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Enhanced Use of Data for Case Management in England

Johns Hopkins Bloomberg School of Public Health The Enhanced Use of Primary Care, Ambulatory Hospital Data to Identify Patients for Case Management Programs in England […]

Customizing the Predictive Model

DST Health Solutions Customizing the Predictive Model Amy Salls

Using the ACG System for population segmentation and casemix adjustment

NHS Central Southern Commissioning Support Unit Using the ACG System for Population Segmentation and Casemix Adjustment Chris Morris Principal Analyst

Monday(C1)-A Model for the Risk of Unplanned Inpatient Readmission-Lemke

A Model for the Risk of Unplanned Inpatient Readmission-Klaus Lemke

Sunday-Workshop: Wrapping Your Hands Around the ACG System Advanced Reporting Options – Steve Sutch

Workshop: Wrapping Your Hands Around the ACG System Advanced Reporting Options – Steve Sutch – ACG International – Product Management Director

Using Case Mix To Improve Equity and the Delivery of Primary Care

Goals of Presentation To introduce concepts surrounding population-based case-mix and “predictive risk” modeling. To show examples of applications worldwide where case-mix has proved information to […]

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The ACG System Development Milestones

Jonathan Weiner, DrPH, Professor, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and ACG System co-developer provides an insight into the evolution […]

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Resource Allocation Case Study-Government

Sweden became one of the first international adopters of the Johns Hopkins ACG System in the mid 1990s and has expanded its use to cover […]

Genetics Consultation Rates Following a Diagnosis of High-Grade Serous Ovarian Carcinoma in the Canadian Province of Ontario

Objective: In 2001, the province of Ontario expanded cancer genetic testing eligibility to include all women with high-grade serous ovarian carcinoma (HGSC) of the ovary, […]

Is case-mix adjustment in primary care at the mercy of coding quality? Yes … and no

BACKGROUND:  Primary care clinicians know that case-mix varies between different physician practices and geographical areas. Leicester City Clinical Commissioning Group (CCG) is now able to quantify […]

Effectiveness of a community care management program for multimorbid elderly patients with heart failure in the Veneto Region

Abstract Background The rapidly growing population of elderly subjects with multimorbidity is at risk of receiving fragmented and uncoordinated care, and have frequent hospitalizations and […]

Population risk and burden of health behavioral–related all-cause, premature, and amenable deaths in Ontario, Canada: Canadian Community Health Survey–linked mortality files

Abstract   Purpose To examine the association of all-cause and premature mortality with four modifiable lifestyle behaviors and quantify the burden of behavioral-related premature death in Ontario, […]

An instrumental variable approach quantifies and confirms the duration of pre-transplant dialysis has negative impact on kidney transplant recipient survival

Abstract Dialysis prior to kidney transplantation may have a detrimental effect on post-transplant Outcomes. However, prior studies have not fully characterized the nature of this […]

Interaction between neighborhood walkability and traffic-related air pollution on hypertension and diabetes: The CANHEART cohort

Abstract Background Living in unwalkable neighborhoods has been associated with heightened risk for diabetes and hypertension. However, highly walkable environments may have higher concentrations of […]

Understanding those overdue for cancer screening by five years or more: A retrospective cohort study in Ontario, Canada

Abstract Populations that are more than just slightly overdue for breast, cervical and colorectal screening should likely be targeted for policy and practice interventions. We […]

Association of Patient, Prescriber, and Region With the Initiation of First Prescription of Biologic Disease-Modifying Antirheumatic Drug Among Older Patients With Rheumatoid Arthritis and Identical Health Insurance Coverage

Abstract Importance Prescribing the first biologic treatment for rheumatoid arthritis (RA) is an important decision for patients, their physicians, and payers, with considerable costs and […]

Multimorbidity patterns in patients with heart failure: an observational Spanish study based on electronic health records

Abstract Objectives To characterise the comorbidities of heart failure (HF) in men and women, to explore their clustering into multimorbidity patterns, and to measure the […]

A Revised Classification Algorithm for Assessing Emergency Department Visit Severity of Populations

ABSTRACT Objectives: Analyses of emergency department (ED) use require visit classification algorithms based on administrative data. Our objectives were to present an expanded and revised version […]

Health care service usage and costs for high-needs elderly patients with heart failure

Abstract Background Heart failure (HF) has been defined as global disease of pandemic proportions, since it affects around 26 million people worldwide.[1] According to a recent […]

Personalized prediction of early childhood asthma persistence: A machine learning approach

Abstract Objective Early childhood asthma diagnosis is common; however, many children diagnosed before age 5 experience symptom resolution and it remains difficult to identify individuals […]

Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty

Abstract Objective To determine whether an anterior approach is associated with lower risk of complications than either a lateral or posterior approach. Design, Setting, and […]

Effect of frailty on postoperative readmissions and cost of care for ovarian cancer

Abstract Objectives Frailty, defined as loss of reserve and vulnerability to changes in health, affects many ovarian cancer patients who are planned to undergo surgery. […]

Healthcare resource utilization in myeloproliferative neoplasms: a population-based study from Ontario, Canada

Abstract Background Health resource utilization (HRU) and associated factors of high cost are not well understood in myeloproliferative neoplasms (MPNs). Methods In this population-based, retrospective […]

Impact of Coronary Artery Severity and Revascularization Prior to Transcatheter Aortic Valve Implantation

Abstract Objective The prevalence of coexisting coronary artery disease (CAD) is high in patients who underwent transcatheter aortic valve implantation (TAVI). Our objective was to […]

Stratifying for Value: An Updated Population Health Risk Stratification Approach

Abstract Objective Most risk stratification approaches attempt to predict clinical outcomes rather than value. For a provider organization or health system to have financial success […]

Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations

Abstract Background: Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II […]

Factors Associated With Nonreceipt of Recommended COPD Medications

Abstract Background COPD medications reduce exacerbations and improve quality of life. Despite this, some individuals do not receive medications recommended by practice guidelines. Research Question […]

Performance of quantitative measures of multimorbidity: a population-based retrospective analysis

Abstract Background Multimorbidity measures are useful for resource planning, patient selection and prioritization, and factor adjustment in clinical practice, research, and benchmarking. We aimed to […]

Identifying Complex Patients Using Adjusted Clinical Groups Risk Stratification Tool

ABSTRACT Objectives To produce an efficient and practically implementable method, based on primary care data exclusively, to identify patients with complex care needs who have […]

Validating and Improving Adjusted Clinical Group’s Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care

Abstract The rise in health care costs, caused by older and more complex patient populations, requires Population Health Management approaches including risk stratification. With risk […]

Understanding Data and Opportunities Focused on Value: A Single-Center Experience in Headache Care

Abstract Background and Objectives Headache syndromes are highly prevalent, disabling, and costly. Our goals were to (1) describe headache care delivery and costs in a […]

Mapping Healthcare Needs: A Systematic Review of Population Stratification Tools

Abstract Background and Aim: In 2021, healthcare expenditure in Italy represented 7.3% of the national gross domestic product, with approximately 80% attributed to the management […]

Is the Barthel index a valid tool for patient selection before urological surgery? A systematic review

Background The Barthel Index (BI) measures the level of patient independence in activities of daily living. This review aims to summarize current evidence on the […]

Multimorbidity and Hospital Admissions in High-Need, High-Cost Elderly Patients

Abstract Objective: The aim was to clarify which pairs or clusters of diseases predict the hospital-related events and death in a population of patients with complex […]

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Predictive Modeling Part II

This webinar is a follow up to the previous Predictive Modeling Part I webinar, which provides an overview of the predictive models available within in the […]

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Population Segmentation

Presented by: Sarah Kachur
Director, Population Health R&D, JHHC Business Lead, Pop. Health Precision Medicine

This webinar explores how applying risk taxonomy to a Medicare Advantage population helped a health plan improve their identification of high-risk members.

Sitagliptin use in patients with diabetes and heart failure: a population-based retrospective cohort study

JACC Heart Fail. University of Alberta, Edmonton, AB, Canada OBJECTIVES: The study objective was to evaluate the effects of sitagliptin in patients with type 2 […]

The roles of primary care PAs and NPs caring for older adults with diabetes

JAAPA 27:45-49. Duke University School of Medicine, Durham, NC; VetUnerans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Pharmacy, Pittsburgh, PA; University of […]

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

BMC Geriatr 14:131. Department of Patient Safety, Blekinge County Council, Karlskrona, Sweden BACKGROUND: Risk factors for hip fracture are well studied because of the negative […]

How do immigrants use primary health care services? A register-based study in Norway

Eur J Public Health 25:72-78. University of Bergen, Norway; Carlos III Health Institute, Madrid, Spain; Aragón Health Sciences Institute (IACS), Zaragoza, Spain; University of Zaragoza, […]

Applying a risk-adjustment framework to primary care: can we improve on existing measures?

Ann Fam Med 1:44-51. Center for Health Quality, Outcomes and Economic Research, VAMC, Bedford, MA, USA Outcome-based performance measurement and prospective payment are common features […]

Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure

Aten Primaria 48:102-109. Published in Spanish. Hospital Universitario Infanta Sofía, Madrid, España; Unidad Docente Multiprofesional de Atención Familiar y Comunitaria; Madrid, España; Unidad Sistemas de […]

Multimorbidity and its patterns according to immigrant origin. A nationwide register-based study in Norway

PLoS One 10:e0145233. University of Bergen, Bergen, Norway; Norwegian Centre for Minority Health Research, Oslo, Norway; Aragón Health Sciences Institute (IACS), Zaragoza, Spain; Carlos III […]

Impact of language barriers on complications and mortality among immigrants with diabetes: a population-based cohort study

Diabetes Care 38:189-196. University Health Network, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; St. Michael’s […]

Association between age, gender and multimorbidity level and receiving home health care: a population-based Swedish study

BMC Res Notes 8:714. Lyckeby Primary Healthcare Centre and Blekinge Centre of Competence, Lyckeby, Sweden; University of Southern Denmark, Odense, Denmark BACKGROUND: Home health care […]

Comparing accuracy of risk-adjustment methodologies used in economic profiling of physicians

Inquiry 41:218-231. Department of Health Management and Policy, School of Public Health, University of Michigan, USA This paper examines the relative accuracy of risk-adjustment methodologies […]

Use of a shared medical record with secure messaging by older patients with diabetes

Diabetes Care 33:2314-2319. Department of Medicine, University of Washington, Seattle, WA, USA OBJECTIVE: Evaluate use of a web-based shared medical record (SMR) between older patients […]

Do we need more physicians?

Health Aff W4:67-69. Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH, USA A reexamination of physician productivity can resolve the current workforce […]

Impact of discontinuity in health insurance on resource utilization

BMC Health Serv Res 10:195. Division of Health Care Policy & Research, Mayo Clinic, Rochester, MN, US BACKGROUND: This study sought to describe the incidence […]

Comparing apples with apples in clinical populations: applications of the Adjusted Clinical Group system in British Columbia

Healthc Manage Forum 15:11-16. Department of Healthcare and Epidemiology, University of British Columbia, Vancouver, BC, Canada This article reviews the Adjusted Clinical Group Case-Mix System […]

Comparison of alternative risk adjustment measures for predictive modeling: high risk patient case finding using Taiwan’s National Health Insurance claims

BMC Health Serv Res 10:343. Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA BACKGROUND: Predictive modeling […]

Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP)

J Manag Care Pharm 17:345-354. Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA BACKGROUND: As defined by the Medicare Prescription […]

Morbidity trajectories as predictors of utilization: multi-year disease patterns in Taiwan’s national health insurance program

Med Care 49:918-923. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA BACKGROUND: Little is known about […]

Age difference explains gender difference in cardiac intervention rates after acute myocardial infarction

Healthc Policy 6:88-103. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada Many investigators have reported higher rates of cardiac procedures for males […]

Characteristics and risk factors associated with high-cost Medicaid recipients

Manag Care Interface 17:20-27. College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA Characteristics and risk factors of fee-for-service Medicaid patients (age 65 yr) with […]

Variations in health services utilization by primary care patients

Health Serv Manage Res 15:116-125. Departamento de Estumatologia, Facultad de Odontologia, Universidad de Granada, Campus Univeristario de Cartuja, Granada, Spain This study analyses how both […]

The risk-adjustment debate

N Engl J Med 339:1952-1956. Risk adjustment refers to the adjustment of payments to health plans (or to doctors) to reflect more accurately the actual […]

Development and validation of a psychiatric case-mix system

Med Care 44:568-580. VA Puget Sound Health Care System, and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA BACKGROUND: Although […]

Effect of risk adjustment method on comparisons of health care utilization between complementary and alternative medicine users and nonusers

J Altern Complement Med 19:250-256. Saint Luke’s Health System, Boise, ID, USA OBJECTIVES: Complementary and alternative medicine (CAM) providers are becoming more integrated into the […]

Obesity and respiratory hospitalizations during influenza seasons in Ontario, Canada: a cohort study

Clin Infect Dis 53:413-421. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Previous studies suggest that obesity may be a risk factor for complications […]

Capitation adjustment for pediatric populations

Pediatrics 98:10-17. Institute for Research and Education, HealthSystem Minnesota, Minneapolis, MN, USA OBJECTIVE: The objective of this study is to assess the predictive performance of […]

Risk adjustment using automated ambulatory pharmacy data: the RxRisk model

Med Care 41:84-99. Center for Health Studies, Group Health Cooperative, Seattle, WA, USA OBJECTIVES: Develop and estimate the RxRisk model, a risk assessment instrument that […]

Using propensity scores subclassification to estimate effects of longitudinal treatments: an example using a new diabetes medication

Med Care 45:S149. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA BACKGROUND: When using observational data to compare the effectiveness of […]

Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006

Rev Esp Salud Publica 82:315-322. Published in Spanish. Dirección de Planificación, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain BACKGROUND: Arterial hypertension is one of the […]

Patterns and predictors of restrictive health care service use by youths with bipolar disorder

Adm Policy Ment Health 37:379-387. Health Services Research Department, Institute of Psychiatry, King’s College London, London, UK Patterns of behavioral health service utilization were examined […]

Comparison of inhaled long-acting beta-agonist and anticholinergic effectiveness in older patients with chronic obstructive pulmonary disease: a cohort study

Ann Intern Med 154:583-592. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. BACKGROUND: Chronic obstructive pulmonary disease (COPD), a largely preventable and manageable respiratory condition, […]

Influence of compliance on the incidence of cardiovascular events and health costs when using single-pill fixed-dose combinations for the treatment of hypertension

Med Clin (Barc) 136:183-191. Directorate of Planning, Badalona Serveis Assistencials SA, Badalona, Spain BACKGROUND AND OBJECTIVE: To determine the incidence of cardiovascular events (CVE) and […]

High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia

Schizophr Res 142:52-57. Centre for Addiction and Mental Health, Toronto, ON, Canada OBJECTIVES: The primary objective of this study was to compare mortality following incident […]

Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia

Mayo Clin Proc 87:120-129. Mayo Clinic, Rochester, MN, USA OBJECTIVE: To study the association between exposure to procedures performed under general anesthesia before age 2 […]

Are cervical and breast cancer screening programmes equitable? The case of women with intellectual and developmental disabilities

J Intellect Disabil Res 57:478-488. School of Nursing Sciences, University of East Anglia, Norwich, UK BACKGROUND: Effective cancer screening must be available for all eligible […]

Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country

BMC Public Health 13:918. Oberri, Basque Institute for Healthcare Innovation, Sondika, Spain BACKGROUND: Multimorbidity is clearly a major challenge for healthcare systems. However, currently, its […]

Predictors of colorectal cancer screening variation among primary-care providers and clinics

Am J Gastroenterol 108:1159-1167. University of Wisconsin School of Medicine and Public Health, Madison, WI, USA OBJECTIVES: Colorectal cancer (CRC) screening is underutilized. To effect […]

Antihypertensive medication initiation among young adults with regular primary care use

J Gen Intern Med Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA BACKGROUND: Young adults with hypertension have […]

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses

Med Care 34:798-810. Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, MD, USA OBJECTIVES: This study illustrates how claims […]

Obesity and co-morbidities in type 2 diabetes: an opportunity to bend the Health Care Cost Curve

Rev Clin Esp 214:140-142. University of Southern Denmark, Odense, Denmark Obesity has long been known as a driver and predictor of the increasing global prevalence […]

Using a health information exchange system for imaging information: patterns and predictors

AMIA Annu Symp Proc 2013:1402-1411. Weill Cornell Medical College, New York, NY, USA Health information exchange (HIE) systems may address the challenges that prevent easy […]

Children and youth with traumatic brain injury: Who uses homecare services, what do they use, and how much does it cost?

First International Conference on Pediatric Acquired Brain Injury, September 2015, Liverpool, UK. University of Toronto, Toronto, ON, Canada Objective: To determine, by sex, the predictors, […]

Women are less likely to be admitted for inpatient rehabilitation after hypoxic-ischemic brain injury

Arch Phys Med Rehabil 96:e17-e18. Toronto Rehabilitation Institute, Toronto, ON, Canada Objective(s): To investigate demographic and acute care clinical determinants  of admission to inpatient rehabilitation […]

Child health and young adult outcomes

J Hum Resources 45:517-548. Columbia University, New York, NY, USA; University of Toronto, Toronto, ON, Canada; University of Manitoba, Winnipeg, MB, Canada Research has shown […]

Patients gain information and skills to improve self-management through innovative tools

Quality Matters December 2010/January 2011. Commonwealth Fund, New York, NY, USA Health reform strategies such as creating patient-centered medical homes depend on an actively engaged […]

What works? A first look at evaluating Manitoba’s regional health programs and policies at the population level

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada Although many descriptive healthcare studies are […]

The New Mexico primary care network

Chapter 5. In: Gavin NI, Farrelly MC, ed. Evaluation of Medicaid managed care programs with 1915(b) waivers. Presented to HCFA Office of R&D. Rockville, MD, […]

Johns Hopkins risk tool used in south

EHI ehealth Insider :5 March 2012. More than 200 GP practices in South Central England are getting quarterly risk stratification and predictive modelling information on […]

Health system use by frail Ontario seniors: an in-depth examination of four vulnerable cohorts

Toronto, ON, Canada: Institute for Clinical Evaluative Sciences. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Key Findings OLDER WOMEN: A look at gender differences […]

Predicting elderly at risk of increased future healthcare use: how much does diagnostic information add to prior utilization?

Health Serv Outcomes Res Methodology 3:266-277. Adamian Academic Center, Bentley College, Waltham, MA, USA; Center for Health Quality, Outcomes and Economic Research, Veterans Administration Medical […]

Hopkins health pricing tool a managed care hit

Hopkins health pricing tool a managed care hit. Baltimore Business Journal July 21. Baltimore Business Journal, Baltimore, MD, USA Johns Hopkins University’s links with private […]

Event analysis of all-cause and ambulatory care sensitive hospitalization of long-stay nursing home residents

Baltimore, MD, USA: Centers for Medicare and Medicaid Services. Schneider Institutes for Health Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, […]

Adult obesity in Manitoba: prevalence, associations, and outcomes, 3rd edition

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada Obesity is a major public health concern in Canada […]

Healthcare expenditure in the last year of life: the experience of South African medical schemes

Cape Town, South Africa: Actuarial Society of South Africa. School of Management Studies, University of Cape Town, Rondebosch, South Africa The aim of this paper […]

Pressupostos e proposta de modelo para a remuneração do trabalho do médico cirurgião nas operadoras de planos de saúde

São Paulo, Brazil: Fundação Getúlio Vargas, Escola de Administração de Empresas de São Paulo (doctoral dissertation). Published in Portuguese. Fundação Getúlio Vargas, Escola de Administração […]

A predictive model to identify patients at risk of unplanned 30-day acute care hospital readmission

In: 2013 IEEE International Conference on Healthcare Informatics, September 9-11, 2013, Philadelphia, PA, USA. Los Alamitos, CA, USA: IEEE:551-556. Department of Health Policy and Management, […]

Central Midlands CSU Case Study

Midlands and Lancashire CSU – ACG® System Case Management Report

Population Health and Resource Allocation Case Study Payer

Slough CCG used data output from the Johns Hopkins ACG System to gain a better understanding of their patient population, understand the factors that drive […]