin, g/dL | 10.60 [9.30, 12.10] |
| Hematocrit, % | 32.30 [28.40, 36.50] |
| Platelets, 10*3/uL | 226.00 [178.00, 287.00] |
| Sodium, mEq/L | 138.00 [136.00, 140.00] |
| Potassium, mEq/L | 4.00 [3.70, 4.30] |
| BUN, mg/dL | 13.00 [9.00, 21.00] |
| Creatinine, mg/dL | 0.90 [0.70, 1.20] |
| NT-ProBNP, pg/mL | 1535.50 [266.25, 6024.50] |
| Comorbidities, n (%) | |
| Heart Failure | 6050 (16.3) |
| Coronary Artery Disease | 5784 (15.6) |
| Atrial Fibrillation | 2786 (7.5) |
| Hypertension | 18,421 (49.6) |
| Dyslipidemia | 6731 (18.1) |
| Chronic Obstructive Pulmonary Disease | 3616 (9.7) |
| Diabetes | 8569 (23.1) |
| Valvular Heart Disease | 2692 (8.5) |
| Renal Disease | 7203 (22.8) |
| Liver Disease | 2429 (7.7) |
| Medications, n (%) | |
| Antiplatelets | 10,285 (27.7) |
| Beta Blockers | 12,233 (33.0) |
| ACE/ARB | 10,919 (29.4) |
| Aldosterone Antagonist | 1953 (5.3) |
| Loop Diuretic | 6422 (17.3) |
| Statins | 11,195 (30.2) |
| Anticoagulants | 23,080 (62.2) |
| Insulin | 9241 (24.9) |
| HOSPITAL risk score, n (%) | |
| Low risk (≤ 4) | 22,223 (71.1) |
| Intermediate risk (5, 6) | 5648 (18.1) |
| High risk (≥ 7) | 3364 (10.8) |
| Prior Health System Utilization, n (%) | |
| Number of readmissions 1 month before index | 0.18 (0.47) |
| Number of ER visits 1 month before index | 0.25 (0.66) |
| Social Vulnerability Index Components, median [IQR] | |
| Age 65 and above (% of census tract) | 13.80 [9.40, 17.30] |
| Crowding (% of census tract) | 3.00 [0.90, 5.20] |
| Disabled (% of census tract) | 14.30 [10.90, 17.80] |
| Limited English (% of census tract) | 0.60 [0.00, 2.20] |
| Minority (% of census tract) | 98.00 [89.90, 99.50] |
| Mobile home (% of census tract) | 0.00 [0.00, 0.00] |
| No high school diploma (% of census tract) | 13.90 [9.90, 19.80] |
| No vehicle (% of census tract) | 34.80 [24.50, 43.00] |
| Per capita income ($) | 19,064.00 [14,715.00, 25,467.00] |
| Poverty (% of census tract) | 30.00 [19.90, 39.30] |
| Single parent household (% of census tract) | 15.20 [9.70, 20.80] |
| Unemployment (% of census tract) | 19.20 [12.20, 25.90] |
| Hardship Index Components, median [IQR] | |
| Crowding (% of census tract) | 3.30 [2.40, 4.00] |
| Poverty (% of census tract) | 29.00 [19.20, 30.70] |
| Aged 16+ and unemployed (% of census tract) | 20.30 [15.70, 24.00] |
| Aged 25+ and no high school diploma (% of census tract) | 16.50 [14.00, 21.00] |
| Aged under 18 and over 64 (% of census tract) | 39.50 [35.70, 41.10] |
| Per capita income ($) | 18,672.00 [16,563.00, 23,791.00] |
| Neighborhood cluster type, n (%) | |
| Rural Affordable | 2516 (6.8) |
| Vibrant Urban Core | 1502 (4.0) |
| Suburban Affordable | 941 (2.5) |
| Extreme Poverty | 23,461 (63.2) |
| Multilingual Working | 1276 (3.4) |
| Suburban Affluent | 7409 (20.0) |
| Violent crime rate (% of census tract) | 48.87 [25.55, 71.76] |
| Area Deprivation Index Score | 7.00 [5.00, 9.00] |