Table 1.
Demographic, Medical, and Social Characteristics of SMHCVH Patients with Diabetes
| Patients with diabetes (n = 1764) | No population health team (n = 969) | Minimal population health team (n = 234) | Population health team intervention (n = 561) | p value | |
|---|---|---|---|---|---|
| Age (mean, SD) | 68.7 (12.4) | 69.5 (12.5) | 67.5 (11.6) | 68.0 (12.6) | 0.012 |
| Race/ethnicity, n (%) | |||||
| White, non-Hispanic | 1718 (98.2) | 938 (96.8) | 230 (98.3) | 550 (99.0) | 0.341 |
| Non-White, non-Hispanic, and Hispanic | 31 (1.8) | 22 (3.2) | 4 (1.7) | 5 (1.0) | |
| Missing/unknown | 15 | 9 | 6 | ||
| Sex, n (%) | |||||
| Female | 767 (43.5) | 351 (36.2) | 127 (54.3) | 289 (51.5) | < 0.001 |
| Missing | 75 | 55 | 6 | 14 | |
| Insurance status, n (%) | |||||
| Medicare | 934 (53.9) | 525 (54.2) | 105 (49.0) | 327 (54.7) | 0.004 |
| Medicare + Medicaid | 172 (9.9) | 85 (8.8) | 25 (10.6) | 62 (11.6) | |
| Medicaid | 109 (6.3 | 45 (4.6) | 19 (9.1) | 45 (8.0) | |
| Commercial/third party | 473 (27.3) | 287 (29.6) | 56 (26.9) | 130 (23.2) | |
| Uninsured | 46 (2.7) | 27 (2.8) | 9 (4.3) | 10 (1.8) | |
| Missing | 30 | 0 | 26 | 4 | |
| Medical needs | |||||
| Chronic conditions, n (%) | |||||
| Anxiety and fear-related disease | 258 (14.6) | 103 (10.6) | 41 (17.5) | 114 (20.3) | < 0.001 |
| Heart failure | 155 (8.8) | 77 (7.9) | 22 (9.4) | 56 (10.0) | 0.374 |
| Chronic kidney disease | 269 (15.2) | 113 (11.7) | 44 (18.8) | 112 (20.0) | < 0.001 |
| Chronic obstructive pulmonary disorder | 210 (11.9) | 91 (9.4) | 27 (11.5) | 92 (16.4) | < 0.001 |
| Cardiovascular disease | 668 (37.9) | 326 (33.6) | 86 (36.8) | 256 (45.6) | < 0.001 |
| Depression | 322 (18.3) | 116 (12.0) | 42 (17.9) | 164 (29.2) | < 0.001 |
| Hypertension | 712 (40.4) | 371 (38.3) | 87 (37.2) | 254 (45.3) | 0.015 |
| Obesity | 461 (26.1) | 191 (19.7) | 54 (23.1) | 216 (38.5) | < 0.001 |
| Medical complexity, n (%) | |||||
| 3 or more chronic conditions | 580 (32.9) | 252 (26.0) | 79 (33.8) | 249 (44.4) | < 0.001 |
| Not taking medications as prescribed (n = 1121) | 65 (5.9) | 35 (6.2) | 6 (4.4) | 24 (5.9) | 0.701 |
| Taking 6 or more medications (n = 1189) | 626 (52.7) | 297 (49.3) | 71 (44.9) | 258 (60.3) | < 0.001 |
| Utilization, n (%) | |||||
| Self-reported, recent hospital admission (n = 1193) | 291 (24.4) | 138 (22.8) | 27 (16.9) | 126 (29.5) | 0.003 |
| Self-reported, recent emergency dept. use (n = 1193) | 319 (26.7) | 151 (25.0) | 35 (21.9) | 133 (31.1) | 0.030 |
| Social needs, n (%) | |||||
| Transportation barrier (n = 1194) | 66 (5.5) | 24 (4.0) | 8 (5.1) | 34 (7.9) | 0.021 |
| Difficulty affording food (n = 1117) | 62 (5.2) | 23 (4.1) | 8 (5.7) | 31 (7.6) | 0.059 |
| Current housing issue (n = 1203) | 15 (1.3) | 7 (1.2) | 2 (1.3) | 6 (1.4) | 0.941 |
| Difficulty paying meds (n = 1192) | 109 (9.1) | 51 (8.4) | 11 (7.0) | 47 (11.0) | 0.220 |
Definitions: No population health team: 0 visits with members of the population health team, minimal population health team: 1 visit with a member of the population health team, population health team intervention: 2 or more visits with a member of the population health team. Note: p values are two-sided and from chi-squared tests for categorical variables or Kruskal Wallis test for continuous variables, between study groups. p values < 0.05 indicate significant differences in at least 2 groups
SMHCVH St. Mary’s Health and Clearwater Valley Health