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Association of Care Management Intensity With Healthcare Utilization in an All-Condition Care Management Program

ABSTRACT Objectives: To identify care needs among Medicaid and Medicare patients in an all-condition care management program involving case managers (CMs) and community health workers (CHWs), […]

One-Year Mortality After Emergency Department Visit for Nonfatal Opioid Poisoning: A Population-Based Analysis

Abstract Study objective We aim to characterize the incidence and risk factors for opioid-related and all-cause mortality in the year after an emergency department (ED) […]

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population‐based cross‐sectional study

Abstract Background Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of […]

Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study

Abstract Background Variation in health care, when not based on patient preference, may result in poorer care. We determined whether variation in health services utilization, […]

Mental Health Services Provision in Primary Care and Emergency Department Settings: Analysis of Blended Fee-for-Service and Blended Capitation Models in Ontario, Canada

Abstract Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are […]

Impact of Frailty on Clinical Outcomes after Carotid Artery Revascularization

Abstract Objectives : Frailty has been increasingly recognized as an important risk factor for vascular procedures. To assess the impact of frailty on clinical outcomes and […]

Health Status of Females Who Experience Incarceration: A Population-Based Retrospective Cohort Study

Abstract Background People who experience incarceration have poor health across a variety of indicators, but we lack population-level data on the health of females in […]

Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass

Abstract Background Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease–related complications. Objectives To examine the association between […]

Explanatory Ability of the ACG System Regarding the Utilization and Expenditure of the National Health Insurance Population in Taiwan—A 5-year Analysis

ABSTRACT Background The adjusted clinical group (ACG) is a diagnosis-based case-mix adjustment system, which has been widely evaluated in several countries other than Taiwan. The […]

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 […]

Predicting Future Health Risk in COPD: Differential Impact of Disease-Specific and Multi-Morbidity-Based Risk Stratification

Abstract Objective Multi-morbidity contributes to mortality and hospitalisation in COPD, but it is uncertain how this interacts with disease severity in risk prediction. We compared […]

A Population-Based Analysis of Long-Term Outcomes Among Older Adults Requiring Unexpected Intensive Care Unit Admission After Cancer Surgery

Abstract Background High-intensity cancer surgery is increasingly common among older adults. However, these patients are at high-risk for unexpected intensive care unit (ICU) admissions after […]

Pain and haemorrhage are the most common reasons for emergency department use and hospital admission in adults following ambulatory surgery: results of a population-based cohort study

Abstract Background Advances in healthcare delivery have allowed for the increase in the number of ambulatory surgery procedures performed in Canada. Despite these advances, patients […]

Intensive Use of Forensic Inpatient Services by People with Intellectual and Developmental Disabilities in Ontario, Canada: Prevalence and Associated Characteristics

Abstract Background People with intellectual/developmental disabilities (IDD) are reportedly intensive users of forensic inpatient services. Methods Using administrative data, we identified people with and without […]

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 […]

The impact of frailty on adjuvant treatment in patients with head and neck free flap reconstruction—A retrospective study using two independent frailty scores

Abstract Objectives Reconstructive surgery may result in prolonged postoperative recovery, especially in frail patients, which in turn may impact delivery of adjuvant therapy. To date, […]

Health Care Utilization among Adult Survivors of Childhood and Adolescent Cancer in Ontario

Abstract Survivors of childhood and adolescent cancers are at increased risk for late effects including subsequent cancer, cardiotoxicities, and poor psychosocial health. Few studies have […]

Differences in health care costs between two social health support programs: findings from a randomized social health integration pilot program

Abstract Introduction More health systems are implementing strategies to understand and address patient social health, also known as social health integration. We examine the impact […]

Incidence of Respiratory Syncytial Virus-Associated Hospitalization Among Adults in Ontario, Canada, 2017–2019

Abstract Background Respiratory syncytial virus (RSV) causes substantial morbidity and mortality among adults. Given recent RSV vaccine authorizations, data on groups at highest risk are […]

Healthcare utilization patterns and costs related to neurofibromatosis 1 in Ontario, Canada

Abstract Background and objectives Neurofibromatosis type 1 (NF1) is a multisystemic disease, characterized by cutaneous manifestations and peripheral nerve sheath tumors. Patients also have a […]

The effect of frailty on early postoperative outcomes of lobectomy for lung cancer in older adults – A United States National Retrospective Cohort Study

Abstract Introduction Pulmonary lobectomy represents the primary curative treatment for lung cancer in older adults, yet frailty’s impact on critical early postoperative outcomes remains inadequately […]

Comorbidities and Healthcare Utilization in 4197 Patients With Prurigo Nodularis in Israel: A Cross-Sectional Population-Based Analysis

ABSTRACT Background Prurigo nodularis patients face a significant burden of comorbidities, necessitating a comprehensive approach to care. We aimed to explore the association between prurigo […]

Improving models to predict care utilization using machine learning: a retrospective observational study

Abstract Background: Use of artificial intelligence (AI) and machine learning (ML) tools is now common in the advancement of healthcare services and clinical risk estimation. Legacy […]

External validation and head-to-head comparison of Eclipse-PRISM and Johns Hopkins ACG risk scores for predicting emergency admissions in an English older population

ABSTRACT Background Predictive risk stratification tools are widely used to support proactive care for older adults, yet head-to-head external validation within local English health systems […]

Return on investment from primary care price reductions in a consumer choice health plan design

Abstract Background There is growing interest among insurers and policy makers in the United States in primary care playing an expanded role to improve quality […]

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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 […]

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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 […]

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

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

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 

Session 2: Myers – Hospitalization Risk

DST Health Solutions Hospitalization Models Brad Myers Predictive Modeling Product Consultant

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

Data Validation: Lisa Kabasakalian, DST Health Solutions

ACG System DST Health Solutions The Johns Hopkins ACG® System Data Validation Lisa Kabasakalian

Session 5: DiLorenzo – An Analysis of Risk Scores of Patients with Less Than Twelve Months of Claims History

MVP Health Care Analysis of Risk Scores of Patients with Incomplete Claims History Tyson DiLorenzo, PhD. Manager, Finance & Actuarial Analytics at MVP

Session 6: Brad Myers – Version 12 Opioid Markers

High Risk Opioid Use MarkersBrad Myers DST Health Solutions 

06 James Barrett – The Benefits of an Integrated Dataset When Predicting Future Risk

James Barrett Johns Hopkins HealthCare Solutions Johns Hopkins ACG System

Assessing the Impact of Incomplete Date: Kelsey Rauch, DST Health Solutions

ACG System DST Health Solutions Patient Identification with Incomplete Data Kelsey Rauch

07a Mark Pierce – Applying the ACG System in Whole Population Management

Leicester, Leicestershire and Rutland Integrated Teams Mark Pierce

Session 5: Khomenko – Health Questionnaires and Population Risk Indexing

DataSmart Solutions Health Questionnaires and Population Risk Indexing Bernard Khomenko, CEBS Vice President of Client Services

Session 7: Sokchay Chiv & Kate Hollidge – Opioids Among the Masses

Opioids Among the Masses: Using Advanced Analytics to Drive Clinical ProgramsSokchay Chiv Director, Population Health Strategies Meridian Health PlanKate Hollidge Senior Manager, Population Health Programs […]