Skip to content

2026 ACG User Summit
September 20 – 22 | Orlando, FL
Register Now

Documents

Documents

The Discovery Health experience with the ACG System in South Africa

Discovery Health The Discovery Health experience with the ACG System in South Africa Dr. Dianne Walker

Association between Continuity of Care and Avoidable Hospitalization in Taiwan

Veteran General Hospital – Taipei Continuity of Care and Its Association to Avoidable Hospitalizations of Taiwan’s Veterans: A Preliminary Study Ping Tao, RN., MHA

Wednesday-Closing-Weiner

Johns Hopkins ACG System Future Directions and Opportunities in the Predictive Modeling and Risk Adjustment Fields: The Next 20 Years of the ACG System Jonathon […]

Tuesday-Management implications-Reams

Brown & Toland Physicians Using Risk Adjustment to Measure Access to Primary Care Kam Reams, MPhil, MPH Manager, Performance Improvement

Monday-Leveraging pharmacy data-Bodycombe

Johns Hopkins ACG System Expanded Horizons for Pharmacy Gap Analysis David Bodycombe

The development path for the ACG System

ACG System Johns Hopkins Bloomberg School of Public Health ACG v11 Introduction to New Tools for Understanding and Managing Population Health Stephen Sutch

Tuesday(C7)-Use of Adjusted Clinical Groups (ACGs) in implementing Chronic Disease Management Programs: preliminary experiences in north- eastern Italy

Use of Adjusted Clinical Groups (ACGs) in implementing Chronic Disease Management Programs: preliminary experiences in north- eastern Italy —Pietro Gallina, Carlo Rampazzo, Stefania Elvini, Domenico […]

Monday(C2)-Quality of Care in Multimorbid Patients-Shadmi

Quality of Care in Multimorbid Patients Efrat Shadmi, PhD, Ran D. Balicer, MD, MPH, PhD

Featured thumbnail
Readmissions: What Health Plans Need to Know

Preventing avoidable hospital readmissions is considered by many to be the most important opportunity for reducing waste in health care. This podcast explains readmissions and why identifying these at-risk patients is important to health plans. Learn more.

Featured thumbnail
Case Mix Adjustment Case Study – Payer

This Case Study shows how Leicester City CCG, one of the most ethnically diverse areas of the UK, analyzed emergency admission rates for all practices, to learn that practices with lower emergency admission rates had significantly higher coding completeness and GP patient survey scores. Learn more.

The uptake of active surveillance for the management of prostate cancer: A population-based analysis

Introduction: Active surveillance (AS) is a strategy for the management of low-risk prostate cancer (PCa). However, few studies have assessed the uptake of AS at […]

Apples and Oranges: Four Definitions of Multiple Chronic Conditions and their Relationship to 30-Day Hospital Readmission

Health Innovation Program, the University of Wisconsin School of Medicine and Public Health from The Wisconsin Partnership Program, and the Community–Academic Partnerships core of the […]

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Abstract Background Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. […]

Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care

ABSTRACT The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast […]

Patient-reported symptoms after breast cancer diagnosis and treatment: A retrospective cohort study

Abstract Aim Breast cancer and its treatment are associated with varying symptoms. The province of Ontario (13.6 million) has implemented a provincial programme to screen for symptoms among […]

Performance on the Operant Test Battery in young children exposed to procedures requiring general anaesthesia: the MASK study

Abstract Background It is not known whether the neurotoxicity produced by anaesthetics administered to young animals can also occur in children. Exposure of infant macaques […]

Prevalence of intellectual and developmental disabilities among first generation adult newcomers, and the health and health service use of this group: A retrospective cohort study

Abstract Background Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This […]

Multimorbidity Patterns in Patients with Back Pain: A Study of Patient Records at a Primary Health Care Centre in Sweden

Abstract In Primary Care, multimorbidity is the norm in most patients. A large part of these have pain disorders, very often related to the spine. […]

Changes in primary care provider utilization by phase of care for women diagnosed with breast cancer: a CanIMPACT longitudinal cohort study

Abstract Background Primary care providers (PCPs) have always played an important role in cancer diagnosis. There is increasing awareness of the importance of their role […]

Does early palliative identification improve the use of palliative care services?

Abstract Purpose To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based […]

Predicting the Cost of Health Care Services : A Comparison of Case-mix Systems and Comorbidity Indices That Use Administrative Data

Abstract Background: Case-mix systems and comorbidity indices aggregate clinical information about patients over time and are used to characterize need for health care services. These […]

Use of administrative record linkage to measure medical and social risk factors for early developmental vulnerability in Ontario, Canada

Abstract Background Linkage of demographic, health, and developmental administrative data can enrich population-based surveillance and research on developmental and educational outcomes. Transparency of the record […]

Analysis of the relationship between surgeon procedure volume and complications after total knee arthroplasty using a propensity-matched cohort study

Abstract Objectives This study aimed to identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection […]

Determinants of vaccination uptake, and influenza vaccine effectiveness in preventing deaths and hospital admissions in the elderly population; Treviso, Italy, 2014/2015-2016/2017 seasons

ABSTRACT Objective Seasonal influenza is an important cause of morbidity and mortality, particularly among the elderly population. Determinants of vaccination uptake and its impact on […]

Frailty impact on postoperative complications and early mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review

Abstract Objective To assess the prevalence of frailty, a status of vulnerability to stressors leading to adverse health events, in bladder cancer patients undergoing radical […]

Medical use of cocaine and perioperative morbidity following sinonasal surgery—A population study

Abstract Background Topical cocaine is favoured by many surgeons for sinonasal surgery due to its superior vasoconstrictive and anesthetic properties. However, historical reports suggesting cocaine […]

Congestive heart failure and comorbidity as determinants of colorectal cancer perioperative outcomes

Abstract Objective There has been an increase in surgical interventions in frailer elderly with concomitant chronic diseases. The purpose of this paper was to evaluate […]

Real-world Safety of Bevacizumab with First-line Combination Chemotherapy in Patients with Metastatic Colorectal Cancer: Population-based Retrospective Cohort Studies in Three Canadian Provinces

Abstract Aims To examine the real-world safety of adding bevacizumab to first-line irinotecan-based chemotherapy for patients with metastatic colorectal cancer (mCRC). Materials and methods Patients diagnosed with CRC in […]

The receipt of information by family physicians about their patient’s emergency department visits: a record linkage study of electronic medical records to health administrative data

Abstract Background Canadians are known to be frequent users of emergency department (ED) care. However, the exchange of information from ED visits to family physicians […]

The effect of frailty on post-operative outcomes and health care expenditures in patients treated with partial nephrectomy

Abstract Objective To examine the effect of frailty on short-term post-operative outcomes and total hospital charges (THCs) in patients with non-metastatic renal cell carcinoma, treated […]

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health

Abstract Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification […]

Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study

Abstract Purpose Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of […]

Predicting Provider Workload Using Predicted Patient Risk Score and Social Determinants of Health in Primary Care Setting

Abstract Background Provider burnout due to workload is a significant concern in primary care settings. Workload for primary care providers encompasses both scheduled visit care […]

Evaluating the impact of capitation funding top-up payments in primary care

Abstract Background Capitation payments account for approximately half of core funding for General Practitioner (GP) practices in England, allocated via the Global Sum Allocation (‘Carr-Hill’) […]

Longitudinal costs and health service utilisation associated with primary care reforms in Ontario: a retrospective cohort study protocol

ABSTRACT Introduction Over the last 20 years, the Canadian province of Ontario implemented several new models of primary care focusing on changes to physician remuneration, […]

Influence of socioeconomic status on health outcomes after treatment of spinal metastases

ABSTRACT OBJECTIVE The aim of this study was to investigate the association of home socioeconomic status (SES) with days at home and survival after treatment […]

Impact of frailty on outcomes following percutaneous coronary intervention for acute myocardial infarction: A propensity-score matched analysis of 45,362 pairs

Introduction Percutaneous coronary intervention (PCI) is the cornerstone of rapid revascularization in acute myocardial infarction (AMI) [1]. Patients undergoing PCI frequently present with multiple comorbidities, […]

Social inequalities in COVID-19 death by area-level income in 11.2 million people in Ontario, Canada: patterns over time and the mediating role of vaccination

Abstract Knowledge of patterns in COVID-19 deaths by area-level income over time and the mediating role of vaccination in inequality patterns remains limited. We used […]

The effect of nurse care management on multimorbid patients’ hospital utilization: a comparative-controlled trial and an exploratory cohort study

Abstract Multimorbidity, defined as the presence of two or more chronic conditions in one individual, poses substantial challenges to patients and healthcare systems, yet evidence […]

The value of recovery after spinal cord injury: long-term healthcare costs in relation to home time in a population-based cohort

Abstract BACKGROUND CONTEXT Traumatic spinal cord injury (SCI) is associated with substantial long-term healthcare utilization. While prior studies have quantified costs, few have contextualized expenditures […]

Association of a Care Coordination Model With Health Care Costs and Utilization The Johns Hopkins Community Health Partnership (J-CHiP)

Abstract Importance  The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective  To determine whether the Johns […]

Featured thumbnail
Case Management and Care Coordination Part 1

This webinar will provide an overview of the data available within the ACG System to support case finding activities. The topics covered will include the […]

Featured thumbnail
Case Mix Adjustment in Primary Care

Presented by: Dr. David Shepherd FRCGP

This webinar shares a case study of Leicester CCG in the UK. The ACG System was used to analyze emergency admission rates for all practices in the area. The top 8 practices were identified and studied further to understand key characteristics of those practices.

Developing a dashboard to help measure and achieve the triple aim: a population-based cohort study

BMC Health Serv Res 14:363. McMaster University, Hamilton, ON, Canada BACKGROUND: Health system planners aim to pursue the three goals of Triple Aim: 1) reduce […]

Performance of the ACG case-mix system in two Canadian provinces.

Med Care 39:86-99. Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada BACKGROUND: While the adjusted clinical group (ACG) system […]

Identifying possible indicators of systematic overuse of health care procedures with claims data

Med Care 52:157-163. Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA BACKGROUND: Health care quality is frequently described with measures representing […]

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

Med Care 39:692-704. Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, MA, USA BACKGROUND: Diagnosis-based case-mix measures are increasingly used for provider profiling, […]

The association between continuity of care and the overuse of medical procedures

JAMA Intern Med Johns Hopkins University, Baltimore, MD, USA Importance: Both the overuse of unnecessary medical procedures and poor continuity of care are thought to […]

Effect of attribution length on the use and cost of health care for a pediatric Medicaid Accountable Care Organization

JAMA Pediatr 170:148-154. Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA IMPORTANCE: Little is known about the effect of pediatric accountable care organizations (ACOs) […]

Factors associated with acute care use among nursing home residents dying of cancer: a population-based study

Int J Palliat Nurs 21:349-356. McMaster University, Hamilton, ON, Canada BACKGROUND: Little is known about residents of long-term care (LTC) facilities who die of cancer. […]

Predictors of opioid-related death during methadone therapy

J Subst Abuse Treat 57:30-35. University of Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; St. Michael’s Hospital, Toronto, ON, Canada; St. […]

The potential for community-based health information exchange systems to reduce hospital readmissions

J Am Med Inform Assoc 22:435-442. Weill Cornell Medical College, New York, NY, USA BACKGROUND: Hospital readmissions are common, costly, and offer opportunities for utilization […]

Fifty years of pediatric asthma in developed countries: how reliable are the basic data sources?

Pediatr Pulmonol 47:211-219. British Columbia’s Children’s Hospital, Vancouver, BC, Canada Given the difficulties in diagnosing, or even defining, asthma in children, claims of a pediatric […]

Application of the Ambulatory Care Groups in the primary care of a European national health care system: does it work?

Med Care 37:238-248. Astrabudúa Health Center, Osakidetza/Basque Health Service, Bizkaia, Spain BACKGROUND: Ambulatory Care Groups (ACGs), a US case mix system that uses the patient […]

Quality assessment: is the focus on providers or on patients?

Int J Qual Health Care 8:231-241. Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA Most studies of ambulatory care quality are based on chart […]

Biphasic fracture risk in diabetes: a population-based study

Bone 40:1595-1601. Department of Medicine, University of Manitoba, Winnipeg, MB, Canada Diabetes is associated with increased fracture rates but the effect size, time course and […]

The comorbidity burden of the treated asthma patient population in British Columbia

Chronic Dis Can 30:46-55. University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada To date there has been little investigation of the prevalence […]

Nonparticipation in a population-based trial to increase colorectal cancer screening

Am J Prev Med 42:390-397. Group Health Permanente, University of Washington Medical School, Seattle, WA, USA BACKGROUND: Many trials have tested different strategies to increase […]

Institutionalization following incident non-traumatic fractures in community-dwelling men and women

Osteoporos Int 23:2381-2386. Division of General Internal Medicine, McGill University Health Center, Montreal, QC, Canada Institutionalization after hip fracture occurs in at least 30% of […]

Methods for analyzing health care utilization and costs

Annu Rev Public Health 20:125-144. Department of Biostatistics, University of Washington, Seattle, WA, USA Important questions about health care are often addressed by studying health […]

Mortality rates after incident non-traumatic fractures in older men and women.

Osteoporos Int 22:2439-2448. Division of General Internal Medicine, McGill University Health Center, Montreal, QC, Canada Non-traumatic fractures at typical osteoporotic sites are associated with increased […]

Comorbidity patterns in patients with chronic diseases in general practice

PLoS One 7:e32141. Multiprofessional Education Unit for Family and Community Care (Southwest), Madrid, Spain INTRODUCTION: Healthcare management is oriented toward single diseases, yet multimorbidity is […]

Primary care physician compensation method in medical groups: does it influence the use and cost of health services for enrollees in managed care organizations?

JAMA 279:853-858. Department of Health Services, University of Washington, Seattle, WA, USA CONTEXT: Growth of at-risk managed care contracts between health plans and medical groups […]

Health-based payment and computerized patient record systems

Eff Clin Pract 1:66-72. Center for Health Research, Kaiser Permanente, Northwest Division, Portland, OR, USA. Health care information technology is changing rapidly and dramatically. A […]

Morbidity and older persons’ perceptions of the quality of their primary care

J Am Geriatr Soc 54:330-334. Department of Health Policy and Management, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA […]

Primary care physicians’ experiences with case finding for practice-based care management

Am J Manag Care 18:e155-161. Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany. OBJECTIVES: The identification of patients most likely […]

A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged without cholecystectomy

J Trauma Acute Care Surg 74:26-30; discussion 30-1. Li Ka Shing Knowledge Institute, St Michael’s Hospital; and Institute for Clinical Evaluative Science, Toronto, ON, Canada […]

Self-referral in point-of-service health plans

JAMA 285:2223-2231. Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA CONTEXT: Most health maintenance organizations offer […]

Cost and quality trends in direct contracting arrangements

Health Aff 21:89-102. Health Systems Management Faculty, School of Public Affairs, University of Baltimore, Baltimore, MD, USA. This paper presents the first empirical analysis of […]

Impact of open-access scheduling on realized access

Health Serv Manage Res 20:134-139. Department of Family Medicine, Mayo Clinic, Rochester, MN, USA Open-access or advanced-access scheduling, which opens the clinic calendar to patients […]

Influence of morbidity and the use of health resources in patients who require care for generalised anxiety disorder in the primary health care setting

Aten Primaria 40:603-610. Published in Spanish. Dirección de Planificación. Badalona Serveis Assistencials, S.A. Badalona. Barcelona, Spain OBJECTIVE: To evaluate the co-morbidity, health care use, economical […]

Patterns in the use of benzodiazepines in British Columbia: examining the impact of increasing research and guideline cautions against long-term use

Health Policy 97:122-129. Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada OBJECTIVE: We examined changes in patterns of benzodiazepine […]

Who cares for Medicaid-enrolled children with chronic conditions?

Pediatrics 108:906-912. Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, MA, USA OBJECTIVE: To estimate generalist, pediatric subspecialist, and any subspecialist […]

Predicting the risk of 1-year mortality in incident dialysis patients: accounting for case-mix severity in studies using administrative data

Med Care 49:257-266. Faculty of Medicine, University of Calgary, Calgary, AB, Canada BACKGROUND: Administrative databases are increasingly being used to study the incident dialysis population […]

Tracking family medicine graduates. Where do they go, what services do they provide and whom do they see?

BMC Fam Pract 13:26. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada BACKGROUND: There are continued concerns over an adequate supply […]

Cost analysis of adding pregabalin or gabapentin to the management of community-treated patients with peripheral neuropathic pain

J Eval Clin Pract 18:1170-1179. Badalona Serveis Assistencials, Badalona, Barcelona, Spain OBJECTIVE: To compare the cost of adding either pregabalin or gabapentin to the management […]

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

J Clin Epidemiol 66:436-444. Population Health Research Centre, Division of Population Health Sciences and Education, St George’s University of London, London, UK OBJECTIVES: Adjustment for […]

Doctor shopping by overweight and obese patients is associated with increased healthcare utilization

Obesity 21:1328-1334. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. OBJECTIVE: Negative interactions with healthcare providers […]

Patient poverty and workload in primary care: study of prescription drug benefit recipients in community health centres

Can Fam Physician 59:384-390. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada Erratum in: Can Fam Physician. 2013 Jun;59(6):612. OBJECTIVE: To […]

Adverse events recorded in English primary care: observational study using the General Practice Research Database

Br J Gen Pract 63:534-542. Department of Primary Care and Public Health (DPCPH), Imperial College London, London, UK BACKGROUND: More accurate and recent estimates of […]

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; Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Pharmacy, Pittsburgh, PA; University of […]

Profiling resource use by primary-care practices: managed Medicare implications

Health Care Financ Rev 17:23-42. Project HOPE Center for Health Affairs, Bethesda, MD, USA Variations in elderly Medicare beneficiaries’ health service use are examined using […]

Evaluating case-mix and predictive modeling measures within the British primary care sector

BMC Health Serv Res 7:A8. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Imperial College London, UK Aim: The goal of this project […]

Clinical analytics and data management for the DNP

New York, NY, USA: Springer. Johns Hopkins Health Care, Glen Burnie, MD, USA Strong data management knowledge and skills are a requirement for every DNP. […]

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

London, UK: National Health Service. National Health Service. London, UK This handbook describes current thinking and provides practitioner insights into case finding and risk stratification […]

Population profiling in Slough CCG

Windsor, UK: NHS Slough Clinical Commissioning Group. NHS Slough Clinical Commissioning Group, Windsor, UK As our population ages and the prevalence of long term conditions […]

Editorial: Managing costs with software. Advance for Health Information Executives

Advance Newsmagazines, King of Prussia, PA, USA More than two years ago when Dave Ford took over as CEO at CareOregon in Portland, Ore., the […]

Validation and uses of the ACG-DX predictive modeling and risk adjustment tool in an Israeli HMO

Clin Med Res 8:51-52. Maccabi Healthcare Services, Tel Aviv, Israel BACKGROUND: With an ever increasing population of HMO members with chronic disease and continuing economic […]

The additional cost of chronic disease in Manitoba

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada Many Manitobans have a chronic disease—indeed […]

A comparative analysis of methods of health risk assessment: final report

Cambridge, MA, USA: Harvard University School of Public Health. Harvard University School of Public Health, Cambridge, MA, USA A key component of many recent proposals […]

Implementing risk assessment and risk adjustment for people with disabilities in state programs: six case studies

Washington, DC, USA: NRH Center for Health and Disability Research. NRH Center for Health & Disability Research, Washington, DC, USA As a group, people with […]

A comparative analysis of claims-based tools for health risk assessment

Schaumburg, IL, USA: Society of Actuaries. Japanese translation published by Tokyo Gakugei University. Society of Actuaries, Schaumburg, IL, USA This Society of Actuaries research project […]

Capitation payment systems – risk factor estimation

Academia Economic Papers 28:231-261. Published in Chinese. PURPOSE: To explore risk factors that can explain individual medical expenditure. SAMPLE: Subjects included in “1996 NHI Satisfaction […]

Managing the gap: evaluating the impact of Medicaid managed care on service use and disparities in health care access

Baltimore, MD, USA: University of Maryland (doctoral dissertation). University of Maryland, Baltimore, MD, USA The National Institutes of Health (NIH) define a health disparity as […]

Identifying patients with high pharmacy consumption by using the Adjusted Clinical Groups in a primary care setting

European Neuropsychopharmacology 19:S340-S341. Badalona Serveis Assistencials SA, Directorate ofPlanning, Badalona. Barcelona, Spain BACKGROUND: Prescription drug costs are rapidly increasing in most countries. The pharmaceutical expenditure […]

Plataforma de proces de dades d’atencio primaria

Barcelona, Spain: Universitat Politecnica de Catalunya (masters thesis). Published in Catalan. Universitat Politecnica de Catalunya, Spain No abstract

Measuring the casemix of physician practices in primary-care reform models in Ontario, Canada

BMC Health Serv Res 11:A22. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada INTRODUCTION: A number of different blended-payment models for primary- care delivery have […]

Patients with chronic illness in the patient-centered medical home: costs, use, quality and morbidity-based variation

Seattle, WA, USA: University of Washington (doctoral dissertation). University of Washington, Seattle, WA, USA Originally described in 1967 as a central source of a medical […]

Evaluation of the full service family practice incentive program and the practice support program: synthesis report for work completed to June 2013

Victoria, BC, Canada: Hollander Analytical Services Ltd. This report constitutes a synthesis of findings from the evaluation of the Full Service Family Practice Incentive Program […]