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Understanding Population Health

With the challenges facing our health and social care services and the need to develop new care models to achieve the triple aim of improving […]

Risk aversion and costs: a comparison of family physicians and general internists

J Fam Pract 49:12-17. Department of Family Medicine, University of Rochester, New York, NY, USA No abstract Comment in: Interspeciality differences in medical resource utilization. […]

Obstructive sleep apnea and incident diabetes

A historical cohort study. Am J Respir Crit Care Med 190:218-225. University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; […]

The pattern of urologic care among traumatic spinal cord injured patients

Can Urol Assoc J 8:E805. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada INTRODUCTION: We assessed the urologic care patterns of traumatic spinal cord injury […]

Risk factors for reoperation and mortality after the operative treatment of tibial plateau fractures in Ontario, 1996-2009

J Orthop Trauma 29:182-188. University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada OBJECTIVE: To define the rates and risk […]

Do different case-mix measures affect assessments of provider efficiency? Lessons from the Department of Veterans Affairs

J Ambul Care Manage 26:229-242. Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, Bedford, MA, USA Although case-mix adjustment is critical for provider […]

Achieving weight loss and hypertension control among obese adults: a US multidisciplinary group practice observational study

Am J Hypertens University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Veterans Affairs Pittsburgh Healthcare System , Pittsburgh, PA, USA; University […]

Association between the patient-centered medical home and healthcare utilization

Am J Manag Care 21:378-386. Weill Cornell Medical College, New York, NY, USA OBJECTIVES: The patient-centered medical home (PCMH) model of primary care is being […]

Caring for dementia: a population-based study examining variations in guideline-consistent medical care

Alzheimers Dement 11:906-916. UBC Centre for Health Services and Policy Research, School of Population and Public Health, Vancouver, BC, Canada BACKGROUND: Evidence indicates that early […]

What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization

Rev Epidemiol Sante Publique 62:305-314. Hôpital Jean-Verdier, Bondy, France; Université Paris, Paris Cité, Bobigny, France BACKGROUND: Multimorbidity is a consequence of both epidemiological and demographic […]

The development of a risk-adjusted capitation payment system: the Maryland Medicaid model

J Ambul Care Manage 21:29-52. School of Public Health, Johns Hopkins University, Baltimore, MD, USA This article describes the risk-adjusted payment methodology employed by the […]

Does high-risk pool coverage meet the needs of people at risk for disability?

Inquiry 45:340-352. University of Kansas, Lawrence, KS, USA State high-risk insurance pools serve people denied coverage because of pre-existing conditions. With benefit plans modeled on […]

Comparison of Rx-defined morbidity groups and diagnosis-based risk adjusters for predicting healthcare costs in Taiwan

BMC Health Serv Res 10:126./p> Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan BACKGROUND: Medication claims are commonly used to […]

Classification systems in case-mix groups in ambulatory care. Perspectives for our primary health care

Aten Primaria 17:76-82. Published in Spanish. Unitat d’Investigació Centre, Institut Català de la Salut, CESCA, Barcelona, Spain No abstract PMID: 8742149

Proton-pump inhibitor use is not associated with osteoporosis or accelerated bone mineral density loss

Gastroenterology 138:896-904. Section of Gastroenterology, Division of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada BACKGROUNDS and AIMS: Recent studies have shown an association between […]

Primary care and specialty care for US children: what is the right mix?

Arch Pediatr Adolesc Med 157:219-220. Institute for Health Policy, MassGeneral Hospital for Children, Boston, MA, USA THE VERY TITLE of the article by Forrest et […]

Evaluation of the equity of age-sex adjusted primary care capitation payments in Ontario, Canada

Health Policy 104:186-192. Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada OBJECTIVE: Several innovative primary care models have recently been introduced […]

Ambulatory care provided by office-based specialists in the United States

Ann Fam Med 7:104-111. National Primary Care Research and Development Centre, University of Manchester, Manchester, UK PURPOSE: Increasing use of specialist services in the United […]

Adjust utilization for case mix and make physicians responsible for remaining variation

Data Strateg Benchmarks 2:25-28. “But my patients are sicker!” Health Source/CIGNA put a stop to this physician complaint by switching to quarterly physician profiles that […]

Comparing the medical expenses of adults with Medicaid and commercial insurance in a health maintenance organization

J Health Care Poor Underserved 14:420-435. Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA, USA The objective of this study […]

Risk adjustment of mental health and substance abuse payments

Inquiry 35:223-239. Department of Health Care Policy, Harvard Medical School, Boston, MA, USA This study used 1992 and 1993 data from private employers to compare […]

The importance of the data quality in the validation of the ACG case mix

Ambulatory Care Groups. Aten Primaria 22:128. Published in Spanish. Osakidetza Servicio Vasco de Salud, Bizkaia, Spain No abstract Comment on:[A retrospective evaluation of the behaviour […]

Promoting advance directives among elderly primary care patients

J Gen Intern Med 19:944-951. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA OBJECTIVE: To determine efficient ways of promoting advance directives among […]

Licit prescription drug use in a Swedish population according to age, gender and socioeconomic status after adjusting for level of multi-morbidity

BMC Public Health 12:575. Blekinge Centre of Competence, Karlskrona, Sweden BACKGROUND: There is a great variability in licit prescription drug use in the population and […]

A method for estimating cost savings for population health management programs

Health Serv Res 48:582-602. Research and Development, Johns Hopkins HealthCare LLC, Glen Burnie, MD, USA OBJECTIVE: To develop a quasi-experimental method for estimating Population Health […]

The prospective risk adjustment system

J Ambul Care Manage 22:41-52. 3M Health Information Systems, Wallingford, CT, USA The Episode Classification System is intended to perform two tasks. First, it will […]

Effects of comorbidity and clustering upon referrals in primary care

J Am Board Fam Pract 18:449-452. Department of Family Medicine, University of Washington, Seattle, WA, USA OBJECTIVE: To examine the effect of patient characteristics and […]

A pilot test of the effect of guided care on the quality of primary care experiences for multimorbid older adults

J Gen Intern Med 23:536-542. Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA OBJECTIVE: Improving […]

Increasing value for money in the Canadian healthcare system: new findings on the contribution of primary care services

Healthc Q 12:32-44. Hollander Analytical Services Ltd., Victoria, BC, Canada This article presents a major new finding in regard to the value for money of […]

The economic value of a wellness and disease prevention program

Popul Health Manag 13:309-317. HealthMedia, Inc., Ann Arbor, MI, USA The objective of this study was to determine the economic impact of the Hawaii Medical […]

Employment of mid-level providers in primary care and control of diabetes

Prim Care Diabetes 5:25-31. Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA AIMS: Examine potential associations between inclusion […]

High-deductible insurance: two-year emergency department and hospital use

Am J Manag Care 17:e410-8. Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA OBJECTIVES: To determine the […]

Evaluating patient adherence to antidepressant therapy among uninsured working adults diagnosed with major depression: results of the Texas Demonstration to Maintain Independence and Employment study

Adm Policy Ment Health 39:374-382. Addiction Research Institute, University of Texas at Austin, Austin, TX, USA This study examined antidepressant adherence and persistence among uninsured […]

Factors associated with 90-day death after emergency department discharge for atrial fibrillation

Ann Emerg Med 61:539-548.e1. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada STUDY OBJECTIVE: More than 10% of patients treated in the emergency department (ED) […]

Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes

Health Aff 32:1942-1948. University of Wisconsin–Madison, WI, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA One approach to the patient-centered medical home, particularly […]

The influence of socio-economic status and multimorbidity patterns on healthcare costs: a six-year follow-up under a universal healthcare system

Int J Equity Health 12:69. Center of Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, […]

Spreading a medical home redesign: effects on emergency department use and hospital admissions

Ann Fam Med 11 Suppl 1:S19-S26. Group Health Physicians, Seattle, WA, USA PURPOSE: The patient-centered medical home (PCMH) is being rapidly deployed in many settings […]

High use of health services in patients with suboptimal asthma drug regimens: a population-based assessment in British Columbia, Canada

Pharmacoepidemiol Drug Saf 22:744-751. University of British Columbia, Vancouver, BC, Canada; BC Children’s Hospital, Vancouver, BC, Canada; Child and Family Research Institute, Vancouver, BC, Canada; […]

Impact of poorly controlled hypertension on healthcare resource utilization and cost

Am J Manag Care 7:389-398. MEDTAP International, Bethesda, MD, USA OBJECTIVE: To examine the relation between blood pressure (BP) control and utilization and cost of […]

Comparison of comorbidity classification methods for predicting outcomes in a population-based cohort of adults with human immunodeficiency virus infection

Ann Epidemiol 24:532-537. St. Michael’s Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada PURPOSE: We […]

Development of a predictive risk model for unplanned admissions in the Basque Country

Rev Esp Salud Publica 88:251-260. Published in Spanish. Centro de Salud de Astrabudua,.Osakidetza (Servicio Vasco de Salud), Erandio. Bizkaia, Spain; Instituto Vasco de Innovación Sanitaria. […]

Do some physician groups see sicker patients than others? Implications for primary care policy in Manitoba

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada Canadian policy makers are considering a variety of new […]

Ontario MedsCheck annual pharmacy medication review service: a comparison between initial and well established implementation periods

International Conference for Pharmacoepidemiology (ICPE) – August, 2015 Boston, MA, USA. Background: A MedsCheck Annual (MCA) consultation is a government-funded, medication review service in Ontario, […]

Risks of hospitalizations and surgery in elderly-onset inflammatory bowel disease: a population based study

Gastroenterology 146:S-171. Background: The incidence of Crohn’s disease (CD) and ulcerative colitis (UC) in the elderly population is reported to be increasing. Comorbid diseases, which […]

Patient based patterns of morbidity, a 17 year follow-up on patient records in primary care in Sweden

BMC Health Serv Res 7:A13. Karolinska Institute, Stockholm, Sweden BACKGROUND: Longitudinal studies on clinical categories of patients in primary health care are rare, as are […]

Development and evaluation of the Johns Hopkins University risk adjustment models for Medicare+Choice plan payment

Final report to Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Baltimore, MD, USA: Johns Hopkins University. Johns Hopkins University, […]

Characteristics of Maryland residents who obtain health insurance from the small and large group markets

Bethesda, MD, USA: Project Hope Center for Health Affairs. Project Hope, Bethesda, MD, USA This report contains findings from a project conducted by the Project […]

Developing re-insurance and carve-out risk adjusters for an under 65 population

Johns Hopkins University, Lewin Group. Prepared for Health Care Financing Administration. Fairfax, VA, USA: Lewin Group. Johns Hopkins University, Baltimore, MD, USA; Lewin Group, Fairfax, […]

The ambulatory case-mix development project

Project final report. Baltimore, MD, USA: Johns Hopkins University and Aetna Health Plans. Johns Hopkins University and Aetna Health Plans, USA As the US health […]

Analysis of Medicaid payments for American Indians and Alaska Natives

Baltimore, MD, USA: CMS Tribal Affairs Group.. CMS Tribal Affairs Group, Baltimore, MD, USA The Indian Health Service (IHS) is a discretionary federal program that […]

Quality, costs and the role of primary health care

Linkoping, Sweden: Linkoping University. Linkoping University, Linkoping, Sweden The general aim of this thesis is to describe and analyse the role of primary  care in […]

Adherence to prescription drugs and adverse health events for patients with hypertension

Los Angeles, CA, USA: University of California, Los Angeles (doctoral dissertation). University of California, Los Angeles, CA, USA Increased technology in the development of effective […]

Time to readmission among chronically ill community-resident beneficiaries: variations by geographic area and provider type

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

Optimal primary care for elders: periodic health examination and interdisciplinary geriatric team care

Waltham, MA, USA: Brandeis University (doctoral dissertation). Brandeis University, Waltham, MA, USA Health care organizations must find creative ways to achieve cost-efficient, high-quality primary care […]

Ischemic heart disease (IHD) and related health care utilization in Metis in Manitoba

Winnipeg, MB, Canada: Manitoba Metis Federation. Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Health & Wellness Department, Manitoba Metis Federation, Winnipeg, […]

Evaluation of the implementation of advanced nursing competencies in the Basque health care system

J Nurs Ed Pract 3:23-29. Basque Institute for Healthcare Innovation, Sondika, Bizkaia, Spain In 2011 advanced competences in nursing were defined and pilot tested in […]

Developing new comorbidity indices for cancer populations using administrative data

Dunedin, New Zealand: University of Otago (doctoral dissertation). University of Otago, Dunedin, New Zealand BACKGROUND: Comorbidity has an important impact on cancer outcomes, but the […]

Using case finding and risk stratification: A key service component for personalised care and support planning

Using case finding and risk stratification: A key service component for personalised care and support planningThis handbook describes current thinking and provides practitioner insights into […]

Data Visualization and Patient Identification – Military

The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high-quality health services to Military Health System (MHS) beneficiaries and is responsible for […]

How Health Information Technology can Impact the Delivery of Health Care

Johns Hopkins Bloomberg School of Public Health How Health Information Technology can Impact the Delivery of Health Care Karen Kinder, PhD, MBA

Tuesday-Managing hospitalization risk-Sylvia and Lu

Johns Hopkins HealthCare Develop a Risk Prediction Model to Identify Diabetic Members at High Risk of Hospitalization Martha Sylvia and Yanyan Lu

Monday-Pilot Experiences-Zhang

University of Minnesota Chinese Health Insurance System and Pilot Study for Applying ACG System to Chinese Healthcare System Yi Zhang and Stephen T. Parente, Ph.D.

Monday-Advances in modeling risk-Lemke

Johns Hopkins ACG System ACG Predictive Model for Readmission Risk Klaus Lemke

The ACG system in Leicester

NHS ACGs in Leicestershire and Leicester city Mark Pierce

Medication Therapy Management

DST Health Solutions Medication Therapy Management Amy Salls, Director Population Health Strategy Diana R. Kesser, Director Care Management Strategy

Monday(C3)-Cluster Analysis: Conditions and Variables That Are the Best Predictors of High Cost Members-Bob Gladden and Cathy Meade

Cluster Analysis: Conditions and Variables That Are the Best Predictors of High Cost Members  —Bob Gladden and Cathy Meade, CareSource

Tuesday(C8)- Use of ACG within Benefit Informatics for employer health plan cost management-Bruns

 Use of ACG within Benefit Informatics for employer health plan cost management-Bruns Benefit Focus

THE INTEGRATION OF ACG WITH THE BUSINESS INTELLIGENCE SYSTEM OF A LOCAL HEALTH UNIT IN VENETO REGION, ITALY 

N. Alba1, C. Bovo1, R. Marchi1, R. Borin1, F. Avossa2, E. Schievano2, M. Saugo2, M.C. Corti3, E. Boscolo3, C. Abrams4, K. Kinder4, D. Mantoan3;  1Local […]

ICD-10: Kelsey Rauch, DST Health Solutions

ACG System DST Health Solutions The Impact of Transitioning Coding Systems on Risk Adjustment Kelsey Rauch

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Various ACG System Applications

Amy Salls, Director of Population Health Strategy at DST Health Solutions, provides a summary on the commercialization process and the various populations, applications, and user needs that the ACG System helps in the United States. Learn More.

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Population Segmentation Case Study – Payer

Johns Hopkins Healthcare (JHHC) develops and manages medical care contracts for close to 400,000 plan members. JHHC created a framework based on an adapted version of the National Academy of Medicine taxonomy, combined with ACG System output, to provide a more extensive set of risk categories in an effort to expand their care management programs to high-risk Medicare patients.

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

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

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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

01 Karen Kinder Welcome Presentation

ACG System Dr. Karen Kinder Executive Director

Session 1: Brad Myers – Version 12 Supplementary Data

Version 12 Supplementary Medical ServicesBrad Myers DST Health Solutions 

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 1: Mitchell – Assessing Patient Morbidity: Risk Factors

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