Applications of the ACG® System in the UK

Below is sample from the Johns Hopkins ACG System white paper: Applications of the ACG System in the UK. If you would like to download the complete PDF, please enter your email address in the form at the bottom of the page. You will then receive an email with a link to the download.


As our population ages and the prevalence of long term conditions increases, the case for managing our multi-morbid population in a different and more holistic way emerges. As a result, the need for information that describes our populations and the individual people in it has never been greater.

The Johns Hopkins ACG System responds to this growing need by taking data from primary and secondary care sources for all patients in a population and processing this to provide accessible information that benefits healthcare practitioners, commissioners and providers.

Within the UK, the two categories of current use for the ACG System in the NHS can be summarised as:

  • Patient level risk stratification – The outputs are used by clinicians for the purposes of supporting direct patient care (e.g. case management). The information produced describes each patient’s overall morbidity and their risk of particular outcomes such as emergency admission and high cost in the coming year.
  • Population level risk profiling – The outputs of this process are used by non-clinical staff for the purposes of supporting commissioning activities. The information produced describes disease prevalence and morbidity distribution across the wider population and can be used to inform planning, benchmarking and service redesign activities.

The ACG System includes a number of industry standards as well as a number of unique features that can help the NHS address the challenges it faces over the coming years in relation to an ageing population, an increasing prevalence of long term conditions and the increase in multi-morbidity.

These features are being used in the UK and internationally to:

  • Identify high-risk individuals for inclusion in care management programmes that can help reduce adverse outcomes, for example, unnecessary emergency admissions.
  • Identify people at lower levels of the risk pyramid who may be suitable for other care programmes offered within primary care.
  • Profile disease and morbidity burden across a population to support public health and planning activities.
  • Profile the health needs of local populations to support commissioning and service redesign activities.
  • Make comparisons across a locality or CCG that takes into account differences in case-mix between different GP practices. For example, case-mix adjusted comparisons could be made on the prevalence of particular diseases or utilisation measures such as prescribing or emergency admission rates.
  • Identify opportunities for improved efficiency that are not as obvious when non case-mix adjusted comparisons are used.
  • Provide fair and equitable methods of allocating budgets and resources.

Johns Hopkins ACG System - UK Applications White Paper 2017 Cover

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