Table 2.
Demographics of included patients by psychosocial factor presence
| No PS Factors N (%) |
1+ PS Factor N (%) |
|
|---|---|---|
| Total | 55,112 (100%) | 21,367 (100%) |
| Age | ||
| 66–70 | 17,435 (31.62%) | 3,824 (17.90%) |
| 71–75 | 13,498 (24.49%) | 6,775 (31.71%) |
| 76–80 | 10,041 (18.22%) | 4,761 (22.28%) |
| 81–85 | 6,570 (11.92%) | 2,889 (13.52%) |
| 86–90 | 4,084 (7.41%) | 1,698 (7.95%) |
| 91+ | 3,494 (6.34%) | 1,420 (6.65%) |
| Race/ethnicity | ||
| American Indian/Alaska Native | 297 (.54%) | 108 (.48%) |
| Asian | 1,488 (2.7%) | 599 (2.8%) |
| Black | 639 (1.16%) | 270 (1.26%) |
| Hispanic | 1,180 (2.14%) | 449 (2.1%) |
| Multiracial | 360 (.65%) | 151 (.71%) |
| Other | 1,604 (2.91%) | 420 (1.97%) |
| Pacific Islander | 106 (.19%) | 31 (.15%) |
| White | 49,438 (89.70%) | 19,344 (90.53%) |
| Female Sex | 29844 (54.15%) | 11,807 (55.26%) |
| Psychosocial factors | ||
| Chronic Stress | N/A 0 (0%) | 15,734 (73.64%) |
| Social isolation | 0 (0%) | 559 (2.62%) |
| Housing insecurity | 0 (0%) | 4,338 (20.30%) |
| Financial insecurity | 0 (0%) | 7,117 (33.31%) |
| Baseline utilization | ||
| 1+ Hospitalization | 4,987 (9.05%) | 7281 (34.08%) |
| 1+ ED visit | 2,294 (4.2%) | 2,909 (14.38%) |
| 1+ Office Visit | 51,607 (93.64%) | 20121 (94.17%) |
| Year before baseline utilization | ||
| 1+ Hospitalization | 2,356 (4.27%) | 1,616 (7.56%) |
| 1+ ED Visit | 1,083 (1.97%) | 1,310 (6.13%) |
| 1+ Office Visit | 26,617 (48.3%) | 12,303 (57.58%) |
| Most Frequent Diagnoses | ||
| Hypertension | 14772 (27.3%) | 8434 (41.69%) |
| Cancer | 14143 (26.14%) | 7021 (34.71%) |
| Hyperlipidemia | 8189 (15.13%) | 5078 (25.10%) |
| Arthritis | 6927 (12.80%) | 4419 (21.84%) |
| Dorsopathy | 5597 (10.34%) | 3880 (19.18%) |
| Depression | 4102 (7.58%) | 3268 (16.16%) |
| Diabetes | 6730 (12.44%) | 3135 (15.5%) |
| CAD | 4031 (7.45%) | 3035 (15%) |
| Osteoporosis | 3454 (6.38%) | 2723 (13.46%) |
| Anxiety | 2500 (4.62%) | 2413 (11.93%) |
| Severe Psychiatric illness | 1960 (3.62%) | 2196 (10.86%) |
| Multimorbidity-weighted index (Mean ± SD) | 7.7±6.8 | 12.1±9.5 |
| Outcomes in Prediction Year | ||
| 1+ Hospitalization | 2285 (4.15%) | 2480 (11.61%) |
| 1+ ED visit | 1687 (3.06%) | 2052 (9.6%) |
| Death* | 902 (1.6%) | 1028 (4.8%) |
| Hospitalization, ED visit or Death | 4320 (7.8%) | 4377 (20.48%) |
*
Deaths reported to health system only.