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Predictive Modelling in Action

An introduction to the principles of predictive modeling in health care and examples of how predictive models are being used in the NHS in England. Learn more.

Do physicians who diagnose more mental health disorders generate lower health care costs?

J Fam Pract 49:305-310. University of Rochester School of Medicine, New York, NY, USA BACKGROUND: Underrecognition and undertreatment of mental health disorders in primary care […]

A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario

BMC Public Health 14:161. Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada BACKGROUND: As people diagnosed with HIV and receiving combination antiretroviral […]

Health information exchange and the frequency of repeat medical imaging

Am J Manag Care 20:eSP16-24. Weill Cornell Medical College, New York, NY, USA OBJECTIVES: Medical imaging, which is expensive, is frequently repeated for the same […]

Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study

Stroke 46:108-113. University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND AND PURPOSE: […]

The effect of pelvic fractures on future stress incontinence and pelvic organ prolapse surgery

Int Urogynecol J Western University, London, ON, Canad INTRODUCTION AND HYPOTHESIS: Pelvic fractures in women significantly disrupt the pelvic floor, which may cause stress urinary […]

Association between metformin use and mortality after cervical cancer in older women with diabetes

Cancer Epidemiol Biomarkers Prev 25:507-512. University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Women’s College Hospital, Toronto, ON, Canada; Institute of […]

Effect of specialized diagnostic assessment units on the time to diagnosis in screen-detected breast cancer patients

Br J Cancer 112:1744-1750. Queen’s University, 10 Stuart Street, Kingston, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada; Kingston General Hospital, Kingston, ON, Canada; University […]

Is the association between physical activity and healthcare utilization affected by self-rated health and socio-economic factors?

BMC Public Health 15:737. Lund University, Malmö, Sweden BACKGROUND: Physical activity and healthcare utilization has negative association. However, there appears to be limited knowledge of […]

Full-service family practice in British Columbia: policy interventions and trends in practice, 1991-2010

Healthc Policy 9:32-47. University of British Columbia Vancouver, BC, Canada BACKGROUND: British Columbia’s primary care reform (initiated in 2002) aims to promote “full-service family practice” […]

Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses

Health Care Financ Rev 17:77-99. Johns Hopkins School of Public Health, Baltimore, MD, USA Researchers at The Johns Hopkins University (JHU) developed two new diagnosis-oriented […]

Patient ability and willingness to participate in a web-based intervention to improve hypertension control.

J Med Internet Res 13:e1. Group Health Research Institute, Seattle, WA, USA BACKGROUND: Patient-shared electronic health records provide opportunities for care outside of office visits. […]

Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide

Ann Fam Med 10:134-141. Academic Unit of Primary Health Care, School of Social and Community Medicine, Bristol University, Bristol, UK PURPOSE: Many patients consulting in […]

Development of a risk-adjusted capitation model based on principal inpatient diagnoses in Taiwan

J Formos Med Assoc 102:637-643. Graduate Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan BACKGROUND AND PURPOSE: Taiwan’s […]

Use of proton pump inhibitors and risk of osteoporosis-related fractures

CMAJ 179:319-326. Department of Gastroenterology, Division of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada BACKGROUND: The use of proton pump inhibitors has been associated […]

Formal risk adjustment by private employers

Inquiry 38:299-309. Department of Economics, Boston University, Boston, MA, USA This paper explores explanations for why few private employers have adopted formal risk adjustment. The […]

Patient use of secure electronic messaging within a shared medical record: a cross-sectional study

J Gen Intern Med 24:349-355. Group Health Cooperative, Center for Health Studies, Seattle, WA, USA BACKGROUND: Most patients would like to be able to exchange […]

HMO family physicians: men and women differ in their work

HMO Pract 9:155-161. Group Health Cooperative of Puget Sound, Seattle, WA, USA OBJECTIVE: The goal was to identify differences in the type of work and […]

Effect of premium, copayments, and health status on the choice of health plans

Med Care 46:1033-1040. Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA OBJECTIVE: Explore effects of comorbidity […]

Patient sharing among physicians and costs of care: a network analytic approach to care coordination using claims data

J Gen Intern Med 28:459-465. Johns Hopkins University School of Medicine, Baltimore, MD, USA BACKGROUND: Improving care coordination is a national priority and a key […]

Case-mix index and length of hospitalization

G Chir 31:211-214. Published in Italian. Department of Surgical Sciences, Sapienza University of Rome, Italy. The ACG (Adjusted Clinical Groups) case-mix system is a classification […]

ACG case-mix system aids contract assessment, improves performance

Data Strateg Benchmarks 4:21-26. The ABCs of ACGs. Adjusted clinical groups, or ACGs, a risk adjustment system developed by Baltimore-based Johns Hopkins University, are being […]

Realigning incentives in fee-for-service Medicare

Health Aff 22:59-70. Schneider Institute for Health Policy, Brandeis University, Waltham, MA, USA This paper proposes Medicare payment reform built on the fee-for-service system, with […]

Work limitations and their relationship to morbidity burden among academic health center employees with diabetes

Workplace Health Saf 60:425-434. Department of Acute and Chronic Care, John Hopkins University School of Nursing, Baltimore, MD, USA The objective of this study was […]

Population-based trends in osteoporosis management after new initiations of long-term systemic glucocorticoids (1998-2008)

J Clin Endocrinol Metab 97:1236-1242. University of Alberta and University of Alberta Hospital, Edmonton, AB, Canada OBJECTIVES: Our objective was to describe changes in glucocorticoid-induced […]

Ambulatory care casemix measures

J Gen Intern Med 10:162-170. HSR&D Field Program, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA No abstract PMID: 7769475

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in Medicaid

J Health Care Poor Underserved 15:562-575. General Internal Medicine and Health Services Research, UCLA School of Medicine, Los Angeles, CA, USA. We evaluated racial and […]

The effect of acupuncture utilization on healthcare utilization

Med Care 46:41-48. Department of Pharmacy Practice, Albany College of Pharmacy, Research Institute for Health Outcomes, Albany, NY, USA OBJECTIVE: To determine whether acupuncture is […]

A systematic review of health care efficiency measures

Health Serv Res 44:784-805. RAND, Arlington, VA, USA OBJECTIVE: To review and characterize existing health care efficiency measures in order to facilitate a common understanding […]

Achieving cost control, care coordination, and quality improvement in the Medicaid program

J Ambul Care Manage 33:38-49; discussion 69-70. ACS Government Healthcare Solutions, Helena, MT, USA As Medicaid spending rises quickly, controlling cost while coordinating care and […]

Bone microarchitecture assessed by TBS predicts osteoporotic fractures independent of bone density: the Manitoba study

J Bone Miner Res 26:2762-2769. Bone Disease Unit, University of Lausanne, Lausanne, Switzerland The measurement of BMD by dual-energy X-ray absorptiometry (DXA) is the “gold […]

Two-year trends in colorectal cancer screening after switch to a high-deductible health plan

Med Care 49:865-871. Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA BACKGROUND: Recent health reform laws might […]

Postoperative health-care utilization in Crohn’s disease: the impact of specialist care

Am J Gastroenterol 107:1522-1529. Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, ON, Canad OBJECTIVES: Crohn’s disease (CD) patients frequently require […]

How does complementary private prescription drug insurance coverage affect seniors’ use of publicly funded medications?

Health Policy 110:147-155. School of Public Policy and Governance, University of Toronto, Toronto, ON, Canada BACKGROUND: Like in many other high-income jurisdictions, the public drug […]

Division of primary care services between physicians, physician assistants, and nurse practitioners for older patients with diabetes

Med Care Res Rev 70:531-541. University of Wisconsin–Madison, WI, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA Team-based care involving physician assistants and/or […]

Resources allocation and health care needs in diabetes care in Danish GP clinics

Health Policy 113:206-215. Institute of Public Health, Centre of Health Economics Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark BACKGROUND: In several […]

Measuring medical productivity to gauge the value of Medicare

Minn Med 96:46-48. Department of Finance, Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota, Minneapolis, MN, USA. Having a measure of productivity […]

The effect of medical malpractice liability on rate of referrals received by specialist physicians

Health Econ Policy Law 8:453-475. Yale University School of Medicine, New Haven, CT, USA; Wayne State University, Detroit, MI, USA; University of Michigan, School of […]

Determinants of buprenorphine treatment for opioid dependence

J Subst Abuse Treat 46:315-319. Washington State University, Spokane, WA, USA; Group Health Research Institute, Seattle, WA, USA This study assessed the social, demographic and […]

How is the electronic health record being used? Use of EHR data to assess physician-level variability in technology use

J Am Med Inform Assoc Weill Cornell Medical College, New York, NY, USA BACKGROUND: Studies of the effects of electronic health records (EHRs) have had […]

Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up

Health Aff 33:764-769. University of Louisville, Louisville, KY, USA; University of Minnesota, Minneapolis, MN, USA During the past thirty years outpatient surgery has become an […]

The association between parental depression and children’s health care utilization and expenditures: exploring the dimensions of parental gender and timing of depressive symptoms

Baltimore, MD, USA: Johns Hopkins University (doctoral dissertation). Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA Methods: The study used multiple […]

A descriptive analysis of the Ontario MedsCheck annual pharmacy medication review service

Canadian Pharmacists Journal 148:S27. OBJECTIVES: A MedsCheck Annual (MCA) consultation is a medication review service funded by the Ontario government for people taking three or […]

Associations among socioeconomic status (SES), patterns of care and outcomes in breast cancer (BC) patients (pts) in a universal health care system: Ontario’s experience

2014 American Society of Clinical Oncology Annual Meeting. Abstract 6625. J Clin Oncol 32 (suppl; abstr 6625). University of Toronto, Toronto, ON, Canada; Sunnybrook Health […]

The impact of not having a primary care physician among people with chronic conditions

Toronto, ON, Canada: Institute for Clinical Evaluative Sciences. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Primary care plays a pivotal role in health […]

Using the Adjusted Clinical Groups System to identify high-risk hemodialysis patients in Taiwan

J Healthc Manag 11:311-326. Published in Chinese. OBJECTIVES: There has been a rising number and cost of patients with regular hemodialysis in Taiwan. The objective […]

Risk distribution and risk assessment among enrollees in Washington state’s Medicaid SSI population

Hamilton, NJ, USA: Center for Health Care Strategies. Center for Health Care Strategies, Hamilton, NJ, USA Washington state began enrolling Medicaid SSI (low income, disabled) […]

Risk adjustment and rate setting methods in public programs

A report to legislature. St. Paul, MN, USA: Minnesota Department of Health. Health Economics Program, Minnesota Department of Health, St. Paul, MN, USA The 1995 […]

Updating and calibrating the Johns Hopkins University ACG/ADG risk adjustment method for application to Medicare risk contracting

Final report to Health Care Financing Administration. Baltimore, MD, USA: Johns Hopkins University. Johns Hopkins University, Baltimore, MD, USA The Balanced Budget Act (BBA) of […]

An operational framework for paying physician specialists a risk-adjusted fixed payment and incorporating the results in a global premium rating model

Los Angeles, CA, USA: UCLA (doctoral dissertation). University of California, Los Angeles, CA, USA The demand for more accurate and equitable professional medical specialty payments […]

Characteristics and utilization patterns of high-cost recipients in Medicaid population

MEDTAP 2001-2003 Research Project #1. Cincinnati, OH, USA: University of Cincinnati and Institute for Health Policy and Health Services Research. University of Cincinnati and Institute […]

Adjusting for patients’ clinical case mix explains variation in general practice prescribing

Research report no. 291, Department of Statistical Science. London, UK: University College London. University College London, London, UK BACKGROUND: The potential of using patient-level measures […]

Investigating whether the Johns Hopkins ACG case-mix system explains variation in UK general practice

London, UK: University College London (doctoral dissertation). University College London, London, UK This thesis describes the first large-scale studies in the United Kingdom to adjust […]

Familial aggregation of childhood health and the socioeconomic gradient of disease: a longitudinal population-based sibling analysis

Winnipeg, MB, Canada: University of Manitoba (masters thesis). University of Manitoba, Winnipeg, MB, Canada The Johns Hopkins ACG(r) Case-Mix System grouped various physician and hospital […]

Impact of rheumatoid arthritis on recognition of hypertension in a medically homed population

Arthritis Rheum 64:S712-S713. University of Wisconsin, Madison, WI, USA BACKGROUND/PURPOSE: Numerous studies report increased cardiovascular disease (CVD) events and others describe increased arterial stiffness in […]

Adjusted Clinical Groups (ACG) and co-morbidity

ImPrim Report D. Karlskrona, Sweden: ImPrim. Blekinge Centre of Competence, Karlskrona, Sweden No abstract

Depression, anxiety disorders, and related health care utilization in the Manitoba Metis population

Winnipeg, MB, Canada: Manitoba Metis Federation. Manitoba Metis Federation, Winnipeg, MB, Canada This report resulted from the need to understand further the findings in the […]

Leicester City CCG Case Study 3

Use of ACG® System output to support distribution of CCG Better Care Fund monies

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 […]

Poster: Morbidity Burden Resource Use and Quality of Care of Diabetic Patients

Morbidity burden, resource use and quality of care of diabetic patients: A 4-year cohort analysis at a regional hospital in Thailand. Roongkarn Pannarunothai, Buddhachinaraj Hospital, […]

Embedding ACGs in Berkshire

NHS Berkshire Embedding ACGs in Berkshire Karen Grannum Primary Care Business Intelligence Lead

Using the ACG Toolkit to Support Population Monitoring

DST Health Solutions Using the ACG Toolkit to Support Population Monitoring Lisa Kabasakalian

Monday(C3)-Identifying Potentially Actionable Chronic Disease Patterns From Diagnoses Reported in Administrative Claims-Dave Bodycombe

Identifying Potentially Actionable Chronic Disease Patterns From Diagnoses Reported in Administrative Claims —Dave Bodycombe, Johns Hopkins University

Tuesday(C6)-Integration of claim-based diagnoses with diagnoses from General Practitioners (GPs) clinical database records improves the comorbidity description”-Corti

 Integration of claim-based diagnoses with diagnoses from General  Practitioners (GPs) clinical database records improves the comorbidity description” Maria Chiara Corti,  E. Schievano F. Avossa, K. Kinder, […]

What causes ’poly-morbidity’? Searching for triggers of multi-morbidity: tracing patient record 30 years back

Lennart Carlsson, PhD; Gunnar H Nilsson, Professor; Centre for Family Medicine, Karolinska Institutet, Sweden

Beyond Risk Scores: Lisa Kabasakalian, DST Health Solutions

ACG System DST Health Solutions Beyond Risk Scores: Identifying “High-Risk” and “At-Risk” Populations Lisa Kabasakalian

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The ACG System Worldwide

ACG System Executive Director Karen Kinder, PhD, provides a candid tour of the ACG System’s international history and evolution to what is now the most […]

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Population Segmentation Case Study – Government

Three Clinical Commissioning Groups (CCGs) analyzed their local populations as part of a new national initiative to address the care of people who are frail.  Learn more.

Post-acute pathways among hip fracture patients: a system-level analysis

Background: Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines […]

Examination of Health System Resources and Costs Associated With Transitioning Cancer Survivors to Primary Care: A Propensity-Score–Matched Cohort Study

Background: Transitioning low-risk cancer survivors back to their primary care provider (PCP) has been shown to be safe but the effect on health system resources […]

Using EMRALD to assess baseline body mass index among children living within and outside communities participating in the Ontario, Canada Healthy Kids Community Challenge

Abstract   Objectives The Healthy Kids Community Challenge is a large-scale, centrally-coordinated, community-based intervention in Ontario, Canada that promotes healthy behaviours towards improving healthy weights […]

The Association Between Continuity of Primary Care and Preventive Cancer Screening in Women With Intellectual Disability

Abstract Women with intellectual disability have low screening rates for breast and cervical cancer. This population-based cohort study examined the association between the level of […]

The Lifestyle Medicine Physician’s Case to Self-Insured Employers: A Business Model for Physicians, a Bargain for Companies

Abstract   A majority of Americans have health care insurance through their employers, the cost for which is rising at an alarming rate. Unfortunately, higher […]

Predicting Short-Term Outcomes After Radical Cystectomy Based on Frailty

Abstract Objective To evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer. Material and Methods We […]

Production of physician services under fee‐for‐service and blended fee‐for‐service: Evidence from Ontario, Canada

Abstract We examine family physicians’ responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003–2008, a period during which […]

Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy

Abstract Background Relatively few studies investigated the importance of frailty in radical cystectomy (RC) patients. We tested the ability of frailty, using the Johns Hopkins […]

Patient-reported symptoms following diagnosis in esophagus cancer patients treated with palliative intent

Summary The majority of patients with esophagus cancer have advanced-stage disease without curative options. For these patients, treatment is focused on improving symptoms and quality […]

Peri‐complication diagnosis of hepatitis C infection: Risk factors and trends over time

Abstract Background & Aims Hepatitis C virus (HCV) is a common and treatable cause of cirrhosis and its complications, yet many chronically infected individuals remain […]

Using Health Plan Authorization Data to Predict Hospitalizations and Readmissions in a Combined Commercial and Medicaid Population

Abstract Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and […]

Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

Abstract Background Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality […]

Breast cancer diagnosis and treatment wait times in specialized diagnostic units compared with usual care: a population-based study

Abstract Background Breast assessment sites (bass) were developed to provide expedited and coordinated care for patients being evaluated for breast cancer (bca) in Ontario. We […]

Epidemiology and Impact of Spinal Cord Injury in the Elderly: Results of a Fifteen-Year Population-Based Cohort Study

Abstract Objective Although experience suggests a shift in the epidemiology of spinal cord injury (SCI) toward an older demographic, population studies are lacking. We aimed […]

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes

ABSTRACT Objectives There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are […]

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study

Abstract Background Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those […]

Prevalence, determinants, and outcomes of SARS-COV-2 infection among cancer patients. A population-based study in northern Italy

Abstract Background It is well established that cancer patients infected with SARSCoV-2 are at particularly elevated risk of adverse outcomes, but the comparison of SARS-CoV-2 […]

Outcomes after the regionalization of care for high-grade endometrial cancers: a population-based study

Abstract Background In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that […]

Pre-operative wait times in high-grade non-endometrioid endometrial cancer: Do surgical delays impact patient survival?

Abstract Objective Practice guidelines advocating for regionalization of endometrial cancer surgery to gynecologic oncologists practicing in designated gynecologic oncology centres were published in Ontario in […]

Patterns Of Multimorbidity Of Patients In Geriatric Care – A Register-Based Cohort Study In Sweden

Abstract Background Patients in geriatric care display a high degree of multimorbidity. We aimed to explore and visualise various patterns of multimorbidity in a person-oriented […]

Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population

Abstract Patients enrolled in Medicaid have significantly higher social needs (SNs) than others. Using claims and electronic health records (EHRs) data, managed care organizations (MCOs) […]

Creating a Cost-map From Claims Data to Guide Improvement Actions for Children With Asthma

Abstract Purpose It is difficult to reduce cost and improve quality without knowledge pertaining to the distribution of expenses in the population in question. We […]

Effect of sustained virologic response on liver-related mortality among individuals living with hepatitis C by treatment era: A population-based retrospective cohort study

Abstract Purpose Sustained virologic response (SVR) is a validated surrogate marker for successful hepatitis C virus (HCV) treatment. Historically, interferon-based therapies, the standard of care […]

Risk Profile of Young Adults with Chronic Obstructive Pulmonary Disease

Abstract Background: COPD risk profiles have been described in populations comprised of or including older adults, leaving factors associated with COPD in younger adults overlooked. […]

Variations in multimorbidity measurement in studies evaluating hospitalisation in older adults: a systematic review

Abstract Background Multimorbidity is the coexistence of two or more chronic diseases, and in older adults is more common which can lead to increased rates […]

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ACG System White Paper

 THE JOHNS HOPKINS ACG® SYSTEM is a leading risk measurement methodology that was developed and continues to be tested and improved at the Bloomberg School […]

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Risk Stratification: Identifying Geriatric Frailty from EHR Unstructured Data

With providers engaging more with risk stratification tools, unstructured data and free text from Electronic Health Records (EHRs), a potential exists to more effectively identify […]

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Care Density: A Social Network Approach to Claims Data

If optimizing quality of care, clinical outcomes and cost effectiveness is one of your priorities, ensuring your patient population receives comprehensive, coordinated care from their […]