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] |