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Outcomes of care for South Carolina Medicaid managed care enrollees, state fiscal year 2007

Final report to the South Carolina Department of Health and Human Services. Columbia, SC, USA: University of South Carolina. University of South Carolina, Columbia, SC, […]

Primary health care reimbursement based on socioeconomics or disease burden

Primärvårdsersättning efter socioekonomi eller sjukdomsbörda. [Primary health care reimbursement based on socioeconomics or disease burden. Registry study from Östergötland shows different results depending on analysis […]

Implementation of electronic medical records and preventive services: a mixed methods study

Toronto, ON, Canada: University of Toronto (masters thesis). University of Toronto, Toronto, ON, Canada The implementation of Electronic Medical Records (EMRs) may lead to improved […]

Primärvården som koordinator för de mest sjuka äldre – implikationer för mål och indikatorer

In: Karlsson AK, Winberg H, ed. På väg mot en värdefull styrning. LHC Report: #1, 2012. Stockholm, Sweden: Stiftelsen Leading Health Care:150-172. Published in Swedish. […]

Demand for health among Canadians: roles of immigration status, country of origin, and year since migration

Toronto, ON, Canada: University of Toronto (doctoral dissertation). University of Toronto, Toronto, ON, Canada This thesis investigates the effects of immigration status, country of origin, […]

Complications following total joint arthroplasty in patients with rheumatoid arthritis

Toronto, ON, Canada: University of Toronto (doctoral dissertation). University of Toronto, Toronto, ON, Canada BACKGROUND: Total joint arthroplasty (TJA) is indicated in persons with end-stage […]

Working for Better Health in Wandsworth -The ACG System’s role in transforming services through innovative care models

Working for Better Health in Wandsworth -The ACG System’s role in transforming services through innovative care models

Leicester City CCG Case Study 1

Use of ACG® System output to support practices in participating in the Unplanned Admissions DES 2014-15

Predictive Models in the ACG® System: Recalibration of Existing Models and Development of New Ones

This short report provides details of the second recalibration of the existing models and the development of new models that was carried out by the […]

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 

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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 […]

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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.

New Summary Measures of Population Health and Well-Being for Implementation by Health Plans and Accountable Care Organizations

Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Sachin Rauri, MS; Juliana O. Tillema, MPA; Nicolaas P. Pronk, PhD, FACSM; Susan M. Knudson, MA […]

Comprehensive preventive care assessments for adults with intellectual and developmental disabilities-Part 1: How do we know if it’s happening?

Objective To determine how to best measure the provision of comprehensive preventive care assessment to adults with IDD. Design Cross-sectional. Setting Ontario. Participants Adults with […]

Comparing Five Comorbidity Indices to Predict Mortality in Chronic Kidney Disease: A Retrospective Cohort Study

Abstract Background: Several different indices summarize patient comorbidity using health care data. An accurate index can be used to describe the risk profile of patients, […]

Exploring the use of machine learning for risk adjustment: A comparison of standard and penalized linear regression models in predicting health care costs in older adults

Abstract   Background Payers and providers still primarily use ordinary least squares (OLS) to estimate expected economic and clinical outcomes for risk adjustment purposes. Penalized […]

Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada

Abstract Study design Retrospective cohort study. Objectives The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord […]

Impact of timing of methadone initiation on perinatal outcomes following delivery among pregnant women on methadone maintenance therapy in Ontario

Abstract BACKGROUND AND AIMS Methadone maintenance therapy (MMT) is associated with improved outcomes for children exposed to maternal opioid dependence in utero. We examined Ontario’s […]

Home care nursing after elective vascular surgery: an opportunity to reduce emergency department visits and hospital readmission

Abstract Background Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research. Objective To quantify regional variation in home care […]

Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada

Abstract Importance  Sex-based income disparities are well documented in medicine and most pronounced in surgery. These disparities are commonly attributed to differences in hours worked. […]

Emergency department use among young adult Medicare beneficiaries with autism and intellectual disabilities

Abstract Background Individuals on the autism spectrum are at greater risk for a variety of co-occurring psychiatric and medical conditions, which could result in greater […]

Serious infections in patients with myasthenia gravis: population‐based cohort study

Abstract Background and purpose To characterize the frequency and risk of serious infections in patients with myasthenia gravis (MG) relative to age/sex/area‐matched comparators. Methods This […]

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

Abstract Background Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published […]

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture

Aims Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective […]

90-90-90 for everyone?: Access to HIV care and treatment for people with HIV who experience imprisonment in Ontario, Canada

ABSTRACT Background We examined HIV care and treatment in prison and after release for people with HIV in Ontario, Canada, and compared HIV care and […]

Correlation between potentially inappropriate medication and Alzheimer’s disease among the elderly

Abstract Purpose This study is conducted to explore the association between potentially inappropriate medication (PIM) and Alzheimer’s disease (AD) among the elderly. Methods We used […]

Fracture Risk in Patients with Myasthenia Gravis: A Population-Based Cohort Study

Abstract Objective Prednisone is a common treatment for myasthenia gravis (MG), and osteoporosis is a known potential risk of chronic prednisone therapy. Our aim was […]

Impact of frailty on inpatient outcomes in thyroid cancer surgery: 10-year results from the U.S. national inpatient sample

Abstract Background Frailty is linked to perioperative morbidity and mortality. We evaluated the impact of preoperative frailty on inpatient outcomes of patients undergoing surgery for […]

Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study

Abstract Background Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, […]

Type 1 diabetes prevalence and incidence rates in the pediatric population of Veneto Region (Italy) in 2015–2020

Abstract The prevalence of Type 1 Diabetes (T1D) in the Veneto Region (Italy) in the 2015–2020 years was 152.5/100,000 subjects and the incidence 19.7/100,000 person-years. Accordingly, Veneto Region […]

Second and later-line erlotinib use in non-small cell lung cancer: real world outcomes and practice patterns overtime in Canada

Abstract Background In Canada, epidermal growth factor receptor (EGFR) inhibitor therapies in advanced non-small cell lung cancer (NSCLC) were initially approved regardless of EGFR status. The purpose […]

Patient Service Utilization Among Individuals with Co‑occurring Disorders: A Comparison of Two Models of Care Coordination

Abstract Background Healthcare systems have increasingly adopted integrated care models with demonstrated effectiveness. However, few studies examine integrated care for individuals with co-morbid mental illness […]

Effectiveness of COVID-19 vaccines against symptomatic SARS-CoV-2 infection and severe outcomes with variants of concern in Ontario

Abstract SARS-CoV-2 variants of concern (VOC) are more transmissible and may have the potential for increased disease severity and decreased vaccine effectiveness. We estimated the […]

Assessing the Added Value of Vital Signs Extracted from Electronic Health Records in Healthcare Risk Adjustment Models

Abstract Objective Patient vital signs are related to specific health risks and outcomes but are underutilized in the prediction of health-care utilization and cost. To […]

Hip Fractures in Adults with Schizophrenia: A Population-based Evaluation of the Burden and Quality of Care

Abstract Hip fractures have life-altering consequences. Individuals with schizophrenia may experience a higher likelihood of hip fractures, worse postfracture outcomes, and suboptimal care. This thesis […]

Impact of Immigration Status on Survival Among Stage 1 and 2 HER2-Positive and Triple-Negative Breast Cancer in Ontario, Canada

ABSTRACT Background This study examined death from breast cancer and death from other causes among women with Stage 1 and 2 Her2-positive and triple-negative breast […]

The Impact of Frailty on Short-Term Outcomes After Surgery for Zenker Diverticulum

Abstract Objective Determine relationship between frailty and hospital mortality, length of stay, cost, and medical and surgical complications in Zenker diverticulum surgery. Study Design Retrospective […]

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 […]

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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 […]

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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 […]

Atypical antipsychotic drugs and the risk for acute kidney injury and other adverse outcomes in older adults: a population-based cohort study

Ann Intern Med 161:242-248. London Health Sciences Centre, London, ON, Canada; St. Michael’s Hospital, Toronto, ON, Canada; Yale University and Veterans Affairs Medical Center, New […]

Conspicuous consumption: characterizing high users of physician services in one Canadian province

J Health Serv Res Policy 8:215-224. http://www.ncbi.nlm.nih.gov/pubmed/14596756. Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada OBJECTIVES: To examine medical […]

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario

Curr Oncol 22:97-104. Women’s College Research Institute, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: […]

READMIT: A clinical risk index to predict 30-day readmission after discharge from acute psychiatric units

J Psychiatr Res 61:205-213. Women’s College Hospital, Toronto, ON, Canada; Women’s College Research Institute, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; […]

Geriatric conditions in patients undergoing defibrillator implantation for prevention of sudden cardiac death: prevalence and impact on mortality

Circ Cardiovasc Qual Outcomes 9:23-30. Johns Hopkins University Baltimore, MD, USA; Yale School of Medicine, New Haven, CT, USA; University of Colorado, Aurora, CO, USA; […]

Association of anxiety and depression with hypertension control: a US multidisciplinary group practice observational study

J Hypertens 33:221-2222. University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Veterans Affairs Pittsburgh Healthcare System. Pittsburgh, PA, USA; University of […]

Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study

Arthritis Rheumatol 67:162-168. University of Toronto, Toronto, Ontario, Canada OBJECTIVE: Therapeutic intraarticular injections are used in the management of hip osteoarthritis (OA). Some studies suggest […]

Adjusting for case mix and social class in examining variation in home visits between practices

Fam Pract 21:355-363. Public Health Policy Unit, School of Public Policy, University College London, London, UK OBJECTIVES: The purpose of this study was to investigate […]

Profiling primary care physician resource use: examining the application of case mix adjustment

J Ambul Care Manage 19:60-80. Health Services Research and Development Center, Johns Hopkins School of Public Health, Baltimore, MD, USA Growing emphasis on managed care […]

Towards a more equitable distribution of resources and assessment of quality of care: validation of a comorbidity based case-mix system

Harefuah 149:665-669. Published in Hebrew. Planning & Health Policy Division, Clalit Health Services Head Offices, Israel BACKGROUND: Equitable distribution of healthcare resources and fair assessments […]

Forecasting physician workforce requirements

JAMA 273:111; author reply 113. Dr Weiner1 presents an exacting analysis of the likely effects of health system reform on physician workforce requirements. His market approach […]

Healthcare utilization patterns and risk adjustment under Taiwan’s National Health Insurance system

J Formos Med Assoc 101:52-59. Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan BACKGROUND AND PURPOSE: Some […]

06 Working Together to Deliver Population Health – Chris Roche

Chris Roche Information Manager Gloucestershire STPPlease note: There are three buttons below. One will link to the presentation slides. One will link to a separate […]

07 Using Predictive Models to Support Case Finding – David Brown & Peter Glover

Dr. David Brown Peter Glover Farnham Integrated Care Services

08 Risk-Adjusted Resource Allocation in Leicester – Mark Pierce

Mark Pierce Senior Strategy & Implementation Manager Leicester City CCG

Conference Welcome – Amy Salls

ACG Training Conference WelcomeAmy Salls Director, Population Health Strategy DST Health Solutions 

01 Welcome & Introduction – Alan Thompson

Alan Thompson Director of User Support Johns Hopkins HealthCare Solutions

02 Population Health Management – Ming Tang

Ming Tang Director of Data & Analytics Data, Analysis and Insights Service (DAIS) NHS England and NHS Improvement

Welcome & Introduction – Jonathan Weiner & Mark Cochran

Welcome and IntroductionJonathan Weiner Professor and Director, Center for Population Health IT  Mark Cochran Executive Director, Johns Hopkins HealthCare Solutions

03 Complex Case Management Programme – Jim O’Donnell

Dr. Jim O’Donnell Slough Locality Lead, NHS East Berkshire CCG Frimley ICS Clinical Commissioning Lead EBCCG Reducing Variation Workstream Clinical Lead Deputy Chair Slough Wellbeing […]

04 Advances in Population Health Sharing Insights – GE Healthcare & Sollis

Pat Nichols, GE Sarah Ouanhnon, GE Graham Head, Sollis

05 From Cake-mix to Case-mix – David Shepherd

Dr. David Shepherd GP & HNN Lead Leicester City CCG

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New Medicaid Enrollees with Highest Care Needs

The ACG System can help identify new Medicaid enrollees with high care needs.

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COVID-19: Marathon Health Outreach

By leveraging the Johns Hopkins ACG System, Marathon Health was able to offer outreach and options to individuals identified as a higher risk of contracting or experiencing complications as a result of COVID-19.

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Recalibration of Predictive Models

This short report provides details of the third recalibration of the predictive models within the ACG System for the UK.

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Reducing Disparities in the Delivery of Primary Care

This report details the work of 2020 Starfield award winner Discovery Health to demonstrate, using the Johns Hopkins ACG System, the impact of improving primary care utilization.

01 David Shephard – Casemix Adjustment in Primary Care

Dr. David Shephard GP and Health Need Neighbourhood Chair, Leicester South

Session 1: Brad Myers – Version 12 Supplementary Data

Version 12 Supplementary Medical ServicesBrad Myers DST Health Solutions 

01 Karen Kinder Welcome Presentation

ACG System Dr. Karen Kinder Executive Director

Session 1: Mitchell – Assessing Patient Morbidity: Risk Factors

DST Health Solutions Assessing Patient Morbidity: Risk Factors Anna-Marie Mitchell Senior Product Consultant

02 David Colin Thome – Primary Care Home

The Primary Care Home (PCH) David Colin-Thomé Independent Healthcare consultant Visiting Professor Manchester Business School Former General Medical Practitioner and National Clinical Director for Primary […]

Keynote I – Jonathan Weiner – Analytics & Big Data in Support of the Social and Medical Health of Populations

Analytics & Big Data in Support of the Social and Medical Health of Populations: The ACG System Today and TomorrowJonathan P. Weiner, DrPH Professor and […]

Session 2: Don McGaw – Version 12 JHU ED Visit Classification

Version 12 JHU ED Visit ClassificationDon McGaw DST Health Solutions 

Session 2: Myers – Hospitalization Risk

DST Health Solutions Hospitalization Models Brad Myers Predictive Modeling Product Consultant

03 Nick Harding – Challenges Faced By Primary Care

NHS Sandwell and West Birmingham Clinical Commissioning Group The challenges faced by primary care and the need for good quality information Professor Nick Harding OBE FRCGP […]

Session 3: Anna-Marie Mitchell – Version 12 Laboratory Measures

Version 12 Laboratory MeasuresAnna-Marie Mitchell Senior Analytic Product Consultant DST Health Solutions 

Session 4: Amy Salls – Assessing Candidates for Care Coordination

Assessing Candidates for Care CoordinationAmy Salls Director, Population Health Strategy DST Health Solutions 

Session 3: McGaw – Care Coordination

DST Health Solutions Care Coordination and Care Density Donald D. McGaw Jr. Client Relations Consultant

Session 4: Salls – Assessing Candidates for Care Management

DST Health Solutions Assessing Candidates for Care Management Programs Amy Salls Director, Population Health Strategy

Hospitalization Risk Scores: Amy Salls, DST Health Solutions

ACG System DST Health Solutions Hospitalization Models Amy Salls

Session 5: Sokchay Chiv & Kate Hollidge – Catching a Breath Program for COPD

Catching a Breath Program: Implementing and Expanding Clinical ProgramsSokchay Chiv Director, Population Health Strategies Meridian Health PlanKate Hollidge Senior Manager, Population Health Programs Meridian Health […]

05 Lizelle Steenkamp – Segmentation and the Impact of Vitality

Discovery Health Vitality Segmentation and impact of Vitality (Population Health Management) Lizelle Steenkamp