riskfactor

Unique identifier representing a unique person that may include data from several sources that have been linked. This identifier is the person_id of a HIEBus recordgroup.

The date on which all risk factors in this row have been computed. Typically the first of a month.

The risk level computed, based on all risk factors, on the specified date.

Annual Spend over 100K

Annual Spend over 50K

Annual Spend over 75K

Last A1c 8 or greater

A1C 8 or greater, no med therapy

Last A1c 9 or greater

Age 90 or greater

ASC Hospitalization, prior 45d

1 or more ASCs coded on Hospitalization/ED, past 365 days

1 or more ASCs coded on Hospitalization/ED, past 3 mo

1 or more ASCs coded on Hospitalization/ED, past 6 mo

Hospitalization BH Condition, prior 120d

Hospitalization BH Condition, prior 90d

Last cGFR 20 or less

Last cGFR 25 or less

Last cGFR 30 or less

Last cGFR 35 or less

Last cGFR 40 or less

Chronic Meds 10 or more, last 6 month

Chronic Meds 15 or more, last 6 month

Dementia

ED or Hosp, prior 6m + Congestive Heart Failure

ED or Hosp, prior 6m + Chronic Obstructive Pulmonary Disease

ED or Hosp, prior 6m + Dementia

ED or Hosp, prior 6m + Medication: ACE INHIBITORS

ED or Hosp, prior 6m + Medication: ANESTHETICS,MUCOSAL

ED or Hosp, prior 6m + Medication: ANTIARRHYTHMICS

ED or Hosp, prior 6m + Medication: ANTICONVULSANTS

ED or Hosp, prior 6m + Medication: ANTIHYPERTENSIVES,OTHER

ED or Hosp, prior 6m + Medication: ANTIPARKINSON AGENTS

ED or Hosp, prior 6m + Medication: BENZODIAZEPINE DERIVATIVE SEDATIVES/HYPNOTICS

ED or Hosp, prior 6m + Medication: BRONCHODILATORS,SYMPATHOMIMETIC,INHALATION

ED or Hosp, prior 6m + Medication: GENITO-URINARY AGENTS,OTHER

ED or Hosp, prior 6m + Medication: H. PYLORI AGENTS

ED or Hosp, prior 6m + Medication: HISTAMINE ANTAGONISTS

ED or Hosp, prior 6m + Medication: INSULIN

ED or Hosp, prior 6m + Medication: LOCAL ANESTHETICS,TOPICAL

ED or Hosp, prior 6m + Medication: LOOP DIURETICS

ED or Hosp, prior 6m + Medication: OPIOID ANALGESICS

ED or Hosp, prior 6m + Medication: OSMOTIC AGENTS,SYSTEMIC OPHTHALMIC

ED or Hosp, prior 6m + Medication: PLATELET AGGREGATION INHIBITORS

ED or Hosp, prior 6m + Medication: POTASSIUM SPARING/COMBINATIONS DIURETICS

ED or Hosp, prior 6m + Acute Renal Failure

ED 1 or more, prior 6m + Hospitalizations 1 or more, prior 6m

ED 1 or more, prior 12m

ED 1 or more, prior 3m

ED 1 or more, prior 3m + Last A1c 9 or greater

ED 1 or more, prior 3m + Chronic Meds 10 or more, last 6 month

ED 1 or more, prior 3m + Dementia

ED 1 or more, prior 3m + HCC 2

ED 1 or more, prior 3m + HCC 2.5

ED 1 or more, prior 3m + HCC 3

ED 1 or more, prior 3m + HCC change 1 or more

ED 1 or more, prior 3m + Opioid usage

ED 1 or more, prior 3m + UM 1.0

ED 1 or more, prior 3m + UM 2.0

ED 1 or more, prior 6m

ED 1 or more, prior 6m + Last A1c 9 or greater

ED 1 or more, prior 6m + Dementia

ED 1 or more, prior 6m + HCC 1.5

ED 1 or more, prior 6m + HCC 2

ED 1 or more, prior 6m + HCC change 1 or more

ED 2 or more, prior 6m + Hospitalizations 1 or more, prior 6m

ED 2 or more, prior 12m

ED 2 or more, prior 3m

ED 2 or more, prior 6m

ED 3 or more, prior 6m + Hospitalizations 1 or more, prior 6m

ED 3 or more, prior 6m + Hospitalizations 2 or more, prior 6m

ED 3 or more, prior 12m

ED 3 or more, prior 3m

ED 3 or more, prior 6m

ED 4 or more, prior 6m + Hospitalizations 1 or more, prior 6m

ED 4 or more, prior 12m

ED 4 or more, prior 3m

ED 4 or more, prior 6m

ED 6 or more, prior 12m

Hosp + 2 more ED/Hosp, prior 12m

ED or Hosp, prior 6m + HCC 1.5

ESLD

ESRD

HCC 1.5 or higher

HCC 2 or higher

HCC 2.5 or higher

HCC 2 or greater + Opioid usage

HCC 3 or higher

HCC 3.5 or higher

HCC 4 or higher

HCC 4.5 or higher

HCC 5 or higher

HCC 5.5 or higher

HCC 6 or higher

HCC change 1.5 or greater, prior 3m

HCC change 1 or greater + Opioid usage

HCC change 1.0 or greater, prior 3m

HCC change 2 or greater, prior 3m

Hospitalizations 1 or more, prior 12m

Hospitalizations 1 or more, prior 3m

Hospitalizations 1 or more, prior 3m + HCC 2

Hospitalizations 1 or more, prior 3m + HCC 3

Hospitalizations 1 or more, prior 3m + HCC change 1 or more

Hospitalizations 1 or more, prior 6m

Hospitalizations 1 or more, prior 6m + HCC 1.5

Hospitalizations 2 or more, prior 12m

Hospitalizations 2 or more, prior 3m

Hospitalizations 2 or more, prior 6m

Hospitalizations 3 or more, prior 12m

Medication: ACE INHIBITORS

Medication: ANESTHETICS,MUCOSAL

Medication: ANTIARRHYTHMICS

Medication: ANTIPARKINSON AGENTS

Medication: BENZODIAZEPINE DERIVATIVE SEDATIVES/HYPNOTICS

Medication: GENITO-URINARY AGENTS,OTHER

Medication: H. PYLORI AGENTS

Medication: HISTAMINE ANTAGONISTS

Medication: LOCAL ANESTHETICS,TOPICAL

Medication: LOOP DIURETICS

Medication: OPIOID ANALGESICS

Medication: OSMOTIC AGENTS,SYSTEMIC OPHTHALMIC

Medication: PLATELET AGGREGATION INHIBITORS

Medication: POTASSIUM SPARING/COMBINATIONS DIURETICS

3 or more opioid prescriptions, last 6 months

30d Readmit, prior 120d

30d Readmit, prior 45d

30d Readmit, prior 90d

Stable BH condition

Substance abuse, prior 12m

Substance abuse, prior 90d

UM 1 or higher

UM 2 or higher

UM 3 or higher