Skip to content

Software Update Available: Version 13.0.4. and 14.0.2
This release includes a refinement to Patient Need Group classification logic.
Click for details

Upcoming WEBINAR: Population Health at the Neighborhood Level
Community Care Best Practices from NHS Kent and Medway ICB
Register Now

Documents

Documents

Leicester City CCG Case Study 3

Use of ACG® System output to support distribution of CCG Better Care Fund monies

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 […]

Poster: Morbidity Burden Resource Use and Quality of Care of Diabetic Patients

Morbidity burden, resource use and quality of care of diabetic patients: A 4-year cohort analysis at a regional hospital in Thailand. Roongkarn Pannarunothai, Buddhachinaraj Hospital, […]

Embedding ACGs in Berkshire

NHS Berkshire Embedding ACGs in Berkshire Karen Grannum Primary Care Business Intelligence Lead

Using the ACG Toolkit to Support Population Monitoring

DST Health Solutions Using the ACG Toolkit to Support Population Monitoring Lisa Kabasakalian

Monday(C3)-Identifying Potentially Actionable Chronic Disease Patterns From Diagnoses Reported in Administrative Claims-Dave Bodycombe

Identifying Potentially Actionable Chronic Disease Patterns From Diagnoses Reported in Administrative Claims —Dave Bodycombe, Johns Hopkins University

Tuesday(C6)-Integration of claim-based diagnoses with diagnoses from General Practitioners (GPs) clinical database records improves the comorbidity description”-Corti

 Integration of claim-based diagnoses with diagnoses from General  Practitioners (GPs) clinical database records improves the comorbidity description” Maria Chiara Corti,  E. Schievano F. Avossa, K. Kinder, […]

What causes ’poly-morbidity’? Searching for triggers of multi-morbidity: tracing patient record 30 years back

Lennart Carlsson, PhD; Gunnar H Nilsson, Professor; Centre for Family Medicine, Karolinska Institutet, Sweden

Beyond Risk Scores: Lisa Kabasakalian, DST Health Solutions

ACG System DST Health Solutions Beyond Risk Scores: Identifying “High-Risk” and “At-Risk” Populations Lisa Kabasakalian

Featured thumbnail
The ACG System Worldwide

ACG System Executive Director Karen Kinder, PhD, provides a candid tour of the ACG System’s international history and evolution to what is now the most […]

Featured thumbnail
Population Segmentation Case Study – Government

Three Clinical Commissioning Groups (CCGs) analyzed their local populations as part of a new national initiative to address the care of people who are frail.  Learn more.

New Summary Measures of Population Health and Well-Being for Implementation by Health Plans and Accountable Care Organizations

Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Sachin Rauri, MS; Juliana O. Tillema, MPA; Nicolaas P. Pronk, PhD, FACSM; Susan M. Knudson, MA […]

Comprehensive preventive care assessments for adults with intellectual and developmental disabilities-Part 1: How do we know if it’s happening?

Objective To determine how to best measure the provision of comprehensive preventive care assessment to adults with IDD. Design Cross-sectional. Setting Ontario. Participants Adults with […]

Comparing Five Comorbidity Indices to Predict Mortality in Chronic Kidney Disease: A Retrospective Cohort Study

Abstract Background: Several different indices summarize patient comorbidity using health care data. An accurate index can be used to describe the risk profile of patients, […]

Exploring the use of machine learning for risk adjustment: A comparison of standard and penalized linear regression models in predicting health care costs in older adults

Abstract   Background Payers and providers still primarily use ordinary least squares (OLS) to estimate expected economic and clinical outcomes for risk adjustment purposes. Penalized […]

Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada

Abstract Study design Retrospective cohort study. Objectives The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord […]

Impact of timing of methadone initiation on perinatal outcomes following delivery among pregnant women on methadone maintenance therapy in Ontario

Abstract BACKGROUND AND AIMS Methadone maintenance therapy (MMT) is associated with improved outcomes for children exposed to maternal opioid dependence in utero. We examined Ontario’s […]

Home care nursing after elective vascular surgery: an opportunity to reduce emergency department visits and hospital readmission

Abstract Background Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research. Objective To quantify regional variation in home care […]

Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada

Abstract Importance  Sex-based income disparities are well documented in medicine and most pronounced in surgery. These disparities are commonly attributed to differences in hours worked. […]

Emergency department use among young adult Medicare beneficiaries with autism and intellectual disabilities

Abstract Background Individuals on the autism spectrum are at greater risk for a variety of co-occurring psychiatric and medical conditions, which could result in greater […]

Serious infections in patients with myasthenia gravis: population‐based cohort study

Abstract Background and purpose To characterize the frequency and risk of serious infections in patients with myasthenia gravis (MG) relative to age/sex/area‐matched comparators. Methods This […]

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

Abstract Background Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published […]

Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture

Aims Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective […]

90-90-90 for everyone?: Access to HIV care and treatment for people with HIV who experience imprisonment in Ontario, Canada

ABSTRACT Background We examined HIV care and treatment in prison and after release for people with HIV in Ontario, Canada, and compared HIV care and […]

Correlation between potentially inappropriate medication and Alzheimer’s disease among the elderly

Abstract Purpose This study is conducted to explore the association between potentially inappropriate medication (PIM) and Alzheimer’s disease (AD) among the elderly. Methods We used […]

Fracture Risk in Patients with Myasthenia Gravis: A Population-Based Cohort Study

Abstract Objective Prednisone is a common treatment for myasthenia gravis (MG), and osteoporosis is a known potential risk of chronic prednisone therapy. Our aim was […]

Impact of frailty on inpatient outcomes in thyroid cancer surgery: 10-year results from the U.S. national inpatient sample

Abstract Background Frailty is linked to perioperative morbidity and mortality. We evaluated the impact of preoperative frailty on inpatient outcomes of patients undergoing surgery for […]

Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study

Abstract Background Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, […]

Type 1 diabetes prevalence and incidence rates in the pediatric population of Veneto Region (Italy) in 2015–2020

Abstract The prevalence of Type 1 Diabetes (T1D) in the Veneto Region (Italy) in the 2015–2020 years was 152.5/100,000 subjects and the incidence 19.7/100,000 person-years. Accordingly, Veneto Region […]

Second and later-line erlotinib use in non-small cell lung cancer: real world outcomes and practice patterns overtime in Canada

Abstract Background In Canada, epidermal growth factor receptor (EGFR) inhibitor therapies in advanced non-small cell lung cancer (NSCLC) were initially approved regardless of EGFR status. The purpose […]

Patient Service Utilization Among Individuals with Co‑occurring Disorders: A Comparison of Two Models of Care Coordination

Abstract Background Healthcare systems have increasingly adopted integrated care models with demonstrated effectiveness. However, few studies examine integrated care for individuals with co-morbid mental illness […]

Effectiveness of COVID-19 vaccines against symptomatic SARS-CoV-2 infection and severe outcomes with variants of concern in Ontario

Abstract SARS-CoV-2 variants of concern (VOC) are more transmissible and may have the potential for increased disease severity and decreased vaccine effectiveness. We estimated the […]

Assessing the Added Value of Vital Signs Extracted from Electronic Health Records in Healthcare Risk Adjustment Models

Abstract Objective Patient vital signs are related to specific health risks and outcomes but are underutilized in the prediction of health-care utilization and cost. To […]

Hip Fractures in Adults with Schizophrenia: A Population-based Evaluation of the Burden and Quality of Care

Abstract Hip fractures have life-altering consequences. Individuals with schizophrenia may experience a higher likelihood of hip fractures, worse postfracture outcomes, and suboptimal care. This thesis […]

Impact of Immigration Status on Survival Among Stage 1 and 2 HER2-Positive and Triple-Negative Breast Cancer in Ontario, Canada

ABSTRACT Background This study examined death from breast cancer and death from other causes among women with Stage 1 and 2 Her2-positive and triple-negative breast […]

The Impact of Frailty on Short-Term Outcomes After Surgery for Zenker Diverticulum

Abstract Objective Determine relationship between frailty and hospital mortality, length of stay, cost, and medical and surgical complications in Zenker diverticulum surgery. Study Design Retrospective […]

Implementation, impact of vaccination coverage and determinants of VZV immunization in people living with HIV: The HIV-ZoVax study

Abstract Background Shingles remains a significant cause of morbidity in people living with HIV despite advances in antiretroviral therapy. The recombinant zoster vaccine (RZV) is […]

Primary care utilization and attachment among burn survivors: A population-based matched cohort study

Abstract Background Many burn survivors experience poor long-term outcomes, including reduced quality of life and greater mortality than the general population, yet post-discharge interventions to […]

Developing and validating an electronic health record-embedded AI model for managing multimorbid hospitalisation risk in patients with chronic RESpiratory disease (AiRES): a study protocol

Abstract Background Chronic respiratory diseases (CRDs), such as asthma and chronic obstructive pulmonary disease (COPD), are heterogeneous conditions with a high multimorbidity burden. However, existing risk […]

Featured thumbnail
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 […]

Featured thumbnail
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 […]

Featured thumbnail
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 […]

Featured thumbnail
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 […]