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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 […]

Post-acute pathways among hip fracture patients: a system-level analysis

Background: Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines […]

Examination of Health System Resources and Costs Associated With Transitioning Cancer Survivors to Primary Care: A Propensity-Score–Matched Cohort Study

Background: Transitioning low-risk cancer survivors back to their primary care provider (PCP) has been shown to be safe but the effect on health system resources […]

Using EMRALD to assess baseline body mass index among children living within and outside communities participating in the Ontario, Canada Healthy Kids Community Challenge

Abstract   Objectives The Healthy Kids Community Challenge is a large-scale, centrally-coordinated, community-based intervention in Ontario, Canada that promotes healthy behaviours towards improving healthy weights […]

The Association Between Continuity of Primary Care and Preventive Cancer Screening in Women With Intellectual Disability

Abstract Women with intellectual disability have low screening rates for breast and cervical cancer. This population-based cohort study examined the association between the level of […]

The Lifestyle Medicine Physician’s Case to Self-Insured Employers: A Business Model for Physicians, a Bargain for Companies

Abstract   A majority of Americans have health care insurance through their employers, the cost for which is rising at an alarming rate. Unfortunately, higher […]

Predicting Short-Term Outcomes After Radical Cystectomy Based on Frailty

Abstract Objective To evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer. Material and Methods We […]

Production of physician services under fee‐for‐service and blended fee‐for‐service: Evidence from Ontario, Canada

Abstract We examine family physicians’ responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003–2008, a period during which […]

Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy

Abstract Background Relatively few studies investigated the importance of frailty in radical cystectomy (RC) patients. We tested the ability of frailty, using the Johns Hopkins […]

Patient-reported symptoms following diagnosis in esophagus cancer patients treated with palliative intent

Summary The majority of patients with esophagus cancer have advanced-stage disease without curative options. For these patients, treatment is focused on improving symptoms and quality […]

Peri‐complication diagnosis of hepatitis C infection: Risk factors and trends over time

Abstract Background & Aims Hepatitis C virus (HCV) is a common and treatable cause of cirrhosis and its complications, yet many chronically infected individuals remain […]

Using Health Plan Authorization Data to Predict Hospitalizations and Readmissions in a Combined Commercial and Medicaid Population

Abstract Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and […]

Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

Abstract Background Few studies have investigated the outcomes of surgical fracture care among socially deprived patients despite the increased incidence of fractures and the inequality […]

Breast cancer diagnosis and treatment wait times in specialized diagnostic units compared with usual care: a population-based study

Abstract Background Breast assessment sites (bass) were developed to provide expedited and coordinated care for patients being evaluated for breast cancer (bca) in Ontario. We […]

Epidemiology and Impact of Spinal Cord Injury in the Elderly: Results of a Fifteen-Year Population-Based Cohort Study

Abstract Objective Although experience suggests a shift in the epidemiology of spinal cord injury (SCI) toward an older demographic, population studies are lacking. We aimed […]

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes

ABSTRACT Objectives There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are […]

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study

Abstract Background Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those […]

Prevalence, determinants, and outcomes of SARS-COV-2 infection among cancer patients. A population-based study in northern Italy

Abstract Background It is well established that cancer patients infected with SARSCoV-2 are at particularly elevated risk of adverse outcomes, but the comparison of SARS-CoV-2 […]

Outcomes after the regionalization of care for high-grade endometrial cancers: a population-based study

Abstract Background In June 2013, Ontario Health (Cancer Care Ontario), the agency responsible for advancing cancer care in Ontario, Canada, published practice guidelines recommending that […]

Pre-operative wait times in high-grade non-endometrioid endometrial cancer: Do surgical delays impact patient survival?

Abstract Objective Practice guidelines advocating for regionalization of endometrial cancer surgery to gynecologic oncologists practicing in designated gynecologic oncology centres were published in Ontario in […]

Patterns Of Multimorbidity Of Patients In Geriatric Care – A Register-Based Cohort Study In Sweden

Abstract Background Patients in geriatric care display a high degree of multimorbidity. We aimed to explore and visualise various patterns of multimorbidity in a person-oriented […]

Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population

Abstract Patients enrolled in Medicaid have significantly higher social needs (SNs) than others. Using claims and electronic health records (EHRs) data, managed care organizations (MCOs) […]

Creating a Cost-map From Claims Data to Guide Improvement Actions for Children With Asthma

Abstract Purpose It is difficult to reduce cost and improve quality without knowledge pertaining to the distribution of expenses in the population in question. We […]

Effect of sustained virologic response on liver-related mortality among individuals living with hepatitis C by treatment era: A population-based retrospective cohort study

Abstract Purpose Sustained virologic response (SVR) is a validated surrogate marker for successful hepatitis C virus (HCV) treatment. Historically, interferon-based therapies, the standard of care […]

Risk Profile of Young Adults with Chronic Obstructive Pulmonary Disease

Abstract Background: COPD risk profiles have been described in populations comprised of or including older adults, leaving factors associated with COPD in younger adults overlooked. […]

Variations in multimorbidity measurement in studies evaluating hospitalisation in older adults: a systematic review

Abstract Background Multimorbidity is the coexistence of two or more chronic diseases, and in older adults is more common which can lead to increased rates […]

Risk Adjustment in Capitation Payments to Primary Care Providers

Abstract Background: One of the critical challenges with capitation payment to primary care providers is ensuring that the fixed payments are equitable and adjusted for […]

Patterns of care of gestational trophoblastic disease in Ontario: a population-based study

Abstract Objectives Gestational trophoblastic disease (GTD) is a rare condition that affects reproductive-age women with excellent clinical outcomes if treated appropriately. The study aims to […]

Surgeon-patient Sex Concordance and Long-term Clinical Outcomes and Costs Following Common Surgeries

Abstract Objective: To evaluate the associations between surgeon-patient sex concordance, long-term clinical outcomes and healthcare costs. Background Data: Emerging data suggest surgeon-patient sex concordance may […]

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: […]