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Health Care Reform In the US and England

The Johns Hopkins University Health Care Reform In the US and England: Commonalities and potential contribution of case-mix & predictive risk modeling tools Jonathan Weiner, […]

Applying the ACG® System to a Retrospective Electronic Database

Applying the Johns Hopkins ACG Applying the Johns Hopkins ACG Casemix Casemix System to a Retrospective Electronic Database: A 5 to a Retrospective Electronic Database: […]

Patient Identification with Incomplete Data

DST Health Solutions Patient Identification with Incomplete Data Kelsey Rauch

Tuesday(C6)-Refining Patient Risk Assessment with Clinical Lab Results-Lemke

Refining Patient Risk Assessment with Clinical Lab Results-Klaus Lemke

Tuesday(P3)-Moving the Chronic Care Model into the Future-Wagner

Moving the Chronic Care Model into the Future Ed Wagner, MD, MPH, MACP  MacColl Center for Health Care Innovation  Group Health Research Institute 

The ACG System’s Inception

Donald Steinwachs, PhD, Professor, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health goes through the history of the ACG System, the importance […]

Care Management Program Case Study-Payer

Clalit Health (an integrated delivery system in Israel) used the ACG System to identify high-risk patients for enrollment in a comprehensive complex care management program for its multimorbid population. This led to a reduction in length of time spent in the hospital, reductions in readmission rates and lower costs.

Outcomes of patients with chronic obstructive pulmonary disease diagnosed with or without pulmonary function testing

Background: A small number of people with chronic obstructive pulmonary disease (COPD) receive pulmonary function testing around the time of diagnosis. Because omitting testing increases […]

Defining and Assessing Geriatric Risk Factors and Associated Health Care Utilization Among Older Adults Using Claims and Electronic Health Records

Abstract Background: Using electronic health records (EHRs), in addition to claims, to systematically identify patients with factors associated with adverse outcomes (geriatric risk) among older […]

A Canadian Population-Based Cohort to the Study Cost and Burden of Surgically Resected Hidradenitis Suppurativa

Abstract Background: Hidradenitis suppurativa (HS) is a chronic debilitating disease with long-lasting comorbidities that impose direct and indirect costs on the health care system. However, […]

Medicaid trends in prescription opioid and non-opioid use by HIV status

Abstract   Background Pain is more common among people living with HIV (PLWH) than their counterparts; however, it is unclear whether analgesic use differs by […]

Supporting general practice to make timely decisions for better health care: a population health approach

Abstract Primary Health Networks (PHNs) are tasked to enhance the efficiency and effectiveness of general practice. Gold Coast Primary Health Network (GCPHN) has been collecting […]

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

Abstract Background Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications […]

Prediction of 30-day pediatric unplanned hospitalizations using the Johns Hopkins Adjusted Clinical Groups risk adjustment system

Abstract Background The Johns Hopkins ACG System is widely used to predict patient healthcare service use and costs. Most applications have focused on adult populations. […]

Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto, Canada

Abstract Background The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have […]

Association of Follow-Up Care With Long-Term Death and Subsequent Hospitalization in Patients With Atrial Fibrillation Who Receive Emergency Care in the Province of Ontario

Abstract Background Currently, 11% of patients seen in the emergency department for atrial fibrillation die within 1 year of the visit. Our objective was to […]

Measuring multimorbidity beyond counting diseases: systematic review of community and population studies and guide to index choice

Abstract Objectives To identify and summarise existing indices for measuring multimorbidity beyond disease counts, to establish which indices include mental health comorbidities or outcomes, and […]

Health characteristics of reproductive-aged autistic women in Ontario: A population-based, cross-sectional study

Abstract While an increasing number of girls and women are being identified with autism, we know little about the health of reproductive-aged autistic women. Our […]

The effect of frailty on postoperative readmissions, morbidity, and mortality in endometrial Cancer surgery

Abstract Objectives To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer. Methods Patients with endometrial […]

Association between mental health comorbidity and health outcomes in type 2 diabetes mellitus patients

Abstract Background Type 2 diabetes mellitus (T2D) is often accompanied by chronic diseases, including mental health problems. We aimed at studying mental health comorbidity prevalence […]

Analysis of modifiable and nonmodifiable risk factors in patients undergoing pituitary surgery

Abstract OBJECTIVE Pituitary adenomas (PAs) are among the most common intracranial tumors. Understanding the clinical effects of various modifiable risk factors (MRFs) and nonmodifiable risk […]

Health care service use and costs for a cohort of high-needs elderly diabetic patients

Abstract Aims To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes […]

Management and outcomes of patients with chronic obstructive lung disease and lung cancer in a public healthcare system

Abstract Hypothesis There is limited data on the care and outcomes of individuals with both chronic obstructive pulmonary disease (COPD) and lung cancer, particularly in […]

Guideline interval: A new time interval in the diagnostic pathway for symptomatic cancer

Abstract Background: A standard measure of the cancer diagnostic pathway, diagnostic interval, is the time from “first presentation of cancer” to diagnosis. Cancer presentation may be […]

Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis

Abstract Objective Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and […]

The clinical impact of frailty on the postoperative outcomes of patients undergoing gastrectomy for gastric cancer: a propensity-score matched database study

Abstract Background Frailty aggregates a composite of geriatric and elderly features that is classified into a singular syndrome; literature thus far has proven its influence […]

Outcomes of SARS-CoV-2 infection in cancer versus non-cancer-patients: A population-based study in northeastern Italy

Abstract Introduction This study assesses the risk of infection and clinical outcomes in a large consecutive population of cancer and non-cancer patients tested for SARS-CoV-2 […]

Survival effects of time to surgery for Stage I lung cancer: A population-based study

Abstract Objectives To examine the impact of time to surgery (TTS) on survival among patients with stage I non-small cell lung cancer (NSCLC). Methods All […]

Development and validation of predictive models for unplanned hospitalization in the Basque Country: analyzing the variability of non-deterministic algorithms

Abstract Background The progressive ageing in developed countries entails an increase in multimorbidity. Population-wide predictive models for adverse health outcomes are crucial to address these […]

Health Utilities in People with Hepatitis C Virus Infection: A Study Using Real-World Population-Level Data

Abstract Background Hepatitis C virus (HCV) infection is associated with reduced quality of life and health utility. It is unclear whether this is primarily due […]

Can high-cost spending in the community signal admission to hospital? A dynamic modeling study for urgent and elective cardiovascular patients

Abstract Background Much of the research on high-cost patients in healthcare has taken a static approach to studying what is actually a dynamic process. High-cost […]

Population Health Management: Innovations in Risk Adjustment and Predictive Modeling

Jonathan Weiner, DrPH participated as one of the featured presenters in the 8th Annual Predictive Modeling Web Summit. Watch the below recording of Dr. Weiner’s […]

Using EHR’s Unstructured Data for Risk Stratification

Presented by: Hadi Kharrazi, MHI, MD, PhD
Asst. Professor, JH School of Public Health; Asst. Professor, JH School of Medicine; Research Director, JHCPHIT

This presentation focuses on the potential role of EHR’s unstructured data in identifying frailty markers and improving the prediction of utilization outcomes.

Attention-deficit/hyperactivity disorder in children: excess costs before and after initial diagnosis and treatment cost differences by ethnicity

Arch Pediatr Adolesc Med 160:1063-1069. Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA, USA OBJECTIVES: To estimate the excess costs […]

Comparative analysis of outcome measures used in examining neurodevelopmental effects of early childhood anesthesia exposure

Anesthesiology 120:1319-1332. Columbia University, New York, NY, USA; University of Western Australia, Perth, Australia; Princess Margaret Hospital for Children, Perth, Australia; New York State Psychiatric […]

Inequities in ambulatory care and the relationship between socioeconomic status and respiratory hospitalizations: a population-based study of a Canadian city

Ann Fam Med 12:402-407. University of Manitoba, Winnipeg, MB, Canada PURPOSE: Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive […]

Neurodevelopment of children exposed to anesthesia: design of the Mayo Anesthesia Safety in Kids (MASK) study

Contemp Clin Trials 41:45-54. Mayo Clinic, Rochester, MN, USA; Baylor College of Medicine, Houston, TX, USA; National Center for Toxicological Research, Food and Drug Administration, […]

Diagnosis and treatment of incident hypertension among patients with diabetes: a U.S. multi-disciplinary group practice observational study

J Gen Intern Med 30:768-776. University of Wisconsin, Madison, WI, USA BACKGROUND: Early hypertension control reduces the risk of cardiovascular complications among patients with diabetes […]

Comorbidity burden and health services use in community-living older adults with diabetes mellitus: a retrospective cohort study

Can J Diabetes 40:35-42. University of Alberta, Edmonton, AB, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Women’s College Hospital, Toronto, ON, Canada; McMaster […]

Exploring indicators of use of costly health services in community-dwelling adults with multiple chronic conditions

Prof Case Manag 20:3-11. Mayo Clinic College of Medicine, Rochester, MN, USA; Mayo Clinic, Rochester, MN, USA; Case Western Reserve University, Cleveland, OH, USA Although […]

Comorbidity and the use of primary care and specialist care in the elderly

Ann Fam Med 3:215-222. Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA PURPOSE: The impact of comorbidity on […]

All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: a population based cohort study

PLoS One 9:e91286. Women’s College Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Because […]

Development and application of a population-oriented measure of ambulatory care case-mix

Med Care 29:452-472. Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA This article describes a […]

Adjusted Clinical Groups (ACGs) explain the utilization of primary care in Spain based on information registered in the medical records: a cross-sectional study

Health Policy 76:38-48. Centro de Salud Astrabudua, Consulado Bilbao, Bizkaia, Spain BACKGROUND: Previous studies have shown the validity of Adjusted Clinical Groups (ACGs) in the […]

Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis

Diabetes Care 32:1182-1187. Department of Health Services, University of Washington School of Public Health and Community Medicine, Seattle, WA, USA OBJECTIVE: To test the hypothesis […]

Imputation of 10-year osteoporotic fracture rates from hip fractures: a clinical validation study.

J Bone Miner Res 25:388-392. Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada The World Health Organization (WHO) fracture risk assessment system (FRAX) allows […]

Differences in referral rates to specialised health care from four primary health care models in Klaipeda, Lithuania

BMC Fam Pract 9:63. Lund University, Department of Clinical Sciences in Malmö, General Practice/Family Medicine, Malmö, Sweden BACKGROUND: Lithuanian primary health care (PHC) is undergoing […]

Managing the gap: evaluating the impact of Medicaid managed care on preventive care receipt by child and adolescent minority populations

J Health Care Poor Underserved 21:92-111. St. Mary’s College of Maryland, St. Mary’s City, MD, USA The increased use of managed care in Medicaid warrants […]

Patient web services integrated with a shared medical record: patient use and satisfaction

J Am Med Inform Assoc 14:798-806. Center for Health Studies, Group Health Cooperative, Seattle, WA, USA OBJECTIVES: This study sought to describe the evolution, use, […]

Using the Johns Hopkins’ Aggregated Diagnosis Groups (ADGs) to predict 1-year mortality in population-based cohorts of patients with diabetes in Ontario, Canada

Diabet Med 29:1134-1141. Institute for Clinical Evaluative Sciences, University of Toronto, ON, Canada AIMS: There are limited validated methods to ascertain comorbidities for risk adjustment […]

Quantifying morbidity burdens and medical utilization of children with intellectual disabilities in Taiwan: A nationwide study using the ACG case-mix adjustment system

Res Dev Disabil 33:1270-1278. Department of Medical Affairs and Planning, Taipei Veterans General Hospital, Taipei City, Taiwan, ROC The purpose of this study was to […]

Is it necessary that some patients come to see us so often? Factors associated with primary care use in pediatrics

Gac Sanit 14:195-202. Published in Spanish. Centro de Salud de Astrabudúa (Bizkaia), Osakidetza-Servicio Vasco de Salud, Bilbao, Spain OBJECTIVES: To analyze the relationship between pediatric […]

Development of a claims-based risk score to identify obese individuals

Popul Health Manag 13:201-207. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA Obesity is underdiagnosed, hampering system-based health promotion […]

Comparison of health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington State: a cost minimization analysis

J Altern Complement Med 16:411-417. Department of Health Services, University of Washington, Seattle, WA, USA OBJECTIVES: The purpose of this analysis was to compare health […]

Guided care: cost and utilization outcomes in a pilot study

Dis Manag 11:29-36. Johns Hopkins HealthCare, Glen Burnie, MD, USA Guided Care (GC) is an enhancement to primary care that incorporates the operative principles of […]

Identifying frail older people using predictive modeling

Am J Manag Care 18:e392-e397. Department of Geriatric Medicine, Maccabi Healthcare Services, Tel Aviv, Israel OBJECTIVES: To determine whether a designation of frailty using the […]

A randomized study to decrease the use of potentially inappropriate medications among community-dwelling older adults in a southeastern managed care organization

Am J Manag Care 10:761-768. Department of Medicine and Center for Healthcare Improvement, Medical College of Georgia, Atlanta, Ga, USA BACKGROUND: Despite progress in describing […]

Development and validation of a model for predicting inpatient hospitalization

Med Care 50:131-139. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and School of Medicine, Baltimore, MD, USA BACKGROUND: Hospitalizations […]

Involuntary unemployment and mortality in Taiwan

J Formos Med Assoc 103:900-907. Institute of Public Health, National Yang-Ming University, Taipei, Taiwan. BACKGROUND AND PURPOSE: Unemployment is known to be associated with increased […]

Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients

Infect Control Hosp Epidemiol 29:44-50. Permanente Medical Group, Oakland, CA, USA OBJECTIVE: To determine which antibiotics increase or decrease the risk of Clostridium difficile-associated diarrhea […]

More preventive care, and fewer emergency room visits and prescription drugs–health care utilization in a consumer-driven health plan

Benefits Q 24:46-54. Healthcare Informatics, Blue Cross Blue Shield of Minnesota, USA. Although consumer-driven health plans (CDHPs) have grown dramatically, the question of whether CDHPs […]

Assessing comorbidity using claims data: an overview

Med Care 40:IV-26-IV-35. Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA Comorbidity, […]

Pharmacy- and diagnosis-based risk adjustment for children with Medicaid

Med Care 43:1155-1159. Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Department of Pediatrics, Harvard Medical School, Boston, MA, USA BACKGROUND: Risk […]

The influence of incidental abdominal aortic aneurysm monitoring on patient outcomes

J Vasc Surg 54:1290-1297.e2. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada BACKGROUND: Incidental abdominal aortic aneurysms (AAAs) are identified when the abdomen is […]

Population based study of long-term rates of surgery for urinary incontinence after radical prostatectomy for prostate cancer

J Urol 188:502-506. Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada PURPOSE: Urinary incontinence can be a significant complication of […]

Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases

PeerJ 1:e168. Faculty of Pharmacy, University of Manitoba , Winnipeg, MB, Canada BACKGROUND. Psychotropic medications, in particular second-generation antipsychotics (SGAs) and benzodiazepines, have been associated […]

Comparative safety and effectiveness of sitagliptin in patients with type 2 diabetes: retrospective population based cohort study

BMJ 346:f2267. Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, AB, Canada OBJECTIVE: To determine if the use of sitagliptin […]

Association between fee-for-service expenditures and morbidity burden in primary care

Eur J Health Econ 15:599-610. Faculty of Health Sciences, COHERE-Centre of Health Economics Research, Institute of Public Health, University of Southern Denmark, Odense, Denmark BACKGROUND: […]

Using risk-adjustment models to identify high-cost risks

Med Care 41:1301-1312. Center for Health Research, Northwest and Hawaii, Kaiser Permanente Northwest, Portland, OR, USA BACKGROUND: We examine the ability of various publicly available […]

Predicting persistently high primary care use

Ann Fam Med 3:324-330. Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA PURPOSE: […]

Specialty use among patients with treated hypertension in a patient-centered medical home

J Gen Intern Med Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA BACKGROUND: Little is known about […]

One-year outcomes associated with using observation services in triaging patients with nonspecific chest pain

Clin Cardiol 37:591-596. Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, Texas. BACKGROUND: Observation services are provided in […]

Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH

Ann Fam Med 12:338-343. Group Health Research Institute, Seattle, WA, USA PURPOSE: Telephone- and Internet-based communication are increasingly common in primary care, yet there is […]

Measuring morbidity in populations: performance of the Johns Hopkins Adjusted Clinical Group (ACG) case-mix adjustment system in Manitoba

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada This study examined the performance of the Johns Hopkins […]

Creating meaningful composite scores for primary care

2015 North American Primary Care Research Group Annual Meeting, October 2015, Cancun, Mexico. Context: Composite scores (CSs) provide a global measure of quality. CS development […]

Long-term risk of heart failure associated with adjuvant trastuzumab in breast cancer patients

2014 American Society of Clinical Oncology Annual Meeting. Abstract 9504. J Clin Oncol 32 (suppl; abstr 9504). University of Toronto, Toronto, ON, Canada; St. Michael’s […]

Is the class half empty? A population-based perspective on socioeconomic status and educational outcomes

IRPP Choices 12:1-30. Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine University of Manitoba, Winnipeg, MB, Canada The purpose of […]

Characteristics of risk adjustment systems. Working Paper Series 2

Gainesville, FL, USA: Institute for Child Health Policy, University of Florida. Institute for Child Health Policy, University of Florida, Gainesville, FL, USA Increasing numbers of […]

Using the ACG case-mix adjustment system to evaluate veteran’s morbidity burdens and medical utilizations in Taiwan

J Healthc Manag 8:67-84. Published in Chinese. Department of Medical Affairs and Planning, Taipei Veterans General Hospital, Taipei City, Taiwan, ROC OBJECTIVES: Veterans have been […]

Performance of risk adjusted capitated systems in allocating a global budget

Baltimore, MD, USA: Johns Hopkins University (doctoral dissertation). Johns Hopkins University, Baltimore, MD, USA Rapidly rising health care costs in the United States have led […]

The Adjusted Clinical Groups (ACGs) system in Osakidetza

Final report (1/05/2003 – 30/04/2003). Vitoria-Gasteiz, Spain: Osakidetza Servicio vasco de salud. Published in Spanish. Osakidetza Servicio vasco de salud, Vitoria-Gasteiz, Spain No abstract

How are Manitoba’s children doing?

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada The health and development of Manitoba’s children were examined […]

Using selected diagnoses to improve the Chilean capitation formula

Greifswald, Germany: Ernst Moritz Arndt University of Greifswald. Ernst Moritz Arndt University of Greifswald, Greifswald, Germany OBJECTIVES: To contribute to the policy discussion of equity […]

Home health services in British Columbia: a portrait of users and trends over time

Home health services in British Columbia: a portrait of users and trends over time. Vancouver, BC, Canada: University of British Columbia. University of British Columbia, […]

The effect of a coordinated care program on uninsured, chronically ill patients

Richmond, VA, USA: Virginia Commonwealth University (doctoral dissertation). Virginia Commonwealth University, Richmond, VA, USA This study explored how being enrolled in a program that both […]

Equity in the use and financing of medicines in British Columbia before and after the move to income-based pharmacare

Vancouver, BC, Canada: University of British Columbia (doctoral dissertation). University of British Columbia, Vancouver, BC, Canada BACKGROUND: In May 2003, the B.C. government introduced an […]

Utilizacion de servicios de salud en atencion primaria del area 11 de Madrid y nivel psicobioquimico de estres y de salud bucodental en su poblacion immigrante y autoctona

Madrid, Spain: Universidad Complutense de Madrid (masters thesis). Published in Spanish. Universidad Computense de Madrid, Madrid, Spain La naturaleza trashumante de la Humanidad le es […]

Developing decision trees to classify patients suited for similar interventions by combining clinical judgments with Leeds Risk Stratification Tool

London, UK: London School of Economics and Political Science. London School of Economics and Political Science, London, UK The objectives of the project are to […]

What is most important: social factors, health selection, and adolescent educational achievement

Soc Indic Res 110:385-414. Department of Community Health Sciences, Faculty of Medicine, Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada This paper […]

Case Finding & Population Profiling – Separate Disciplines or Both Sides of the Same Coin?

This award-winning document presented at the 2015 PCSI conference highlights work undertaken with Slough Clinical Commissioning Group in the UK. The work has challenged some […]

Leicester City CCG Case Study 2

 Use of ACG® System output to support practices in participating in a medicines management scheme – STOPP-START

Care Management Program Case Study-Payer

Clalit Health (an integrated delivery system in Israel) used the ACG System to identify high-risk patients for enrollment in a comprehensive complex care management program […]

Case-Mix Information Uses and Health Services Sustainability

Iasist Casemix Information Uses and Health Services Sustainability: A Few Examples From Current Spanish Downturn Mercè Casas Carles Illa

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