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Population Segmentation

Presented by: Sarah Kachur
Director, Population Health R&D, JHHC Business Lead, Pop. Health Precision Medicine

This webinar explores how applying risk taxonomy to a Medicare Advantage population helped a health plan improve their identification of high-risk members.

Sitagliptin use in patients with diabetes and heart failure: a population-based retrospective cohort study

JACC Heart Fail. University of Alberta, Edmonton, AB, Canada OBJECTIVES: The study objective was to evaluate the effects of sitagliptin in patients with type 2 […]

The roles of primary care PAs and NPs caring for older adults with diabetes

JAAPA 27:45-49. Duke University School of Medicine, Durham, NC; VetUnerans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Pharmacy, Pittsburgh, PA; University of […]

Is use of fall risk-increasing drugs in an elderly population associated with an increased risk of hip fracture, after adjustment for multimorbidity level: a cohort study

BMC Geriatr 14:131. Department of Patient Safety, Blekinge County Council, Karlskrona, Sweden BACKGROUND: Risk factors for hip fracture are well studied because of the negative […]

How do immigrants use primary health care services? A register-based study in Norway

Eur J Public Health 25:72-78. University of Bergen, Norway; Carlos III Health Institute, Madrid, Spain; Aragón Health Sciences Institute (IACS), Zaragoza, Spain; University of Zaragoza, […]

Applying a risk-adjustment framework to primary care: can we improve on existing measures?

Ann Fam Med 1:44-51. Center for Health Quality, Outcomes and Economic Research, VAMC, Bedford, MA, USA Outcome-based performance measurement and prospective payment are common features […]

Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure

Aten Primaria 48:102-109. Published in Spanish. Hospital Universitario Infanta Sofía, Madrid, España; Unidad Docente Multiprofesional de Atención Familiar y Comunitaria; Madrid, España; Unidad Sistemas de […]

Multimorbidity and its patterns according to immigrant origin. A nationwide register-based study in Norway

PLoS One 10:e0145233. University of Bergen, Bergen, Norway; Norwegian Centre for Minority Health Research, Oslo, Norway; Aragón Health Sciences Institute (IACS), Zaragoza, Spain; Carlos III […]

Impact of language barriers on complications and mortality among immigrants with diabetes: a population-based cohort study

Diabetes Care 38:189-196. University Health Network, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; St. Michael’s […]

Association between age, gender and multimorbidity level and receiving home health care: a population-based Swedish study

BMC Res Notes 8:714. Lyckeby Primary Healthcare Centre and Blekinge Centre of Competence, Lyckeby, Sweden; University of Southern Denmark, Odense, Denmark BACKGROUND: Home health care […]

Comparing accuracy of risk-adjustment methodologies used in economic profiling of physicians

Inquiry 41:218-231. Department of Health Management and Policy, School of Public Health, University of Michigan, USA This paper examines the relative accuracy of risk-adjustment methodologies […]

Use of a shared medical record with secure messaging by older patients with diabetes

Diabetes Care 33:2314-2319. Department of Medicine, University of Washington, Seattle, WA, USA OBJECTIVE: Evaluate use of a web-based shared medical record (SMR) between older patients […]

Do we need more physicians?

Health Aff W4:67-69. Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH, USA A reexamination of physician productivity can resolve the current workforce […]

Impact of discontinuity in health insurance on resource utilization

BMC Health Serv Res 10:195. Division of Health Care Policy & Research, Mayo Clinic, Rochester, MN, US BACKGROUND: This study sought to describe the incidence […]

Comparing apples with apples in clinical populations: applications of the Adjusted Clinical Group system in British Columbia

Healthc Manage Forum 15:11-16. Department of Healthcare and Epidemiology, University of British Columbia, Vancouver, BC, Canada This article reviews the Adjusted Clinical Group Case-Mix System […]

Comparison of alternative risk adjustment measures for predictive modeling: high risk patient case finding using Taiwan’s National Health Insurance claims

BMC Health Serv Res 10:343. Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA BACKGROUND: Predictive modeling […]

Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP)

J Manag Care Pharm 17:345-354. Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA BACKGROUND: As defined by the Medicare Prescription […]

Morbidity trajectories as predictors of utilization: multi-year disease patterns in Taiwan’s national health insurance program

Med Care 49:918-923. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA BACKGROUND: Little is known about […]

Age difference explains gender difference in cardiac intervention rates after acute myocardial infarction

Healthc Policy 6:88-103. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada Many investigators have reported higher rates of cardiac procedures for males […]

Characteristics and risk factors associated with high-cost Medicaid recipients

Manag Care Interface 17:20-27. College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA Characteristics and risk factors of fee-for-service Medicaid patients (age 65 yr) with […]

Variations in health services utilization by primary care patients

Health Serv Manage Res 15:116-125. Departamento de Estumatologia, Facultad de Odontologia, Universidad de Granada, Campus Univeristario de Cartuja, Granada, Spain This study analyses how both […]

The risk-adjustment debate

N Engl J Med 339:1952-1956. Risk adjustment refers to the adjustment of payments to health plans (or to doctors) to reflect more accurately the actual […]

Development and validation of a psychiatric case-mix system

Med Care 44:568-580. VA Puget Sound Health Care System, and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA BACKGROUND: Although […]

Effect of risk adjustment method on comparisons of health care utilization between complementary and alternative medicine users and nonusers

J Altern Complement Med 19:250-256. Saint Luke’s Health System, Boise, ID, USA OBJECTIVES: Complementary and alternative medicine (CAM) providers are becoming more integrated into the […]

Obesity and respiratory hospitalizations during influenza seasons in Ontario, Canada: a cohort study

Clin Infect Dis 53:413-421. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Previous studies suggest that obesity may be a risk factor for complications […]

Capitation adjustment for pediatric populations

Pediatrics 98:10-17. Institute for Research and Education, HealthSystem Minnesota, Minneapolis, MN, USA OBJECTIVE: The objective of this study is to assess the predictive performance of […]

Risk adjustment using automated ambulatory pharmacy data: the RxRisk model

Med Care 41:84-99. Center for Health Studies, Group Health Cooperative, Seattle, WA, USA OBJECTIVES: Develop and estimate the RxRisk model, a risk assessment instrument that […]

Using propensity scores subclassification to estimate effects of longitudinal treatments: an example using a new diabetes medication

Med Care 45:S149. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA BACKGROUND: When using observational data to compare the effectiveness of […]

Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006

Rev Esp Salud Publica 82:315-322. Published in Spanish. Dirección de Planificación, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain BACKGROUND: Arterial hypertension is one of the […]

Patterns and predictors of restrictive health care service use by youths with bipolar disorder

Adm Policy Ment Health 37:379-387. Health Services Research Department, Institute of Psychiatry, King’s College London, London, UK Patterns of behavioral health service utilization were examined […]

Comparison of inhaled long-acting beta-agonist and anticholinergic effectiveness in older patients with chronic obstructive pulmonary disease: a cohort study

Ann Intern Med 154:583-592. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. BACKGROUND: Chronic obstructive pulmonary disease (COPD), a largely preventable and manageable respiratory condition, […]

Influence of compliance on the incidence of cardiovascular events and health costs when using single-pill fixed-dose combinations for the treatment of hypertension

Med Clin (Barc) 136:183-191. Directorate of Planning, Badalona Serveis Assistencials SA, Badalona, Spain BACKGROUND AND OBJECTIVE: To determine the incidence of cardiovascular events (CVE) and […]

High mortality and low access to care following incident acute myocardial infarction in individuals with schizophrenia

Schizophr Res 142:52-57. Centre for Addiction and Mental Health, Toronto, ON, Canada OBJECTIVES: The primary objective of this study was to compare mortality following incident […]

Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia

Mayo Clin Proc 87:120-129. Mayo Clinic, Rochester, MN, USA OBJECTIVE: To study the association between exposure to procedures performed under general anesthesia before age 2 […]

Are cervical and breast cancer screening programmes equitable? The case of women with intellectual and developmental disabilities

J Intellect Disabil Res 57:478-488. School of Nursing Sciences, University of East Anglia, Norwich, UK BACKGROUND: Effective cancer screening must be available for all eligible […]

Socioeconomic variation in the burden of chronic conditions and health care provision–analyzing administrative individual level data from the Basque Country, Spain

BMC Public Health 13:870. Oberri (The Basque Institute for Health Innovation), Sondika, Bizkaia, Spain BACKGROUND: Chronic diseases are posing an increasing challenge to society, with […]

Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data

JAMA Surg 148:555-561. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA IMPORTANCE: Bariatric surgery is a well-documented […]

Waiting to see the specialist: patient and provider characteristics of wait times from primary to specialty care

BMC Fam Pract 15:16. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Wait times are an important measure of access to various health care […]

Comparison of the predictive validity of diagnosis-based risk adjusters for clinical outcomes

Med Care 43:61-67. Houston Center for Quality of Care and Utilization Studies, Houston VA Medical Center, Houston, TX, USA OBJECTIVES: Many possible methods of risk […]

State funding for health information technology and selected ambulatory healthcare quality measures

Appl Clin Inform 5:594-602. Weill Cornell Medical College, New York, NY, USA BACKGROUND: Previous studies on the effects of health information technology (health IT) on […]

Evaluation of the Maryland Multi-Payer Patient Centered Medical Home Program

First Annual Report. Baltimore, MD, USA: Maryland Health Care Commission. IMPAQ International, Columbia, MD, USA The Maryland Health Care Commission (MHCC), an agency of the […]

Primärvårdens ersättnings- och styrsystem i förändring: ACG – kejsarens nya kläder?

Socialmedicinsk tidskrift Socialmedicinsk tidskrift:200-215. Published in Swedish Academy of Health and Welfare, Mälardalen University, Eskilstuna, Sweden The SALAR-project ‘Care on Equal Terms’ evaluation showed that […]

Determinants of delayed discharge from acute care among patients with hypoxic-ischemic brain injury

Arch Phys Med Rehabil 96:e15. Toronto Rehabilitation Institute, Toronto, ON, Canada Objective(s): To describe key demographic and acute care characteristics  of patients admitted with a […]

The use of drugs in Montrealers aged 65 years and older in 2005-2006

Montreal, QC, Canada: Montreal Health and Social Services Agency. Published in French; also have English translation. Montreal Health and Social Services Agency, Montreal, QC, Canada […]

Center for Health Program Development and Management, University of Maryland, Baltimore County, and Actuarial Research Corporation

A guide to implementing a health-based risk-adjusted payment system for Medicaid managed care programs. Annandale, VA, USA: Center for Health Program Development and Management, University […]

Pharmaceutical use in Manitoba: opportunities to optimize use

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada This report provides a snapshot of […]

The Florida MediPass program

Chapter 4. In: Gavin NI, Farrelly MC, ed. Evaluation of Medicaid managed care programs with 1915(b) waivers. Presented to HCFA Office of R&D. Rockville, MD, […]

Assessment of Ambulatory Care Groups with comparison to existing ambulatory case-mix classification systems

Systems Research and Applications Corporation. Arlington, VA, USA: Systems Research and Applications Corporation. Systems Research and Applications Corporation, Arlington, VA, USA The Office of the […]

L’utilisation des services de sante par les Montrealais atteings de diabete, annees 2001-2002 a 2009-2010

Montreal, QC, Canada: Montreal Health and Social Services Agency. Montreal Health and Social Services Agency, Montreal, QC, Canada No abstract

Evaluation of diagnosis-based risk adjustment among specific subgroups: can existing adjusters be improved by simple modifications?

Health Serv Outcomes Res Methodology 3:57-73. Academic Technology Center, Bentley College, Waltham, MA, USA; Center for Health Quality, Outcomes and Economic Research, Veterans Administration Medical […]

Evaluation of alternative diagnosis based risk adjustment models and morbidity trajectories for application in Taiwan

Baltimore, MD, USA: Johns Hopkins University (doctoral dissertation). Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA OBJECTIVE: The overall goals of […]

Hospitalizations for ambulatory care sensitive conditions among persons with an intellectual disability,

Manitoba, 1999-2003. Toronto, ON, Canada: University of Toronto (doctoral dissertation). University of Toronto, Toronto, ON, Canada This thesis examines hospitalizations for ambulatory care sensitive conditions […]

Nursing home adverse events: further insight into highest risk periods

Journal of the American Medical Directors Association 12:467-474. University of Manitoba, Winnipeg, MB, Canada INTRODUCTION: Adverse events (AEs) occur frequently in nursing homes (NHs). Although […]

The feasibility of an outpatient casemix classification system based on the health insurance database in Thailand

Health Systems Research Institute and Alliances :Published in Thai. The objective of this study was to examine the feasibility of an outpatient casemix classification system […]

Comparing the costs and use of services for military care in military and civilian facilities

Orlando, FL, USA: AcademyHealth Annual Research Meeting. NORC at the University of Chicago, Bethesda, MD, USA RESEARCH OBJECTIVE: The objective is to compare the cost […]

The association between metformin therapy and mortality following breast cancer: a population-based study

Toronto, ON, Canada: University of Toronto (masters thesis). University of Toronto, Toronto, ON, Canada Metformin has been associated with a reduction in breast cancer incidence, […]

Resource Allocation Case Study-Government

The Ministry of Health in Chile used the ACG® System as a risk-adjustment mechanism to improve health care resource allocation and better describe the disease […]

Enhanced Use of Data for Case Management in England

Johns Hopkins Bloomberg School of Public Health The Enhanced Use of Primary Care, Ambulatory Hospital Data to Identify Patients for Case Management Programs in England […]

Customizing the Predictive Model

DST Health Solutions Customizing the Predictive Model Amy Salls

Using the ACG System for population segmentation and casemix adjustment

NHS Central Southern Commissioning Support Unit Using the ACG System for Population Segmentation and Casemix Adjustment Chris Morris Principal Analyst

Monday(C1)-A Model for the Risk of Unplanned Inpatient Readmission-Lemke

A Model for the Risk of Unplanned Inpatient Readmission-Klaus Lemke

Sunday-Workshop: Wrapping Your Hands Around the ACG System Advanced Reporting Options – Steve Sutch

Workshop: Wrapping Your Hands Around the ACG System Advanced Reporting Options – Steve Sutch – ACG International – Product Management Director

Using Case Mix To Improve Equity and the Delivery of Primary Care

Goals of Presentation To introduce concepts surrounding population-based case-mix and “predictive risk” modeling. To show examples of applications worldwide where case-mix has proved information to […]

The ACG System Development Milestones

Jonathan Weiner, DrPH, Professor, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and ACG System co-developer provides an insight into the evolution […]

Resource Allocation Case Study-Government

Sweden became one of the first international adopters of the Johns Hopkins ACG System in the mid 1990s and has expanded its use to cover […]

Comparing Population-based Risk-stratification Model Performance Using Demographic, Diagnosis and Medication Data Extracted From Outpatient Electronic Health Records Versus Administrative Claims.

Department of Health Policy and Management, Johns Hopkins School of Public Health, Center for Population Health Information Technology, Baltimore, MD HealthPartners, Health Informatics Division, Bloomington, […]

Uptake of the Periodic Health Exam Among Adults With Intellectual and Developmental Disabilities from 2003 to 2015

Background: Over the past decade, annual heath exams have been de-emphasized for the general population but emphasized for adults with intellectual and developmental disabilities (IDD). […]

Assessing the Impact of Body Mass Index Information on the Performance of Risk Adjustment Models in Predicting Health Care Costs and Utilization

Abstract BACKGROUND: Using electronic health records (EHRs) for population risk stratification has gained attention in recent years. Compared with insurance claims, EHRs offer novel data […]

Days at Home in the Last 6 Months of Life: A Patient-Determined Quality Indicator for Cancer Care

ABSTRACT   PURPOSE: Quality end-of-life care (EoLC) is a key aspect of oncology. Days at home in the last 6 months of life represents a […]

Population Health Management Exploiting Machine Learning Algorithms to Identify High-Risk Patients

Abstract Population aging and the increase of chronic conditions incidence and prevalence produce a higher risk of hospitalization or death. This is particularly high for […]

Neuropsychological and Behavioral Outcomes after Exposure of Young Children to Procedures Requiring General Anesthesia

Abstract   BACKGROUND Few studies of how exposure of children to anesthesia may affect neurodevelopment employ comprehensive neuropsychological assessments. This study tested the hypothesis that […]

Profiling hospital performance on the basis of readmission after transcatheter aortic valve replacement in Ontario, Canada

Abstract Background Readmission rates are a widely accepted quality indicator. Our objective was to develop models for calculating case‐mixed adjusted readmission rates after transcatheter aortic […]

Development and Validation of a Score to Predict Acute Care Use After Initiation of Systemic Therapy for Cancer

Abstract Importance  Emergency department visits and hospitalizations after starting systemic therapy for cancer are frequent, undesirable, and costly. A score to quantify the risk of […]

Incidence, Treatment, and Implications of Kidney Stones During Pregnancy: A Matched Population-Based Cohort Study

Abstract Purpose To determine the incidence of kidney stones in pregnancy, the risk of adverse birth outcomes, and treatment trends. Methods We performed a population-based […]

Factors associated with emergency department presentation after total joint arthroplasty: a population-based retrospective cohort study

Abstract Background Unplanned visits to the emergency department after total joint arthroplasty are far more common than unplanned readmissions. Our objectives were to characterize the […]

Uptake and survival effects of minimally invasive surgery for lung cancer: A population-based study

Abstract Introduction Despite growing evidence supporting the safety of minimally invasive surgery (MIS) in the treatment of lung cancer, its uptake is still variable and […]

Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada

ABSTRACT BACKGROUND Globally, primary care changed dramatically as a result of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to understand the degree to which […]

A Propensity Score–weighted Comparison of Outcomes Between Living and Standard Criteria Deceased Donor Kidney Transplant Recipients

Abstract Background Consider a theoretical situation in which 2 patients with similar baseline characteristics receive a kidney transplant on the same day: 1 from a […]

Costs Associated with Nontuberculous Mycobacteria Infection, Ontario, Canada, 2001–2012

Abstract Objective To determine incidence-based healthcare costs attributable to nontuberculous mycobacterial (NTM) pulmonary disease (PD) and NTM pulmonary isolation (PI), from the healthcare payer perspective […]

Frailty as a predictor of outcomes in patients undergoing head and neck cancer surgery

Abstract Objectives To evaluate whether frailty and functional measures are predictors of perioperative complications and length of hospital stay (LOS) in patients undergoing head and […]

Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations

Abstract Background Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II […]

Impact of High Deductible Health Plans on Diabetes Care Quality and Outcomes: Systematic Review

Abstract Objective High deductible health plans (HDHPs) were introduced as a mechanism to reduce healthcare spending by incentivizing patients to be more cost-conscious while making […]

Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity

Abstract Purpose This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity. […]

Indicators of publicly funded prescription opioid use among persons with traumatic spinal cord injury in Ontario, Canada

Abstract Objective To describe the proportion and identify predictors of community-dwelling individuals with traumatic spinal cord injury (TSCI) who were dispensed ≥1 publicly funded opioid […]

Analysis of Platelet Count and New Cancer Diagnosis Over a 10-Year Period

Abstract Importance Individuals with cancer often have an elevated platelet count at the time of diagnosis. The extent to which an elevated platelet count is […]

High-Deductible Health Plans Paired With Health Savings Accounts Increased Medication Cost Burden Among Individuals With Bipolar Disorder

ABSTRACT Objective High-deductible health plans paired with health savings accounts (HSA-HDHPs) require substantial out-of-pocket spending for most services, including medications. We examined effects of HSA-HDHPs […]

Social Determinants of Health Influence Future Health Care Costs in the Medicaid Cohort of the District of Columbia Study

Abstract Context Social determinants of health are an important predictor of future health care costs but little is known about their impact on Medicaid spending. […]

Effect of periodic health exam on provider management of preventive services

Abstract Rationale and objective To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period […]

Using Additional Data Sets

This webinar explores the use of data sets from other Health and Social Care providers with the ACG system. In particular, it will focus on […]

Inter-Relationship Between Frailty & Multimorbidity

Presented by: Alan Thompson, MSc
Director of User Support, ACG System

Whilst it is true that resource use increases with an increasing degree of frailty, this presentation will demonstrate that not all frail patients are high cost and not all high cost patients are frail.

The excess medical cost and health problems of family members of persons diagnosed with alcohol or drug problems

Med Care 45:116-122. Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA BACKGROUND: Having a family member with substance use problems affects family functioning, […]

Is socioeconomic status associated with utilization of health care services in a single-payer universal health care system?

Int J Equity Health 13:115. Ben-Gurion University, Beer Sheva, Israel; Clalit Health Services, Tel Aviv, Israel OBJECTIVES: To assess an association of Socio-economic status with […]

Validation of 2 new measures of continuity of care based on year-to-year follow-up with known providers of health care

Ann Fam Med 12:559-567. Montreal Health and Social Services Agency, Montreal, QC, Canada PURPOSE: In a primary care context favoring group practices, we assessed the […]

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