Table 1 Patient-centered outcomes by source, domain, and measurement frequency over the course of one wave.a EMR Electronic medical record; Intake refers to intake interview by community health worker
Sourcea | Domain | Baseline | Quarterly | 1-Year |
|---|---|---|---|---|
Socio-demographic | ||||
EMR | Sex, age, race, language | ✓ | ||
Intake | Marital status, education, residential status, employment status, income | ✓ | ||
Social determinants of health | ✓ | |||
Health Attitudes and Behavior | ||||
Intake | Self-reported health status | ✓ | ✓ | |
Diabetes risk belief | ✓ | ✓ | ||
Prediabetes awareness | ✓ | ✓ | ||
Physical activity | ✓ | ✓ | ||
Diet | ✓ | ✓ | ||
Awareness of prevention resources | ✓ | ✓ | ||
Patient Activation | ||||
Intake | 6-item Patient Activation Measure ® | ✓ | ✓ | |
Clinical Data | ||||
EMR | Weight | ✓ | ✓ | ✓ |
BMI | ✓ | ✓ | ✓ | |
Hemoglobin A1C | ✓ | ✓ | ✓ | |
Serum glucose | ✓ | ✓ | ✓ | |
Blood pressure (Systolic/Diastolic) | ✓ | ✓ | ✓ | |
Total cholesterol | ✓ | ✓ | ✓ | |
LDL cholesterol | ✓ | ✓ | ✓ | |
HDL cholesterol | ✓ | ✓ | ✓ | |
Triglycerides | ✓ | ✓ | ✓ | |
Smoking status | ✓ | ✓ | ✓ | |
Health service utilization: # of | ||||
EMR | Primary care encounters | ✓ | ✓ | ✓ |
Walk-in clinic encounters | ✓ | ✓ | ✓ | |
Emergency Department encounters | ✓ | ✓ | ✓ | |
Hospitalizations | ✓ | ✓ | ✓ | |
Hospital weight loss clinic | ✓ | ✓ | ✓ | |
Nutrition encounters | ✓ | ✓ | ✓ | |
Diagnostic Codes for: | ||||
EMR | Type 2 Diabetes | ✓ | ✓ | ✓ |
Hypertension | ✓ | ✓ | ✓ | |
Chronic Kidney Disease | ✓ | ✓ | ✓ | |
Cardiovascular Disease | ✓ | ✓ | ✓ | |
Peripheral Artery Disease | ✓ | ✓ | ✓ | |
Obesity | ✓ | ✓ | ✓ | |