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2026 ACG User Summit
September 20 – 22 | Orlando, FL
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Case Finding and Population Profiling

This webinar focuses on a project undertaken in Slough Clinical Commissioning Group where information from the ACG System was used to profile the population of […]

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Leveraging Prescription Data to Derive Future Costs and Predictors Regarding Opioid Abuse Patients

Presented by: David Bodycombe, ScD, MSc

Director ACG System Research

This Webinar describes his study, which created and assessed three measures of high-risk opioid use, presents results supporting the utility of these measures, and describes how the resulting measures are being deployed within the ACG System. Learn More.

Risk prediction models to predict emergency hospital admission in community-dwelling adults: a systematic review

Med Care 52:751-756. Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland BACKGROUND: Risk prediction models have been developed to identify […]

Frequent attenders in general practice and immigrant status in Norway: A nationwide cross-sectional study

Scand J Prim Health Care 32:232-240. Department of Global Public Health and Primary Care, University of Bergen, Norway OBJECTIVE: To compare the likelihood of being […]

Drugs prescribed by general practitioners according to age, gender and socioeconomic status after adjustment for multimorbidity level

BMC Fam Pract 15:183. Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Malmö, Sweden BACKGROUND: Age, gender and socioeconomic […]

Direct medical costs attributable to venous thromboembolism among persons hospitalized for major operation: a population-based longitudinal study

Surgery 157:423-451. Mayo Clinic, Rochester, MN, USA; K Long Health Economics Consulting LLC, St. Paul, MN, USA BACKGROUND: We estimated medical costs attributable to venous […]

Preventive counseling services during primary care visits: a comparison of health centers versus other physician offices

J Health Care Poor Underserved 26:519-535. Johns Hopkins University, Baltimore, MD, USA We compared preventive counseling services provided by health centers versus other physician offices. […]

A comprehensive assessment of family physician gender and quality of care: a cross-sectional analysis in Ontario, Canada

Med Care 54:277-286. University of Ottawa, Ottawa, ON, Canada; Institute of Clinical Evaluative Sciences, Ottawa, ON, Canada; Queen’s University, Kingston, ON, Canada; Monash University, Clayton, […]

Prescription stimulant use and hospitalization for psychosis or mania: a population-based study

J Clin Psychopharmacol 35:667-671. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; St Michael’s Hospital, Toronto, ON, Canada Small […]

Risk of cardiovascular events and mortality among a population-based cohort of immigrants and long-term residents with diabetes: Are all immigrants healthier and if so, for how long?

Am Heart J 170:123-132. University Health Network, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; University […]

Pain among older adults from a gender perspective: findings from the Swedish National Study on Aging and Care (SNAC-Blekinge)

Scand J Public Health Blekinge Institute of Technology, Karlskrona, Sweden; Lund University, Lund, Sweden; Linnaeus University, Växjö, Sweden BACKGROUND AND AIMS: Pain is common in […]

Ethnic disparities in care following acute coronary syndromes among Asian Americans and Pacific Islanders during the initial hospitalization

Cell Mol Biol 47:1209-1215. Hawaii Medical Service Association, Care Management, Honolulu, HI, USA Despite the fact that Asian Americans and Pacific Islanders are the fastest […]

Changes in health care costs over time following the cessation of intimate partner violence

J Gen Intern Med 25:920-925. Group Health Research Institute, Seattle, WA, USA BACKGROUND: Research has documented greater health care costs attributable to intimate partner violence […]

Universal health insurance and equity in primary care and specialist office visits: a population-based study

Ann Fam Med 7:396-405. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada PURPOSE: Universal coverage of physician services should serve to reduce socioeconomic disparities in […]

Geographic variation in primary care visits in Iowa.

Health Serv Res 30:657-671. Graduate Program in Hospital and Health Administration, University of Iowa, Iowa City, IA, USA. OBJECTIVE: This study investigates the determinants of […]

Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data

Med Care 43:1130-1139. Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada OBJECTIVES: Implementation of the International Statistical Classification of Disease and Related […]

Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study

Br J Gen Pract 61:e12-e21. Department of Community Medicine, University of Bristol, Bristol, UK BACKGROUND: In developed countries, primary health care increasingly involves the care […]

Predictive modeling in practice: improving the participant identification process for care management programs using condition-specific cut points

Popul Health Manag 14:205-210. Research and Development Unit, Johns Hopkins HealthCare LLC, Glen Burnie, MD, USA The objective of this study was to optimize predictive […]

Fracture risk from psychotropic medications: a population-based analysis

J Clin Psychopharmacol 28:384-391. Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and antipsychotics have each been […]

Ankle fractures do not predict osteoporotic fractures in women with or without diabetes

Osteoporos Int 23:957-962. Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada It is not clear whether ankle fractures predict future osteoporotic fractures in women, […]

The role of provider continuity in preventing hospitalizations

Arch Fam Med 7:352-357. Department of Family and Community Medicine, Christiana Care Health System, Wilmington, DE, USA OBJECTIVES: To examine the association between provider continuity […]

The effect of distance to primary care physician on health care utilization and disease burden

Health Care Manage Rev 32:22-29. University of Michigan Medical School, Ann Arbor, USA. BACKGROUND: The relationship of distance to care with total health care utilization […]

Case mix measures for ambulatory care

J Public Health Med 13:189-197. University of Newcastle upon Tyne, School of Health Care Sciences, Medical School, Newcastle, UK Resource management in Ambulatory Care is […]

Performance of diagnosis-based risk adjustment measures in a population of sick Australians

Aust N Z J Public Health 26:500-507. Faculty of Health Sciences, School of Public Health, La Trobe University, Victoria, Australia OBJECTIVE: Australia is beginning to […]

Morbidity profiles at three primary care clinics in Perlis, Malaysia

Med J Malaysia 67:363-368. Ministry of Health, Kangar Health Clinic, Jalan Kolam, Kangar, Perlis, Malaysia Allocation of funding within the Ministry of Health of Malaysia […]

Healthcare utilization in patients with Parkinson’s disease: a population-based analysis

Parkinsonism Relat Disord 18:930-935. Movement Disorder Clinic, 200 Woodlawn Street, Winnipeg, MB, Canada PURPOSE: To investigate factors associated with healthcare utilization and prescription drug use […]

Referral of children to specialists in the United States and the United Kingdom

Arch Pediatr Adolesc Med 157:279-285. Department of Health Policy and Management, Health Services Research and Development Center, Bloomberg School of Public Health, Johns Hopkins University, […]

Is quality free? The relationship between cost and quality across 18 provider groups

Am J Manag Care 8:413-422. HealthPartners Research Foundation, Minneapolis, MN, USA OBJECTIVE: To learn whether the healthcare costs for patients of various care delivery systems […]

A patient classification system for our primary care: the Ambulatory Care Groups (ACGs)

Gac Sanit 11:83-94. Published in Spanish. Unitat d’Investigació Centre del Institut Catalá de la Salut, Barcelona, Spain OBJECTIVES: The ambulatory care groups (ACGs) were developed […]

Influence of morbidity, metabolic control, and use of resources in subjects with cardiovascular risk in the primary care setting

Aten Primaria 40:447-454. Published in Spanish. Dirección de Planificación y Desarrollo Organizativo. Badalona Serveis Assistencials S.A. Badalona. Barcelona. España OBJECTIVE: To determine the comorbidity, the […]

Complexity and continuity of treatments among privately insured youth diagnosed with bipolar disorder

Front Psychiatry 1:144. Health Services and Population Research Department, Institute of Psychiatry, King’s College London, London, UK OBJECTIVES: To examine longitudinal patterns of complexity, continuity, […]

Cognitive and behavioral outcomes after early exposure to anesthesia and surgery

Pediatrics 128:e1053-e1061. Erratum in: Pediatrics. 2012 Mar;129(3):595. Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, MN, USA BACKGROUND: Annually, millions of children are exposed […]

Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder

JAMA 285:60-66. Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA CONTEXT: A shortage of data exists on medical care use by persons with […]

Use of other opioids during methadone therapy: a population-based study

Addiction 107:776-780. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada AIMS: To determine the extent to which other opioids are prescribed to patients receiving methadone […]

Adaptive capacity of the Adjusted Clinical Groups Case-Mix System to the cost of primary healthcare in Catalonia (Spain): a observational study

BMJ Open 2:2012-000941. Directorate of Planning, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain OBJECTIVES: To describe the adaptive capacity of the Adjusted Clinical Groups (ACG) […]

Estimating diabetes prevalence in the Military Health System population from 2006 to 2010

Mil Med 178:986-993. Healthcare Informatics Division, United States Air Force Medical Support Agency, San Antonio, TX, USA Evidence-based articles have demonstrated an increase in diabetes […]

Glycemic control associated with secure patient-provider messaging within a shared electronic medical record: a longitudinal analysis

Diabetes Care 36:2726-2733. University of Washington School of Public Health, Seattle, WA, USA; Harvard School of Public Health, Boston, MA, USA; Group Health Research Institute, […]

Direct health-care costs attributed to hip fractures among seniors: a matched cohort study

Osteoporos Int 24:659-669. Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada SUMMARY: Using a matched cohort design, we estimated the mean direct […]

Predictors of dislocation and revision after shoulder stabilization in Ontario, Canada, from 2003 to 2008

Am J Sports Med 41:2034-2040. University of Toronto Orthopaedic Sports Medicine, Women’s College Hospital, Toronto, ON, Canada BACKGROUND: Factors contributing to recurrent dislocation, revision stabilization, […]

Estimating Demand for Care After a Medicaid Expansion: Lessons From Oregon

J Ambul Care Manage. Kaiser Permanente Northwest Center for Health Research, Portland, OR; Oregon Health and Science University, Portland, OR, USA To estimate how the […]

Characteristics of adult primary care patients as predictors of future health services charges

Med Care 39:1170-1181. Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA BACKGROUND: Utilization risk assessment is potentially useful for allocation […]

The patient-centered medical home, electronic health records, and quality of care

Ann Intern Med 160:741-749. Weill Cornell Medical College, New York, NY, USA BACKGROUND: The patient-centered medical home (PCMH) model of primary care is being implemented […]

Relationship between pain and quality of life – findings from the Swedish National Study on Aging and Care – Blekinge study

Scand J Pain 5:270-275. Blekinge Institute of Technology, Karlskrona, Sweden; Lund University, Lund, Sweden; Linnaeus University, Växjö, Sweden BACKGROUND AND AIMS: The influence of pain […]

MEDS-AD Waiver (MTM) Program final report

Prepared for Florida Medicaid. Tallahassee, FL, USA: College of Medicine, Florida State University. Florida State University, Tallahassee, FL, USA This report summarizes the final findings […]

Change in functional outcomes during inpatient rehabilitation for patients with hypoxic-ischemic brain injury

Arch Phys Med Rehabil 96:e18. Toronto Rehabilitation Institute, Toronto, ON, Canada Objective(s): To investigate determinants of change in functional outcomes during inpatient rehabilitation (IR) among […]

Performance of an ambulatory case-mix measurement in primary care in Spain: Ambulatory Care Groups (ACGs)

Eur J Public Health 9:27-35. Unitat d’Investigació Centre del Institut Catalá de la Salut, Barcelona, Spain BACKGROUND: Patient classification systems based on the defining of […]

ACG use in Veterans Administration in Taiwan: final report

Taipei, Taiwan: Veterans General Hospital Taipei. Published in Chinese. Department of Medical Affairs and Planning, Taipei Veterans General Hospital, Taipei City, Taiwan, ROC The goal […]

Sex differences in health status, health care use and quality of care: a population-based analysis for Manitoba’s regional health authorities

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, […]

A comparison of alternative approaches to risk measurement

Final report, grant number 93-G07, Physician Payment Review Commission. Minneapolis, MN, USA: Park Nicollet Medical Foundation. Park Nicollet Medical Foundation, Minneapolis, MN, USA Under health […]

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

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

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

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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 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

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: 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 3: McGaw – Care Coordination

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

Session 4: Amy Salls – Assessing Candidates for Care Coordination

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

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

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

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

07 Alan Thompson – Segmentation: Exploring the Relationship Between Frailty and Other High-Risk Groups

Alan Thompson 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 […]

Session 8: Philip Bruns – Population Health Management for Non-Clinical Analysts

Population Health Management for Non-Clinical AnalystsPhilip Bruns BenefitFocus 

09 Population Segmentation and Risk Stratification – Kelechi Nnoaham

Kelechi Nnoaham Director of Public Health Cwm Taf Morgannwg University Health Board, Wales

Program Evaluation: Amy Salls, DST Health Solutions

ACG System DST Health Solutions Using The Johns Hopkins ACG® System for Program Evaluation Amy Salls