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Outcomes Among Patients Discharged From the Emergency Department With a Diagnosis of Peripheral Vertigo

Objective: We aimed to determine the risk of short- and long-term stroke, as well as accidental injury, in patients discharged from an emergency department who […]

Evaluating the Impact of Prescription Fill Rates on Risk Stratification Model Performance

Risk adjustment models are traditionally derived from administrative claims. Prescription fill rates—extracted by comparing electronic health record prescriptions and pharmacy claims fills —represent a novel […]

First Use of a Population Health Management Strategy in Dutch Primary Health Care

Abstract Introduction: Recently, in Dutch health care the focus is shifting from a disease oriented approach to a more population based approach. Since in The […]

Impactibility Model for Population Health Management in High-Cost Elderly Heart Failure Patients: A Capture Method Using the ACG System

Abstract The aim of the present study is to use the ACG (Adjusted Clinical Groups) System to create an impactibility model by identifying homogeneous clinical […]

The Value of Unstructured Electronic Health Record Data in Geriatric Syndrome Case Identification

Abstract Objectives To examine the value of unstructured electronic health record (EHR) data (free‐text notes) in identifying a set of geriatric syndromes. Design Retrospective analysis […]

A Multi-sourced Data Analytics Approach to Measuring and Assessing Biopsychosocial Complexity: The Vancouver Community Analytics Tool Complexity Module (VCAT-CM)

Abstract Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires […]

Effectiveness and Safety of Inhaled Corticosteroids in Older Individuals with Chronic Obstructive Pulmonary Disease and/or Asthma. A Population Study

Abstract Rationale Inhaled corticosteroids (ICS) are established medications for the management of both asthma and chronic obstructive pulmonary disease (COPD), two common chronic airway diseases. […]

Symptom burden among head and neck cancer patients in the first year after diagnosis: Association with primary treatment modality

Abstract Purpose Head and neck cancer (HNC) and its treatment affects quality of life, with significant symptom burden. The main objectives of this study were […]

Trends in cardiovascular care and event rates among First Nations and other people with diabetes in Ontario, Canada, 1996–2015

Abstract Background Rates of cardiovascular disease among people with diabetes have declined over the last 20–30 years. To determine whether First Nations people have experienced […]

Temporal condition pattern mining in large, sparse electronic health record data: A case study in characterizing pediatric asthma

Abstract Objective This study introduces a temporal condition pattern mining methodology to address the sparse nature of coded condition concept utilization in electronic health record […]

Assessing the geographical distribution of comorbidity among commercially insured individuals in South Africa

Abstract Background Comorbidities are strong predictors of current and future healthcare needs and costs; however, comorbidities are not evenly distributed geographically. A growing need has […]

A population-based study comparing outcomes for patients with metastatic castrate resistant prostate cancer treated by urologists or medical oncologists with first line abiraterone acetate or enzalutamide

Abstract Objectives To compare toxicity and all-cause mortality for mCRPC patients receiving first line oral systemic therapy prescribed by medical oncologists and urologists. Methods Population-based […]

Accidental injury, self‐injury, and assault among children of women with schizophrenia: a population‐based cohort study

Abstract Objective We aimed to compare the risk for injury overall and by intent (accidental injury, self‐injury, and assault) among children born to women with […]

Development and validation of the Cambridge Multimorbidity Score

Abstract BACKGROUND Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and […]

Frailty is highly prevalent in specific cardiovascular diseases and females, but significantly worsens prognosis in all affected patients: A systematic review

Abstract Objective Cardiologists are more often confronted with older (>60 years) cardiovascular disease (CVD) patients. These patients have particular needs in clinical care because, for […]

Multimorbidity and chronic diseases among undocumented migrants: evidence to contradict the myths

Abstract Background There is little verified information on the global health status of undocumented migrants (UMs). Our aim is to compare the prevalence of the […]

Impact of Neighborhood Social and Environmental Resources on Medicaid Spending

Abstract Introduction In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. […]

Development of measurable criteria to identify and prioritize patients for inclusion in comprehensive medication management programs within primary care settings

ABSTRACT BACKGROUND Pharmacists optimize medication use and ensure the safe and effective delivery of pharmacotherapy to patients using comprehensive medication management (CMM). Identifying and prioritizing […]

Emergency department use and hospital admission in children following ambulatory surgery: a retrospective population-based cohort study

ABSTRACT Introduction Paediatric ambulatory surgery (same day surgery and planned same day discharge) is more frequently being performed more in Canada and around the world; […]

Opioid Use after Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study

Abstract Objective To compare the odds of early and prolonged post-operative opioid use in patients undergoing minimally invasive surgery (MIS) versus open surgery for nephrectomy. […]

Evaluating the predictive value of comorbidity indices in pituitary surgery: a mixed-effects modeling study using the Nationwide Readmissions Database

Abstract OBJECTIVE Although pituitary adenomas (PAs) are common intracranial tumors, literature evaluating the utility of comorbidity indices for predicting postoperative complications in patients undergoing pituitary […]

Using the Johns Hopkins ACG Case-Mix System for population segmentation in a hospital-based adult patient population in Singapore

Abstract Objective Population health management involves risk characterisation and patient segmentation. Almost all population segmentation tools require comprehensive health information spanning the full care continuum. […]

Population risk stratification tools and interventions for chronic disease management in primary care: a systematic literature review

Abstract Background Population risk stratification (RS) tools have been proposed to tailor interventions, prioritize resources, and proactively manage high-risk individuals with chronic diseases in primary […]

Enhancing Depression Identification and Stratification with a Claims-Based Analytical Framework

Abstract Depression, a prevalent health condition, substantially impacts both socioeconomic outcomes and individual wellbeing. Despite the availability of diagnostic tools, existing approaches for identifying depression […]

Association of frailty with outcomes of patients undergoing transvenous lead removal for cardiac implantable electronic device infections in the United States

Abstract Background Frailty, marked by reduced physiological resilience, is associated with adverse outcomes in patients undergoing various cardiovascular procedures. The rising incidence of cardiac implantable […]

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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 […]

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.