From: Optimizing care coordination to address social determinants of health needs for dual-use veterans
Patient Factors | Control (N = 475) | ACC (N = 161) | p-value | |
---|---|---|---|---|
Age (Mean (SD)) | Â | 63.90 (15.91) | 63.47 (15.97) | 0.77 |
Sex = Female(%) |  | 49 (10.3) | 16 (9.9) | 1.00 |
Race (%) | 0.99 | |||
 | White | 389 (81.9) | 132 (82.0) |  |
 | Black | 57 (12.0) | 19 (11.8) |  |
 | Other | 11 (2.3) | 4 (2.5) |  |
 | Unknown | 18 (3.8) | 6 (3.7) |  |
Urban Rural Highly Rural (%) | 1.00 | |||
 | Urban | 379 (79.8) | 129 (80.1) |  |
 | Rural | 96 (20.2) | 32 (19.9) |  |
 | Highly Rural | 0 (0.0) | 0 (0.0) |  |
Site (%) | 1.00 | |||
 | Denver | 201 (42.3) | 67 (41.6) |  |
 | Omaha | 274 (57.7) | 94 (58.4) |  |
Elixhauser Comorbidity Index | ||||
Hypertension = 1(%) |  | 291 (61.3) | 100 (62.1) | 0.92 |
Congestive Heart Failure = 1(%) |  | 53 (11.2) | 18 (11.2) | 1.00 |
Chronic Pulmonary Disease = 1(%) |  | 145 (30.5) | 48 (29.8) | 0.94 |
Diabetes without Chronic Complications = 1(%) |  | 127 (26.7) | 42 (26.1) | 0.95 |
Diabetes with Chronic Complications = 1 (%) |  | 114 (24.0) | 36 (22.4) | 0.75 |
Renal Failure = 1 (%) |  | 71 (14.9) | 25 (15.5) | 0.96 |
Obesity = 1(%) |  | 86 (18.1) | 27 (16.8) | 0.79 |
Weight Loss = 1(%) |  | 27 (5.7) | 11 (6.8) | 0.74 |
Fluid and Electrolyte Disorders = 1(%) |  | 105 (22.1) | 41 (25.5) | 0.44 |
AIDS/HIV = 1(%) |  | 0 (0.0) | 0 (0.0) | 1.00 |
Alcohol Abuse = 1 (%) |  | 62 (13.1) | 24 (14.9) | 0.65 |
Anemia Deficiency = 1(%) |  | 91 (19.2) | 33 (20.5) | 0.80 |
Rheumatoid Arthritis = 1(%) |  | 13 (2.7) | 4 (2.5) | 1.00 |
Blood Loss Anemia = 1 (%) |  | 8 (1.7) | 2 (1.2) | 0.98 |
Coagulopathy = 1 (%) |  | 31 (6.5) | 10 (6.2) | 1.00 |
Depression = 1(%) |  | 120 (25.3) | 28 (23.6) | 0.75 |
Drug Abuse = 1(%) |  | 37 (7.8) | 13 (8.1) | 1.00 |
Hypothyroidism = 1(%) |  | 52 (10.9) | 19 (11.8) | Hypothyroidism = 1(%) |
Liver Disease = 1(%) |  | 69 (14.5) | 27 (16.8) | 0.58 |
Lymphoma = 1(%) |  | 5 (1.1) | 4 (2.5) | 0.35 |
Metastatic Cancer = 1(%) |  | 11 (2.3) | 3 (1.9) | 0.98 |
Other Neurological Disorders = 1(%) |  | 135 (28.4) | 48 (29.8) | 0.81 |
Paralysis = 1(%) |  | 28 (5.9) | 12 (7.5) | 0.61 |
Peripheral Vascular Disease = 1(%) |  | 74 (15.6) | 26 (16.1) | 0.96 |
Psychiatric Disorders = 1(%) |  | 36 (7.6) | 15 (9.3) | 0.59 |
Pulmonary Circulation Disorder = 1(%) |  | 6 (1.3) | 2 (1.2) | 1.00 |
Solid Tumor without Metastasis = 1 (%) |  | 24 (5.1) | 12 (7.5) | 0.35 |
Peptic Ulcer Disease = 1(%) |  | 2 (0.4) | 1 (0.6) | 1.00 |
Valvular Disease = 1(%) |  | 42 (8.8) | 17 (10.6) | 0.62 |
Outcomes Prior Intervention | ||||
1Â year Prior PCP visit (mean (SD)) | Â | 2.65 (2.43) | 2.80 (2.30) | 0.50 |
1Â year Prior Hospitalization (mean (SD)) | Â | 0.36 (0.73) | 0.37 (0.70) | 0.87 |
1Â year Prior ED visit (mean (SD)) | Â | 1.54 (2.65) | 1.63 (2.21) | 0.70 |
Outcomes Post Intervention | ||||
30-day Mortality = 1 (%) |  | 5 (1.1) | 2 (1.2) | 1.00 |
60-day Mortality = 1 (%) |  | 10 (2.1) | 3 (1.9) | 1.00 |
90-day Mortality = 1 (%) |  | 17 (3.6) | 5 (3.1) | 0.97 |
30-day ED Visit = 1 (%) |  | 127 (26.7) | 29 (18.0) | 0.03 |
60-day ED Visit = 1 (%) |  | 153 (32.2) | 45 (28.0) | 0.36 |
90-day ED Visit = 1 (%) |  | 176 (37.1) | 54 (33.5) | 0.48 |
30-day Readmission = 1 (%) |  | 21 (4.4) | 4 (2.5) | 0.39 |
60-day Hospital Readmission = 1 (%) |  | 36 (7.6) | 10 (6.2) | 0.69 |
90-day Hospital Readmission = 1 (%) |  | 44 (9.3) | 15 (9.3) | 1.00 |
14-day PCP visit = 1 (%) |  | 140 (29.5) | 53 (32.9) | 0.47 |
30-day PCP Visit = 1 (%) |  | 199 (41.9) | 80 (49.7) | 0.10 |