Table 4.

Pre-specified models with conditions and psychosocial vital signs

Individual	I.2 Diabetes		I.3 ASCVD		I.4 Depression		I.5 Substance Use
	Hospitalization	ED	Hospitalization	ED	Hospitalization	ED	Hospitalization	ED
C-statistic	0.6	0.6	0.63	0.66	0.53	0.56	0.55	0.56
Condition	Diabetes		ASCVD		Depression		Substance Use
Condition result	2.54 (2.31–2.79) *	2.80 (2.53–3.1) *	2.45 (2.29–2.62)	2.85 (2.66–3.06) *	2.59 (2.02–3.33) *	2.49 (1.93–3.22) *	3.1 (2.82–3.41) *	3.18 (2.88–3.52) *
PS Factors	1. Housing, 2. Financial		Chronic Stress		Social isolation		Housing
PS Result 1	2.18 (2.01–2.36) *	1.67 (1.52–1.84) *	1.96 (1.82–2.1) *	2.24 (2.08–2.42) *	1.52 (1.39–1.67) *	2.4 (2.2–2.62) *	1.76 (1.5–2.07) *	2.65 (2.28–3.08) *
PS Result 2	1.52 (1.41–1.64) *	1.73 (1.60–1.99) *
Full: Likelihood Ratio	720.6 (19)	730.3 (19)	674.7 (21)	782.0 (21)	359.2 (21)	542.2 (21)	105.2 (21)	213.6 (21)
C-stat	0.76	0.77	0.71	0.76	0.73	0.74	0.73	0.79
Hosmer-Lemeshow p	<.0001	<.0001	0.0683	<.0001	0.003	0.067	0.09	0.06
Homelessness	1.63 (1.3–2.03) *	1.48 (1.16–1.89) *	1.39 (1.16–1.66) *	1.59 (1.41–1.79) *	1.43 (1.11–1.84) *	1.17 (0.91–1.5)	1.41 (0.92–2.16)	1.2 (0.78–1.85)
Social isolation			1.01 (0.65–1.57)	1.25 (0.93–1.67)	1.27 (0.85–1.9)	1.02 (0.68–1.53)	1.22 (0.5–2.99)	1.12 (0.45–2.79)
Chronic Stress			1.68 (1.48–1.92) *	2.08 (1.92–2.26) *	1.5 (1.24–1.81) *	1.86 (1.56–2.22) *	1.68 (1.18–2.4) *	1.27 (0.89–1.81)
Financial insecurity	1.74 (1.43–2.11) *	1.49 (1.19–1.85) *	1.24 (1.05–1.46) *	1.18 (1.06–1.32) *	1.48 (1.18–1.85) *	1.2 (0.96–1.5)	0.66 (0.42–1.04)	1.05 (0.68–1.62)
Age (ref 66–70)
71–75	0.83 (0.68–1.02)	0.82 (0.66–1.02)	0.96 (0.8–1.15) *	0.76 (0.69–0.84) *	0.88 (0.7–1.11)	0.75 (0.6–0.94) *	1.1 (0.74–1.63)	0.57 (0.37–0.88) *
76–80	0.99 (0.8–1.23)	0.85 (0.67–1.08)	0.9 (0.74–1.09) *	0.78 (0.7–0.87) *	0.74 (0.56–0.98) *	0.9 (0.7–1.15)	0.75 (0.43–1.3)	0.6 (0.35–1.03)
81–85	1.1 (0.86–1.4)	0.93 (0.72–1.22)	0.91 (0.74–1.12)	0.88 (0.78–0.99) *	1.07 (0.79–1.45)	0.96 (0.72–1.29)	0.52 (0.25–1.08)	0.96 (0.54–1.7)
86–90	0.88 (0.63–1.21)	1.13 (0.82–1.56)	0.75 (0.59–0.96) *	1.21 (1.06–1.38) *	1.13 (0.78–1.64)	1.43 (1.03–1.99) *	0.99 (0.43–2.29)	1.61 (0.8–3.24)
91+	1.29 (0.93–1.79)	1.32 (0.94–1.85)	0.88 (0.69–1.13)	1.43 (1.24–1.64) *	1.03 (0.68–1.56)	1.1 (0.75–1.61)	0.81 (0.27–2.4)	1.64 (0.72–3.74)
Race/ethnicity (ref White)
Native American	0.81 (0.36–1.83)	0.37 (0.11–1.23)	0.92 (0.43–1.98)	0.84 (0.51–1.4)	0.77 (0.23–2.59)	0.16 (0.02–1.25)	0.54 (0.07–4.44)	n/a
Asian	0.71 (0.46–1.08)	0.9 (0.59–1.36)	1.27 (0.89–1.81)	1.05 (0.84–1.3)	0.71 (0.37–1.37)	1.07 (0.63–1.82)	n/a	2.56 (0.53–12.32)
Black	0.91 (0.55–1.51)	1.49 (0.94–2.37)	1.25 (0.81–1.92)	1.76 (1.36–2.27) *	1.29 (0.67–2.48)	1.35 (0.72–2.53)	1 (0.4–2.47)	3.08 (1.51–6.31) *
Hispanic	0.98 (0.68–1.4)	1.34 (0.94–1.9)	1.15 (0.77–1.7)	1.33 (1.07–1.65) *	1.05 (0.58–1.89)	1.18 (0.69–2)	0.25 (0.03–1.95)	0.55 (0.12–2.42)
Multiracial	0.82 (0.38–1.77)	1.42 (0.71–2.88)	1.01 (0.51–1.99)	1.08 (0.71–1.62)	0.6 (0.21–1.76)	1.04 (0.43–2.49)	0.83 (0.18–3.74)	0.76 (0.18–3.35)
Pacific Islander	1.22 (0.46–3.26)	1.13 (0.38–3.33)	1.57 (0.58–4.26)	1.26 (0.59–2.69)	2.45 (0.29–20.47)	2.24 (0.27–18.8)	15.38 (1.08–219.8)	0.68 (0.01–95.58)
Female	0.87 (0.75–1.01)	1.01 (0.86–1.18)	0.9 (0.79–1.02)	1.02 (0.95–1.1)	0.86 (0.72–1.04)	0.99 (0.83–1.18)	0.9 (0.64–1.26)	0.93 (0.67–1.29)
hospitalization before baselin	1.23 (1.1–1.36) *	0.88 (0.77–1.01)	1.16 (1.07–1.26) *	1.04 (0.96–1.12)	1.28 (1.13–1.46) *	0.9 (0.77–1.06)	1.16 (0.94–1.43)	1.05 (0.84–1.31)
… during baseline	1.65 (1.53–1.78) *	1.19 (1.1–1.3) *	1.34 (1.26–1.42) *	1.07 (1.02–1.12) *	1.48 (1.33–1.64) *	1.18 (1.06–1.31)	1.55 (1.32–1.82) *	1.15 (0.97–1.37)
Previous ED visit	0.9 (0.77–1.06)	1.46 (1.24–1.72) *	1.08 (0.96–1.21) *	1.57 (1.44–1.71) *	1.01 (0.89–1.14)	1.08 (0.94–1.24)	0.97 (0.83–1.12)	0.98 (0.86–1.11)
… during baseline	1.21 (1.11–1.31) *	2.24 (2.01–2.49) *	1.24 (1.16–1.33) *	2.37 (2.25–2.5) *	1.08 (0.98–1.2)	1.97 (1.76–2.19)	1.11 (1.02–1.21) *	2.08 (1.76–2.46) *
Wei score	1.07 (1.06–1.08) *	1.07 (1.05–1.08) *	1.05 (1.04–1.06) *	1.03 (1.01–1.04) *	1.05 (1.04–1.07) *	1.05 (1.04–1.06) *	1.03 (1.01–1.06) *	1.03 (1.01–1.06) *