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Population Health Management: A Focus On Analytics Using ACGs

Johns Hopkins HealthCare LLC   Population Health Management: A Focus On Analytics Using ACGs Martha Sylvia, PhD, MBA, RN

Monday(C2)-The Association between Patient Sharing among Physicians and Cost of Care-Lemke

The Association between Patient Sharing among Physicians and Cost of Care-Klaus Lemke

Tuesday(C6)-Do Real Time Clinical Measures Improve the Performance of ACG Based Predictive Models?-Fishman

Do Real Time Clinical Measures Improve the Performance of ACG Based Predictive Models? Paul Fishman, PhD  Robert Reid, MD, PhD 

AcademyHealth 2015 HSR Impact Awardee Summary description of the ACG System

2015 HSR Impact Awardee The Johns Hopkins ACG Case-Mix System

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The ACG System and Care Management

Linda Dunbar, Vice President of Population Health Care Management at Johns Hopkins HealthCare discusses how the ACG System assisted with Care Management for high-risk individuals […]

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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 […]

Association of Suicidality and Depression With 5α-Reductase Inhibitors

IMPORTANCE There have been concerns raised by patients and regulatory agencies regarding serious psychiatric adverse effects associated with 5α-reductase inhibitors. OBJECTIVE To determine if there […]

Estimates and predictors of health care costs of esophageal adenocarcinoma: a population-based cohort study

Background Esophageal adenocarcinoma (EAC) incidence is increasing rapidly. Esophageal cancer has the second lowest 5-year survival rate of people diagnosed with cancer in Canada. Given […]

Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk

Abstract This paper studies regulated health insurance markets known as exchanges, motivated by the increasingly important role they play in both public and private insurance […]

Impact of stratification on the effectiveness of a comprehensive patient‐centered strategy for multimorbid patients

Abstract Objective The objective of this work was to assess the effectiveness of a population‐level patient‐centered intervention for multimorbid patients based on risk stratification for […]

Physician procedure volume and related adverse events after surgically induced abortion: a population-based cohort study

Abstract   BACKGROUND Induced abortion is a common procedure performed by physicians with varying degrees of clinical experience. We aimed to determine whether a physician’s […]

A comparison of population segmentation methods

Abstract This paper presents the first comparison of descriptive segmentation methods for population health management. The aim of descriptive segmentation is to identify heterogeneous segments […]

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

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study

Abstract BACKGROUND Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of […]

A systematic review of case-mix models for home health care payment: Making sense of variation

Abstract Background Case-mix based payment of health care services offers potential to contain expenditure growth and simultaneously support needs-based care provision. However, limited evidence exists […]

Assessing guideline-concordant care for patients with multimorbidity treated in a care management setting

Abstract   Background Disease-specific guidelines are not aligned with multimorbidity care complexity. Meeting all guideline-recommended care for multimorbid patients has been estimated but not demonstrated […]

Factors associated with waiting time to breast cancer diagnosis among symptomatic breast cancer patients: a population-based study from Ontario, Canada

Abstract Purpose A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a […]

Assessment of the Adjusted Clinical Groups system in Dutch primary care using electronic health records: a retrospective cross-sectional study

Abstract Background Within the Dutch health care system the focus is shifting from a disease oriented approach to a more population based approach. Since every […]

Association of perioperative red blood cell transfusions with all-cause and cancer-specific death in patients undergoing surgery for gastrointestinal cancer: Long-term outcomes from a population-based cohort

Abstract Background Red blood cell transfusions are common in patients undergoing gastrointestinal cancer surgery. Yet, to adequately balance their risks and benefits, clinicians must understand […]

Incidence of Access to Ambulatory Mental Health Care Prior to a Psychiatric Emergency Department Visit Among Adults in Ontario, 2010-2018

Abstract Importance Psychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use […]

Healthcare utilization in patients with higher-risk MDS/low-blast count AML treated with azacitidine in the ‘real-world’

Abstract Background Despite the adoption of azacitidine (AZA) in higher-risk MDS/low-blast count AML, limited ‘real-world’ data on resource utilization and toxicity exist. Methods We linked […]

Association between Dysphagia and Surgical Outcomes across the Continuum of Frailty

Abstract Objective This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. Methods A retrospective cohort […]

Allopurinol adherence, persistence and patterns of use in individuals with diabetes and gout: A retrospective, population-based cohort analysis

Abstract Objective There has been growing interest in the potential role for allopurinol to reduce cardiovascular events in people with diabetes. While adherence to allopurinol is poor […]

Multimorbidity Patterns in the General Population: Results from the EpiChron Cohort Study

Abstract Objective The correct management of patients with multimorbidity remains one of the main challenges for healthcare systems worldwide. In this study, we analyze the […]

Assessing the Value of Unsupervised Clustering in Predicting Persistent High Health Care Utilizers: Retrospective Analysis of Insurance Claims Data

Abstract Background A high proportion of health care services are persistently utilized by a small subpopulation of patients. To improve clinical outcomes while reducing costs […]

Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

Abstract During recent years, multimorbidity has taken relevance because of the impact of causes in the system, people, and their families, which has been a […]

A bias evaluation checklist for predictive models and its pilot application for 30-day hospital readmission models

Abstract Objective Health care providers increasingly rely upon predictive algorithms when making important treatment decisions, however, evidence indicates that these tools can lead to inequitable […]

Latent Class Analysis of Social Needs in Medicaid Population and Its Impact on Risk Adjustment Models

Abstract Background: A growing number of US states are implementing programs to address the social needs (SNs) of their Medicaid populations through managed care contracts. […]

Differences in use of telemedicine integrated into traditional primary health care – a comparative observational study

Abstract Telemedicine in primary health care is expected to address many of the issues currently challenging service delivery. However, the impact and effect will depend […]

Prevalence and predictors of potentially inappropriate prescribing using codified STOPP-START and Beers criteria: a retrospective cohort study in Ontario’s older population

Abstract Objectives To quantify potentially inappropriate prescribing (PIP) and assess the association between patient characteristics and PIP using previously coded STOPP-START and Beers criteria in […]

Patterns of Telehealth Use Across the Cancer Care Continuum and Assessment of Patient and Geographic Factors Associated With Key Healthcare Outcomes: Retrospective Study

Abstract Background: Although the use of telehealth has declined since the pandemic, it remains a popular mode of care delivery across the cancer care continuum. […]

COVID-19 immunisation among individuals with opioid use disorder in Ontario: a population-based cohort study

Abstract Background The COVID-19 pandemic exacerbated health inequities, particularly among individuals with opioid use disorder (OUD). Disparities in vaccine uptake among people with OUD remain […]

Association between COVID-19 vaccination and sudden death in apparently healthy younger individuals: A population-based case-control study

Abstract Background COVID-19 vaccines can cause rare but serious adverse events such as myocarditis and immune thrombocytopenia. Despite a lack of strong evidence, concerns have […]

Opioid Use During Pregnancy among Individuals with Disabilities

ABSTRACT Introduction To investigate (1) prevalence and time trends in opioid use during pregnancy and (2) patterns of opioid use before and during pregnancy, among […]

Can high-cost spending in the community signal admission to hospital? A dynamic modeling study for urgent and elective cardiovascular patients

Abstract Background Much of the research on high-cost patients in healthcare has taken a static approach to studying what is actually a dynamic process. High-cost […]

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Population Health Management: Innovations in Risk Adjustment and Predictive Modeling

Jonathan Weiner, DrPH participated as one of the featured presenters in the 8th Annual Predictive Modeling Web Summit. Watch the below recording of Dr. Weiner’s […]

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Using EHR’s Unstructured Data for Risk Stratification

Presented by: Hadi Kharrazi, MHI, MD, PhD
Asst. Professor, JH School of Public Health; Asst. Professor, JH School of Medicine; Research Director, JHCPHIT

This presentation focuses on the potential role of EHR’s unstructured data in identifying frailty markers and improving the prediction of utilization outcomes.

Attention-deficit/hyperactivity disorder in children: excess costs before and after initial diagnosis and treatment cost differences by ethnicity

Arch Pediatr Adolesc Med 160:1063-1069. Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA, USA OBJECTIVES: To estimate the excess costs […]

Atypical antipsychotic drugs and the risk for acute kidney injury and other adverse outcomes in older adults: a population-based cohort study

Ann Intern Med 161:242-248. London Health Sciences Centre, London, ON, Canada; St. Michael’s Hospital, Toronto, ON, Canada; Yale University and Veterans Affairs Medical Center, New […]

Conspicuous consumption: characterizing high users of physician services in one Canadian province

J Health Serv Res Policy 8:215-224. http://www.ncbi.nlm.nih.gov/pubmed/14596756. Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada OBJECTIVES: To examine medical […]

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario

Curr Oncol 22:97-104. Women’s College Research Institute, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: […]

READMIT: A clinical risk index to predict 30-day readmission after discharge from acute psychiatric units

J Psychiatr Res 61:205-213. Women’s College Hospital, Toronto, ON, Canada; Women’s College Research Institute, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; […]

Geriatric conditions in patients undergoing defibrillator implantation for prevention of sudden cardiac death: prevalence and impact on mortality

Circ Cardiovasc Qual Outcomes 9:23-30. Johns Hopkins University Baltimore, MD, USA; Yale School of Medicine, New Haven, CT, USA; University of Colorado, Aurora, CO, USA; […]

Association of anxiety and depression with hypertension control: a US multidisciplinary group practice observational study

J Hypertens 33:221-2222. University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Veterans Affairs Pittsburgh Healthcare System. Pittsburgh, PA, USA; University of […]

Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study

Arthritis Rheumatol 67:162-168. University of Toronto, Toronto, Ontario, Canada OBJECTIVE: Therapeutic intraarticular injections are used in the management of hip osteoarthritis (OA). Some studies suggest […]

Adjusting for case mix and social class in examining variation in home visits between practices

Fam Pract 21:355-363. Public Health Policy Unit, School of Public Policy, University College London, London, UK OBJECTIVES: The purpose of this study was to investigate […]

Profiling primary care physician resource use: examining the application of case mix adjustment

J Ambul Care Manage 19:60-80. Health Services Research and Development Center, Johns Hopkins School of Public Health, Baltimore, MD, USA Growing emphasis on managed care […]

Towards a more equitable distribution of resources and assessment of quality of care: validation of a comorbidity based case-mix system

Harefuah 149:665-669. Published in Hebrew. Planning & Health Policy Division, Clalit Health Services Head Offices, Israel BACKGROUND: Equitable distribution of healthcare resources and fair assessments […]

Forecasting physician workforce requirements

JAMA 273:111; author reply 113. Dr Weiner1 presents an exacting analysis of the likely effects of health system reform on physician workforce requirements. His market approach […]

Healthcare utilization patterns and risk adjustment under Taiwan’s National Health Insurance system

J Formos Med Assoc 101:52-59. Graduate Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan BACKGROUND AND PURPOSE: Some […]

The predictors of self-rated health and the relationship between self-rated health and health service needs are similar across socioeconomic groups in Canada

J Clin Epidemiol 63:412-421. Institute for Work and Health, Toronto, ON, Canada OBJECTIVE: To examine if there are systematic differences in the predictors of self-rated […]

The economic impact of a disability prevention program

J Occup Environ Med 52:15-21. Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA We evaluated the effect […]

Predictive modeling of total healthcare costs using pharmacy claims data: a comparison of alternative econometric cost modeling techniques

Med Care 43:1065-1072. Caremark, Hunt Valley, MD, USA OBJECTIVE: We sought to evaluate several statistical modeling approaches in predicting prospective total annual health costs (medical […]

The mortality risk score and the ADG score: two points-based scoring systems for the Johns Hopkins aggregated diagnosis groups to predict mortality in a general adult population cohort in Ontario, Canada

Med Care 49:940-947. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada BACKGROUND: Logistic regression models that incorporated age, sex, and indicator variables for the Johns […]

Association of antiepileptic drugs with nontraumatic fractures: a population-based analysis

Arch Neurol 68:107-112. Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, Calgary, AB, Canada OBJECTIVE: To explore the relationship between antiepileptic drug (AED) use […]

The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician?

Am J Public Health 88:1539-1541. Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA OBJECTIVES: This study examined the effect of continuity […]

Health of Medicare Advantage plan enrollees at 1 year after Hurricane Katrina

Am J Manag Care 15:13-22. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA OBJECTIVE: To assess the effects of Hurricane Katrina on mortality, […]

Chiropractic use by urban and rural residents with insurance coverage

J Rural Health 25:253-258. Department of Health Services, University of Washington, Seattle, WA, USA PURPOSE: To describe the use of chiropractic care by urban and […]

Case-mix and variation in specialist referrals in general practice

Br J Gen Pract 55:529-533. University College London Hospital NHS Trust, London, UK BACKGROUND: The potential of a comprehensive measure of patient morbidity to explain […]

US primary care delivery after the Health Center Growth Initiative: comparison of health centers, hospital outpatient departments, and physicians’ offices

J Ambul Care Manage 35:60-74. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA We compared patient management […]

Depression and use of health care services in patients with advanced cancer

Can Fam Physician 59:e168-e174. University Health Network, Toronto, ON, Canada OBJECTIVE: To examine whether depression in patients with advanced cancer is associated with increased rates […]

Future complexity of care tier affected by depression outcomes

J Prim Care Community Health 5:30-35. Mayo Clinic, Rochester, MN, USA. BACKGROUND: The inclusion of mental health issues in the evaluation of multimorbidity generally has […]

Modelling the ability of risk adjusters to reduce adverse selection in managed care

Appl Health Econ Health Policy 3:107-114. Stanford Prevention Research Center, Stanford University Medical School, Stanford, CA, USA Population-based risk adjustment, as applied to reimbursement in […]

Antihypertensive adherence and drug class among Asian Pacific Americans

Ethn Health 12:265-281. Hawaii Medical Service Association, Honolulu, HI, USA OBJECTIVE: Research on adherence has emphasized the need to consider patient ethnicity when developing adherence […]

Use and costs of care in retail clinics versus traditional care sites

Health Aff 27:1283-1292. HealthPartners in Minneapolis, MN, USA Erratum in Health Aff (Millwood). 2008 Nov-Dec;27(6):1751. Retail clinics have generated much interest, promising convenient, lower-cost service […]

Individual and contextual determinants of regional variation in prescription drug use: an analysis of administrative data from British Columbia

PLoS One 5:e15883. Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC, Canada BACKGROUND: Increasing attention is being paid to variations […]

Comparative performance of community health centers and other usual sources of primary care

J Ambul Care Manage 34:380-390. Schneider Institutes for Health Policy, Brandeis University, Waltham, MA, USA OBJECTIVE: To determine how Community Health Centers (CHCs) perform relative […]

A population-based analysis of esophageal and gastric cardia adenocarcinomas in Ontario, Canada: incidence, risk factors, and regional variation

J Gastrointest Surg 15:782-790. Sunnybrook Health Sciences Centre, Toronto, ON, Canada INTRODUCTION: In Western countries, the incidence of esophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma […]

Use of complementary and alternative medicine providers by fibromyalgia patients under insurance coverage

Arthritis Rheum 57:71-76. University of Washington, Seattle, WA, and Boise State University, Boise, ID, USA OBJECTIVE: To quantify how visits and expenditures differ between insured […]

Two-year trends in cancer screening among low socioeconomic status women in an HMO-based high-deductible health plan

J Gen Intern Med 27:1112-9. Department of Population Medicine, Harvard Medical School, Boston, MA, USA BACKGROUND: Cancer screening is often fully covered under high-deductible health […]

Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice

CMAJO 1:E62-E67. University of Toronto, Toronto, ON, Canada BACKGROUND:  Despite evidence in favour of early cholecystectomy for most patients with acute cholecystitis, variation in practice […]

The impact of high-deductible health plans on men and women: an analysis of emergency department care

Med Care 51:639-645. Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA BACKGROUND: Prior studies show that men […]

Predictive risk modelling in the Spanish population: a cross-sectional study

BMC Health Serv Res 13:269. Osakidetza, Basque Health Service, Bilbao, Spain. BACKGROUND: An increase in chronic conditions is currently the greatest threat to human health […]

Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care

Health Aff 32:1398-1406. Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA One-third of US workers now have high-deductible health plans, and […]

Undiagnosed hypertension among young adults with regular primary care use

J Hypertens 32:65-74. University of Wisconsin School of Medicine and Public Health, Madison, WI; Veterans Affairs Pittsburgh Healthcare System and School of Pharmacy, University of […]

Age and gender differences in the prevalence and patterns of multimorbidity in the older population

BMC Geriatr 14:75. Department of Health Wellbeing and Family, Government of Aragón, Zaragoza, Spain BACKGROUND: The coexistence of several chronic diseases in one same individual, […]

The impact of influenza vaccination on hospitalizations and mortality among frail older people

J Am Med Dir Assoc 15:256-260. National Yang-Ming University, Taipei, Taiwan OBJECTIVES: The objective of this study was to evaluate the benefits of influenza vaccination […]

Federally qualified health center efficacy study

Montpelier, VT, USA: Vermont Program for Quality in Health Care. Vermont Program for Quality in Health Care, Montpelier, VT, USA OBJECTIVE: The objective of the […]

Homecare after pediatric traumatic brain injury: what do they use and how much does it cost?

Arch Phys Med Rehabil 96:e38. University Health Network, Toronto, ON, Canada Objective(s): To determine, by sex, the predictors, types, and direct cost of publicly funded […]

Trends in abdominal aneurysm surgery, 2002-2014

Toronto, ON, Canada: Institute for Clinical Evaluative Sciences (internal report). Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Methods: We conducted a population-based cohort study […]

Building a predictive model for 30-day inpatient readmission using PROC PHREG

Presented at NESUG 2012. Baltimore, MD, USA: North East SAS User Group. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins […]

Adverse selection, welfare and the optimal pricing of employer-sponsored health plans

St. Paul, MN, USA: University of Minnesota and NBER. University of Minnesota, St. Paul, MN, USA We assess the welfare impact of adverse selection in […]

Patterns of regional mental illness disorder diagnoses and service use in Manitoba: a population-based study

Winnepeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada Mental illness is a profound problem […]

Ambulatory Care Groups: an evaluation for military health care use

Fort Sam Houston, TX, USA: United States Army Center for Healthcare Education and Studies, publication #HR 94-004. United States Army Center for Healthcare Education and […]

Models for Medicare payment system reform based on group-specific volume performance standards (GVPS)

Waltham, MA, USA: Brandeis University. Brandeis University, Waltham, MA, USA This report discusses potential policy options for Medicare based on Group-Specific Volume Performance Standards (GVPS). […]

Aging in Ontario: an ICES chartbook of health service use by older adults

Toronto, ON, Canada: Institute for Clinical Evaluative Sciences. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Recent investments by the Ontario Ministry of Health and […]

Impacto economico de las enfermedades y pacientes atendidos en atencion primaria adaptacion de los Grupos Clinicos Adjustados (ACGs) en nuestro medio

Barcelona, Spain: University of Barcelona (doctoral dissertation). Published in Spanish. University of Barcelona, Barcelona, Spain El objetivo general de este trabajo es medir el impacto […]

Outcomes of care for South Carolina Medicaid managed care enrollees, state fiscal year 2007

Final report to the South Carolina Department of Health and Human Services. Columbia, SC, USA: University of South Carolina. University of South Carolina, Columbia, SC, […]

Primary health care reimbursement based on socioeconomics or disease burden

Primärvårdsersättning efter socioekonomi eller sjukdomsbörda. [Primary health care reimbursement based on socioeconomics or disease burden. Registry study from Östergötland shows different results depending on analysis […]

Implementation of electronic medical records and preventive services: a mixed methods study

Toronto, ON, Canada: University of Toronto (masters thesis). University of Toronto, Toronto, ON, Canada The implementation of Electronic Medical Records (EMRs) may lead to improved […]

Primärvården som koordinator för de mest sjuka äldre – implikationer för mål och indikatorer

In: Karlsson AK, Winberg H, ed. På väg mot en värdefull styrning. LHC Report: #1, 2012. Stockholm, Sweden: Stiftelsen Leading Health Care:150-172. Published in Swedish. […]

Demand for health among Canadians: roles of immigration status, country of origin, and year since migration

Toronto, ON, Canada: University of Toronto (doctoral dissertation). University of Toronto, Toronto, ON, Canada This thesis investigates the effects of immigration status, country of origin, […]

Complications following total joint arthroplasty in patients with rheumatoid arthritis

Toronto, ON, Canada: University of Toronto (doctoral dissertation). University of Toronto, Toronto, ON, Canada BACKGROUND: Total joint arthroplasty (TJA) is indicated in persons with end-stage […]

Working for Better Health in Wandsworth -The ACG System’s role in transforming services through innovative care models

Working for Better Health in Wandsworth -The ACG System’s role in transforming services through innovative care models

Leicester City CCG Case Study 1

Use of ACG® System output to support practices in participating in the Unplanned Admissions DES 2014-15

Predictive Models in the ACG® System: Recalibration of Existing Models and Development of New Ones

This short report provides details of the second recalibration of the existing models and the development of new models that was carried out by the […]

Health Care Reform In the US and England

The Johns Hopkins University Health Care Reform In the US and England: Commonalities and potential contribution of case-mix & predictive risk modeling tools Jonathan Weiner, […]

Applying the ACG® System to a Retrospective Electronic Database

Applying the Johns Hopkins ACG Applying the Johns Hopkins ACG Casemix Casemix System to a Retrospective Electronic Database: A 5 to a Retrospective Electronic Database: […]