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2011 State Snapshot MethodsLast Updated: March 10, 2012All-State Snapshot MeasuresState Snapshot Summary MeasuresBest Performing and All Other States TablesState Snapshot Strongest (Weakest) MeasuresState Snapshot Focus on DiabetesState Snapshot Focus on AsthmaState Snapshot Focus on Healthy People 2020State Snapshot Focus on DisparitiesState Snapshot Focus on PayerState Snapshot Focus on Variation Over TimeState Snapshot Ranking TableState Snapshot Contextual FactorsAppendix I: 2011 NHQR Measures, by 2011 State Snapshot Summary Measure AssignmentAppendix II: U.S. Census Region and Division Definitions Used in the 2011 State SnapshotsAcknowledgmentsEndnotesInternet CitationAll-State Snapshot MeasuresThe State Snapshot primarily include State-level estimates selected from the 2011 National Healthcare Quality Report (NHQR). A few Snapshot sections include supplemental State-level analyses. Additional data sources are noted in the appropriate methodology section. Top of PageState Snapshot Summary MeasuresThe following methods were used to develop summary measures from the 2011 NHQR for the following sections of the State Snapshots: state dashboard, overall health care quality, types of care (preventive, acute, chronic), settings of care (hospital, ambulatory, nursing home, home health), care by clinical area (cancer, diabetes, heart disease, maternal and child health, respiratory diseases), and clinical preventive services. For each section the summary measure represented by a multi-colored meter combines multiple NHQR measures in a way that accounts for how a State performed on each measure within a year: better than average, average, or worse than average. The method encompasses three sequential tasks:
Each of these decision points is discussed separately below. Top of Page1. Defining the ContentAll NHQR measures that had State-level estimates available within the 2011 NHQR Data Tables Appendix were grouped into summary measures. These included an overall health care quality measure and summary measures within three broad areas: types of care, settings of care , and care by clinical area. In addition, a summary measure was developed to track performance on clinical preventive services. NHQR measures were assigned to each of these areas on the following basis:
A complete list of the NHQR measures considered, and the summary measures to which they were assigned, is included in Appendix I. Top of Page2. Classifying State PerformanceWhere data are available, each State's performance was measured relative to its regional performance and its national performance. States are assigned to one of nine regions corresponding to the U.S. Census Divisions, as listed in Appendix II. Calculating the all-State and regional averages. Averages were computed using data from all States that had available data for the measure. A State was excluded from these averages for any of the following reasons:
National and regional averages are weighted by the inverse of their variances, which approximates the count of observations. This approach is used because, for many measures, the NHQR data tables do not include data on the number of observations. Assigning performance categories. For each measure, State performance was categorized as better-than-average, average, and worse-than-average relative to the performance of State's in the same region or in the Nation. All measures were translated into a "worst-to-best metric" so that measures for which higher values represent a better result could be combined accurately with measures for which lower values represent a better result. To determine where each State estimate fits within the better-than-average, average, and worse-than-average categories, we applied statistical tests to each State's measures. To ensure that statistical tests gave reasonable results, we carried out the test for a State estimate only when the estimate for an NHQR measure had an RSE below 30 percent. Although this criterion was not applied in the NHQR, it was applied in State Snapshots to ensure statistical reliability across the States being compared. The statistical criteria used are noted in the table below.
3. Scoring State Performance (Meter Score)For each of the summary measures, each State received two sets of performance meter scores—a national performance score (n) and a regional performance score (r). Each state received points based on performance on summary measures, with points assigned as follows:
National and regional scores were based on the distribution of measures by points: National meter score = ((An*1) + (Bn*0.5) + (Cn*0)) * 100
Regional meter score = ((Ar*1) + (Br*0.5) + (Cr*0)) * 100 Where A = number of better-than-average NHQR measures in the summary. Scores range from 0 (if all measures are worse than average) to 100 (if all measures are better than average). Scores between 0 and 100 will represent the mix of measures that are worse than average, average, and better than average. Higher scores represent better performance because the score increases with the number of measures that are average and increases more rapidly with the number of measures that are better than average. These scores are the basis for the performance meter "needles," which represent the score from 0 to 100 on a 180-degree semicircle for visual presentation. The two needles represent two different years—the most recent year of data available (a solid needle) and a baseline year (a dashed needle). After the meter score is calculated for a summary measure, the score is assigned to one of five categories as follows for visual discrimination on the 180-degree semicircle:
All meters show a solid needle for the most recent year of available data if there are a minimum number of measures reported for the composite. The minimum is set to five measures for national comparisons and set to three for the regional comparisons. The baseline year is represented as a dashed needle when the baseline has more than two-thirds of the measures available in the most recent year. This formula is applied to ensure similar comparisons between the baseline and most recent year. Top of PageBest Performing and All Other States TablesBecause comparison to the average does not represent the best that a State can achieve, a table is included in the 2011 NHQR State Snapshots for each summary measure to allow States to compare their score on each summary measure to the top five States in the Nation, plus ties. This score is the same as the meter score described above. Each table simply lists the meter score for the most recent data year for the State of interest and the meter scores individually for the five States with the highest scores. No statistical test is applied to this comparison. It simply shows how far from the best performers the State of interest is in the context of the meter scoring. In addition, these tables include selected percentiles (75th, 50th, 25th) for the meter scores for all States available. Each represents the meter score cutoff for that percentage of States. For example, the score for the 75th percentile is the score that 25 percent of the States exceeded and that 75 percent of the States were below. This gives a view of the spread of scores for each summary measure. A table listing the meter score of all States alphabetically accompanies the Best Performing States Table. This all-States table is included as another tool for comparing States' scores on each summary measure. And, similar to the Best Performing States Table, it simply lists the meter score for each State. No statistical test of differences is applied. Top of PageState Snapshot Strongest (Weakest) MeasuresThe strongest (weakest) measures for a State are identified by first selecting all measures for which performance is better (worse) than average compared to all States with data. Among the better-than-average (worse-than-average) measures for each State, the measure that ranked the highest (lowest) among the States with data was selected until at least five measures were identified. The ranking for this purpose was the ordinal rank from 1 to 51 across the States and the District of Columbia, when all jurisdictions collected the measure. When fewer jurisdictions collected a measure, the ordinal rank was inflated to a relative position. For example, if 25 States collected data on the percent of women receiving mammograms, then their ordinal rank would range from 1 to 25. To obtain a rank comparable to all 51 jurisdictions, the ordinal rank would be multiplied by 2.04 (2.04 = 51/25) to obtain an adjusted relative rank ranging from 2.04 to 51. Top of PageState Snapshot Focus on DiabetesThe Focus on Diabetes section of the NHQR State Snapshots provides information on prevalence, quality, disparities, costs, and potential savings from quality improvement for diabetes care. Diabetes increasingly affects residents of every State, and State health policymakers should understand these issues more completely. The measures and methods used to develop the Focus on Diabetes estimates for the 2011 NHQR State Snapshots are described below. Top of Page1. PrevalenceThe maps visually summarize the prevalence of diabetes for each State in 2011 by categorizing the state-level information into four quartiles. Prevalence is highest in the first quartile (greater than 10.0 percent) and lowest in last quartile (less than 7.5 percent). The data for the maps are self-reported by adults and come from the Behavioral Risk Factor Surveillance System (BRFSS). 2. Quality-of-Care Performance MeasuresThe summary measure for the quality of diabetes processes of care is created and scored in the same manner as the summary measures described in Scoring State Performance (Meter Score) above. The summary measure for diabetes outcomes of care is created differently to show the actual number of hospitalizations for diabetes. This was done because it is useful for States to be able to ascertain the number of hospitalizations related to diabetes to determine the potential for cost savings. Data on the diabetes process measures were gathered from the BRFSS, which collects data on health behaviors from most States. These include measures of appropriate care for people with diabetes: hemoglobin A1c (HbA1c) testing, eye exams, foot exams, and flu shots. When data are not available for all of these measures for a State, that State is not included in the report. When data are available for only 1 year, only that year of data is reported. Diabetes outcome measures were derived from AHRQ's Healthcare Cost and Utilization Project (HCUP). These are measures of avoidable hospital admissions for long-term diabetes complications, short-term diabetes complications, uncontrolled diabetes without complications, and amputations related to diabetes. More information on HCUP, the participating statewide data sources, and the use of HCUP data in the NHQR can be found on the HCUP User Support Web site under Methods Series Reports (http://www.hcup-us.ahrq.gov/reports/methods.jsp). Diabetes outcome measures provide information on the number of hospital admissions for varying levels of diabetes severity, with each measure defined per 100,000 people in the State. Because the denominators of these outcomes are the same, the numerators can be added to determine the total number of diabetes admissions per 100,000 people in the State. The diabetes outcomes bar chart shows the total number of diabetes admissions per 100,000 people in the State, in the region, and in the U.S. The national estimate is labeled "U.S." and is a weighted national estimate that accounts for missing States. The regional estimate is based on the four U.S. Census Regions instead of the nine U.S. Census Divisions due to the lack of sufficient State estimates within each U.S. Census Division. States included within each U.S. Census Region are listed in Appendix II. Top of Page3. Diabetes CostsThe Focus on Diabetes section provides information about the potential impact of implementing diabetes interventions on State government health care costs. This section presents estimates of the burden to State governments of diabetes among State employees and their dependents. It also presents data on the additional costs incurred by State governments if their employees are not in a disease management program or diabetes intervention program. States are significant purchasers of health care, providing health care not only to State government employees but also to poor people and people with disabilities. This section focused on State government employees because of AHRQ's prior work in synthesizing and translating research findings into information that can aid the decisions of employers, including State government employers. These estimates were generated with the Employers' Diabetes Costs Calculator, a tool developed by the Lewin Group, and which drew from research on diabetes care, its costs, and the effectiveness of disease management. The tool was originally intended for use by AHRQ to aid employers' decisions on quality improvement related to diabetes care for their employees. The calculator provides public and private employers with a rough estimate of their diabetes health care costs and of the costs associated with poor control of blood glucose. The result reflects the potential savings that might be realized from a carefully designed disease management program or other type of quality improvement program for diabetes care. The estimates presented in the 2011 NHQR State Snapshots are in 2009 dollars. Three steps are needed to estimate diabetes costs:
Calculations for each of these steps are detailed in the following paragraphs. Step 1: Determine Number of Covered Lives with Diabetes This step involves calculating the following:
Number of covered lives of State government employees and their dependents. Several data sources were used to estimate the number of State government employees by age, gender, and race/ethnicity. First, the number of State government employees was obtained from the Bureau of Labor Statistics, 2004 Quarterly Census of Employment and Wages (QCEW).1 To determine the number of State government employees by age, the age distribution of the employed population in the State was estimated from the Bureau of Labor Statistics Current Population Survey (CPS) averaged over 3 years, 2003-2005, and then applied to the QCEW data.2 Distribution by gender and race/ethnicity was obtained from the U.S. Census Equal Employment Opportunity (EEO) Data Tool and U.S. Census State population estimates. The EEO database provided race/ethnicity data for State government employees in cities with a minimum population of 100,000.3 The distribution of these employees by race/ethnicity was applied to all State government workers to obtain statewide counts of employees by race/ethnicity. When EEO data were missing for the State, the race/ethnicity distribution was taken from the Census data for the State's entire population.4 This was done for Alabama, Alaska, Florida, Illinois, Indiana, Kansas, Kentucky, Maryland, Michigan, Missouri, Nevada, New Jersey, New Mexico, New York, Tennessee, and Washington. Approximately 20 percent of Hawaii's population was not represented in the EEO data tool since a "mixed race" category was unavailable. To account for people of mixed race, Claritas race data were used.5 The race/ethnicity distribution was assumed to be the same for males and females. The race/ethnicity and gender distributions were then applied to the estimated number of State government employees by age to produce the number of State government employees by age, gender, and race/ethnicity for each State. To estimate the number of State government employees who have dependents covered by their health insurance, the model estimates employees who select family coverage and have children. Estimates of the percentage of employees who select family coverage were based on AHRQ's Medical Expenditure Panel Survey (MEPS) data.6 The number of children per employee who selects family coverage was based on State averages from the U.S. Census Bureau.7 Number of covered lives with diabetes. To estimate covered lives with diabetes, the national diabetes prevalence rate was applied to the number of covered lives by State, described above. These prevalence rates were calculated using the 2005 files of the National Health Interview Survey (NHIS), with prevalence rates stratified by age, gender, and race/ethnicity.8 Because NHIS data are based on self-reported diabetes prevalence, another step is needed to account for the number of people with undiagnosed diabetes. The total prevalence estimate is multiplied by 1.42, the factor suggested by the CDC. The CDC (2005) estimates that for every 100 people diagnosed with diabetes, approximately 42 people with diabetes have not yet been diagnosed (see the National Diabetes Fact Sheet) Step 2: Estimate Health Care Expenditures Associated With Diabetes Care Estimates of average, per capita health care expenditures for privately insured people with and without diabetes were calculated by combining information from the following sources:
A review of the literature identified no current estimates of health care costs for people with and without diabetes for the privately insured population. Consequently, cost estimates in the Employers' Diabetes Cost Calculator were calculated using the following steps:
Estimates of the share of employee health care expenditures that was spent on diabetes care were made by comparing diabetes cost estimates for State employees and dependents to the State budget spent on all health care for State employees and dependents. The budget figures were obtained from the National Association of State Budget Officers.11 For three jurisdictions (Alaska, District of Columbia, and New Mexico), the share estimates looked unreasonable and were omitted. The budget estimates for those three jurisdictions may not be as complete as for other States. Step 3: Estimate Excess Costs Associated With Poor Control of Blood Glucose The distribution of HbA1c levels for diabetic employees and their dependents was estimated by fitting the employer population to the distribution of HbA1c levels in the CDC National Health and Nutrition Examination Survey data for 2001-2002.12 The distribution is based on the reported HbA1c levels of respondents who either 1) have been told by their physician that they have diabetes and had HbA1c levels greater than 6, or 2) have not been told by their physician that they have diabetes or have been told that they are borderline diabetic and had HbA1c levels greater than 7. Costs were estimated by assessing the impact of two hypothetical interventions. One assumes that a population's HbA1c levels can be reduced by 0.48 percentage points, on average. Another assumes that the reduction can reach 1.09 percentage points, on average. Evidence suggests that carefully designed diabetes care quality improvement programs can achieve a 0.48-point average reduction. Intensive disease management programs can achieve a 1.09-point average reduction. Both reductions imply improved glycemic control of the population.13 Improved glycemic control results in fewer complications for people with diabetes over time.14 15 Differences in cost associated with an assumed improvement in HbA1c levels were based on the findings of another study. That study observed inpatient and outpatient health care charges of patients with diabetes in a large commercial health plan for 3 years. The researchers analyzed the difference in health care costs for patients who started the study period at different HbA1c levels.16 That study did not reevaluate the HbA1c levels of the study subjects at the end of the 3 years. Thus, the estimates of lower costs associated with better glycemic control assume that changes in HbA1c levels lead to fewer complications, which result in lower costs. These assumptions were applied to State employee and dependent populations so that estimates of the cost impact of reducing their HbA1c levels by either 0.48 percentage points or 1.09 percentage points represent the difference in health care costs for States' employee populations. Their distribution of HbA1c levels was based on national HbA1c distributions for people with diabetes and a distribution of HbA1c levels in which everyone has shifted down either by 0.48 percentage points or 1.09 percentage points. The State Snapshots Web site rounds the percentage point reductions to 0.5 and 1.0, respectively, and rounds all dollar estimates to the nearest $100,000 to denote the precision that the estimates are likely to provide. In addition to estimates of health care cost savings, estimates were made of the cost impact of gains in productivity resulting from a population's reduced HbA1c levels. The findings of a study examining the impact of HbA1c levels on rates of absenteeism and productive capacity17 were used to estimate the change in these rates. The estimates were based on downward shifts of either 0.48 percentage points or 1.09 percentage points in the distribution of State employee and dependent populations' HbA1c levels. The changes were then applied to median hourly wage data from the BLS to produce estimates of cost savings from gains in productivity under both conditions. The State Snapshots Web site rounds the percentage point reductions (to 0.5 and 1.0, respectively) and rounds all dollar estimates to the nearest $100,000 to denote the precision that the estimates are likely to provide. For more detail on these calculations, go to Employers' Diabetes Costs Calculator. Top of Page4. Disparities in TreatmentData. The Disparities in Treatment section provides data on the percentage of adults with diabetes who had an HbA1c measurement in the past year. These estimates are obtained from the Diabetes Supplement to the BRFSS.18 The BRFSS is a household survey that, as noted above, collects data on health behaviors, including diabetes care, in most States. BRFSS data are limited in several ways:
Racial/ethnic comparisons. In the Disparities in Treatment section, three racial/ethnic categories from BRFSS are presented:
Other racial/ethnic categories are not included due to small sample sizes. That is, some States either do not have many people with a specific racial/ethnic heritage or did not collect large enough samples of minority groups to support analyses. Maps of gaps in HbA1c testing. The Maps visually summarize the comparison of two subpopulations across two geographic areas in terms of relative rates of HbA1c testing. That is, non-Hispanic Blacks are compared to non-Hispanic Whites, Hispanics are compared to non-Hispanic Whites, and low-income groups are compared to high-income groups within a State. Then those relative rates are compared to the same relative rates across all States. The result is a ratio of a ratio that represents the gap within the State in treatment between two subpopulations relative to the gap for all States with data. In the maps, the State's gap is presented in terms of three groups and an "unknown" category. Assignment to the groups depends on the relative size of the gap and the relative direction of the gap between the group of interest (e.g., non-Hispanic Blacks versus non-Hispanic Whites in the State) and the comparison group (e.g., non-Hispanic Blacks versus non-Hispanic Whites in all States). To capture size and directional effects, the ratio of ratios can be assessed for whether it is substantially below, near, or substantially above 1.0. The cutoff used was below and above 5 percent. Thus, the three categories are defined as follows:
Bar chart of racial/ethnic HbA1c testing rates. The bar chart shows the percentage of adults with diabetes who had 2 or more HbA1c measurements in the past year for three geographic areas. The bars represent the percentages for the State, for the region (i.e., one of nine Census Divisions) in which the State is located, and for all States with data. The data are from BRFSS. (Refer to the Data subsection above for a description of the BRFSS and the jurisdictions missing this information.) Region (Census Division) or State peer-group average. The calculation of the average for each State's peer group uses the individual responses for all people in the reporting States in the relevant Census Division. (Select Appendix II for list of Census Divisions.) National average. The calculation of the national average uses the individual responses for all the people in all reporting States. Top of PageState Snapshot Focus on AsthmaThe Focus on Asthma section of the NHQR State Snapshots provides information on prevalence, quality, and estimates of the potential financial returns from quality improvement programs for populations diagnosed with asthma. Such information is important to State health policymakers, health plan administrators, and others considering or planning these programs. 1. PrevalenceThe maps visually summarize the prevalence of asthma for each State in 2010 by categorizing the state-level information into four quartiles. Prevalence is highest in the first quartile (greater than 9.8 percent) and lowest in last quartile (less than 7.8 percent). The data for the maps are self-reported by adults and come from the Behavioral Risk Factor Surveillance System (BRFSS). 2. Quality-of-Care Performance MeasuresThe asthma outcome measures were derived from AHRQ's Healthcare Cost and Utilization Project (HCUP). These are measures of avoidable hospital admissions for asthma for children ages 2-17, adults ages 18-64, and adults age 65 and over. More information on HCUP, the participating statewide data sources, and the use of HCUP data in the NHQR can be found on the HCUP User Support Web site under Methods Series Reports (http://www.hcup-us.ahrq.gov/reports/methods.jsp). Asthma outcome measures report the number of hospital admissions for different age groups, with each measure defined per 100,000 people of that age group in the State. The quality of asthma care bar chart shows the total number of asthma admissions per 100,000 people per age group in the State, in the region, and in the U.S. The national estimate is labeled "U.S" and is a weighted national estimate that accounts for missing States. The regional estimate is based on the four U.S. Census Regions instead of the nine U.S. Census Divisions due to the lack of sufficient State estimates within each U.S. Census Division. States included within each U.S. Census Region are listed in Appendix II. Top of Page3. Quality ImprovementAsthma care improvement programs typically follow the guidelines of the National Asthma Education and Prevention Program (NAEPP). The NAEPP calls for education of patients and providers to better manage the disease. The NAEPP activities for patients focus on self-management to avoid triggers, anticipate problems, and use medications appropriately. The activities for providers focus on accurate diagnosis, appropriate medication prescribing, patient monitoring, and patient education on how to maintain control and avoid attacks. Often education leads to reductions in the need for hospitalization, emergency department visits, urgent office visits, and missed work or school days due to asthma attacks, although it may result in greater pharmaceutical use. Ultimately, net reductions save health care dollars and improve productivity. The estimates of the health care savings and productivity gains provided in the Focus on Asthma section were developed using the Asthma Return-on-Investment Calculator. The calculator, developed for AHRQ by Thomson Reuters with AHRQ funding, is a tool that uses findings from the literature to estimate potential financial returns of quality improvement programs. The calculator combines specific characteristics of the targeted population and of the planned asthma program with current research findings (as of March 2007), to generate results which include:
The estimates presented in the Focus on Asthma section were developed based on a hypothetical asthma care quality improvement intervention program which 1) targets patients with persistent asthma with at least one acute care visit in a 1 year period, 2) assumes 25 percent of eligible patients will participate, 3) costs $395 per patient per year, and 4) runs for 4 years. This hypothetical intervention targets the sickest asthma patients, and, thus, shows the best estimated returns. Not all hypothetical intervention programs will result in a favorable ROI. For the purpose of this modeling, State employees are the same as privately insured. For a detailed description of the calculator and the default settings used to generate the estimates, refer to the model description section of the Asthma Return-on-Investment Calculator. Note that results presented in the Focus on Asthma section are in 2010 dollars. Top of PageState Snapshot Focus on Healthy People 2020The Focus on Healthy People 2020 section compiles a table of 15 measures that reflect U.S. health goals and that are reported by States. These health goals are intended to increase life expectancy, improve quality of life, and eliminate health disparities throughout the Nation. Launched by the Department of Health and Human Services in 2010, the goals provide Federal, State, and local government agencies and nongovernmental organizations with a framework for assessing progress in a comprehensive set of seven focus areas:
The table, sorted by focus area, displays the Healthy People 2020 target rate, the most recent State rate and data year, and the baseline State rate and data year. Measure definitions are also provided. Top of PageState Snapshot Focus on Disparities The Focus on Disparities section presents data on disparities in the quality of care among racial, ethnic and socioeconomic groups in the areas of: (1) Ambulatory Care Processes, (2) Home Health Care, (3) Nursing Home Care, (4) Hospital Care, and (5) Ambulatory Care Sensitive Hospitalizations. When disparities are examined by ethnicity, State-level quality-of-care measures for non-Hispanic Blacks, non-Hispanic Asian/Pacific Islanders and Hispanics are compared against the same measures for non-Hispanic Whites, the reference group. Examined by socioeconomic groups, State-level quality-of-care measures for low-income groups are compared against the same measures for high-income groups. Performance meters are used to indicate how State performance compares to that of the Nation and, specifically, whether State performance is about average, below average, or above average when compared to the national level. State/National comparisons are reported only if data are available for five or more measures. Across the different areas of the report the number of performance measures used to derive meter scores range from 5 to 19. HCUP quality-of-care measures used to rate a State's performance on the performance meter focus on ambulatory care sensitive hospitalizations, in addition to hospital mortality and safety, and birth/obstetrics. Ambulatory care sensitive hospitalizations are assessed for the following conditions:
Ambulatory Care Process measures focus on cancer and other screenings, diabetes management and vaccinations. Home Health Care measures focus on functional status preservation and rehabilitation, palliative and supportive care and health care utilization. Nursing Home Care measures focus on long-stay functional status preservation and rehabilitation, long-stay palliative and supportive care and short-stay palliative and supportive care. Information on disparities are presented by focus areas, and indicates how the quality of care or outcomes of the minority population compares to that of the reference group in that State and in comparison to the U.S. These comparisons are determined by calculating the ratio of performance for the minority group to performance for the reference group measure at the State and national levels. Data for subsections dealing with Hospital Care and Ambulatory Care Sensitive Hospitalizations are obtained from AHRQ's Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and use version 4 of the AHRQ Quality Indicator (QI) software. Data are only available for those States that participate in HCUP. More information on HCUP can be found on the HCUP User Support Web site under Method Series Reports (http://www.hcup-us.ahrq.gov/reports/methods.jsp). Data for Ambulatory Care Processes are obtained from the Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System (BRFSS). Data for Home Health Care are obtained from the Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS). Data for Nursing Home Care are obtained from the Centers for Medicare & Medicaid Services, and is gathered from Minimum Data Set (MDS). For each measure the relative rate is calculated by dividing the estimate corresponding to the subgroup of interest (e.g., low income population, racial/ethnic minority) by the estimate corresponding to that of the reference group (e.g., non-Hispanic Whites or high-income population). Data tables also include a field to indicate whether a "high" or "low" value of the measure is the preferred outcome. For measures with a "low" preferred outcome, a relative rate above 1.0 indicates that the subgroup (minority group or low-income population) has worse outcomes or receives poorer quality of care than the reference group (non-Hispanic Whites or high-income population. The higher the relative rate, the greater the disparity. A relative rate less than 1.0 indicates the subgroup of interest has a better outcome or receives better quality of care than the reference group. For measures with a 'High' preferred outcome, the relative rate is interpreted as the opposite of the "low" preferred outcome. Arrows associated with the relative rates are based on whether differences are statistically significant(p-value < 0.05) and whether values differ by at least 10 percent. Comparative rates are calculated by dividing the State-specific relative rate by the relative rate for the U.S. For measures with a "low" preferred outcome a value above 1.0 indicates that the State is doing worse than the U.S. A value below 1.0 indicates that the State is doing better than the U.S.. A relative rate of 1.1 or above is reported as "worse" and a relative rate of 0.9 or below is reported as "better" performance in graphics. A triagngle is used to indicate that differences are at least 10 percent. For measures with a 'High' preferred outcome, the comparative rate should be interpreted as the opposite of measures with 'Low' preferred outcomes. Top of PageState Snapshot Focus on PayerThe Focus on Payer section includes information on hospital care measures that refer to inpatient mortality and potentially avoidable complications by expected primary payer (privately insured, Medicare, Medicaid, and the uninsured). The pie chart on the initial page of the Focus on Payer section shows the distribution of all inpatient hospitalizations for 2008 by expected primary payer in the State and serves as contextual information when reviewing how each insurance type performs on different measures of hospital care. Data for this focus area are from AHRQ's Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Data are only available from selected States that participate in HCUP. More information on HCUP can be found on the HCUP User Support Web site (http://www.hcup-us.ahrq.gov). In the all-payer section, a comparison of Medicare, Medicaid, and the uninsured to the privately insured is featured. Data are from the 2008 HCUP SID and Nationwide Inpatient Sample (NIS) and use version 4 of the AHRQ Quality Indicator (QI) software. The performance meters display how the disparity in quality of care for the State relates to the disparity in the U.S.—whether the State level is about average, below average, or above average when compared to the U.S. level. The performance meter scores are based on up to 13 measures of quality of care and are reported only if at least five measures are available. In each payer-specific section, the State-level payer-specific rates for 13 different measures are compared to the U.S. rates. Data are from the 2008 HCUP SID and NIS and use version 4 of the AHRQ QI software. The performance meter score summarizes the State's performance over the 13 QIs and is reported only if at least five measures are available. The data table displays the State and U.S. rates with an indication of a differential of at least 10 percent. Top of PageState Snapshot Focus on Variation Over TimeThe Focus on Variation Over Time section shows the high degree of variation across States and over time in potentially avoidable adult and pediatric hospital admissions for composites of acute and chronic conditions. Graphs present States' performance compared to that of Nation using the AHRQ Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs) composite measures. These measures refer to hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care. Rates for 3 years (2000, 2004, and 2008) are reported per 100,000 population. Rates for interim years are not available. For adults, the PQI composites are defined as follows:
For children ages 6-17, the PDI composites are defined as follows:
Data for this focus area are from AHRQ's Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and use version 4.1 of the AHRQ Quality Indicator software. Data are only available from those States that participate in HCUP. More information on HCUP can be found on the HCUP User Support Web site under Method Series Reports (http://www.hcup-us.ahrq.gov/reports/methods.jsp). Top of PageState Snapshot Ranking TableTo enable simple direct comparisons of States on some health care quality measures underlying the summary measures, States were ranked from 1 to 51 on a select set of 18 measures from the NHQR for which all States reported. These measures include core measures for the most common diseases reported in the NHQR. Core measures represent the most important and scientifically credible measures of health care quality for the Nation. They were selected by the Department of Health and Human Services Interagency Workgroup for the NHQR. Many of the core measures selected by that workgroup did not have State-level data. The other measures in the core areas were selected to round out the group of 18 reported in the State Snapshots. Top of PageState Snapshot Contextual FactorsThe context of the State's broader demographic and health environment is shown in a series of dials. Seven dials relate to State demographics, three relate to health status, and three relate to health care resources. These factors provide a backdrop to the State's health care quality and may aid in interpreting the State's performance meters. These contextual factors might have a cause, effect, or other indirect association with the results shown in the performance meter. For example, if a high percentage of the State's population is without health insurance, a high percentage of the State's population might not use preventive services. The dials show the State's rate for the factor and the range of rates across all reporting States. An orange wedge on each dial shows the spread of values for all reporting States (or reporting States in the region), ranging from the State with the lowest to the State with the highest value. The needle in the orange portion marks the State's rate (percentage) for the factor. The data sources for the contextual factor dials are:
Appendix I: 2011 NHQR Measures, by 2011 State Snapshot Summary Measure AssignmentThis appendix lists the NHQR measures included in the summary measures, excluding the overall summary measure. The overall summary includes all measures in the tables below (except for those in the excluded table) reported by a State. Individual measures may appear in multiple groupings. The list of measures is organized by: Types of Care
Types of Care: Preventive Care Measures
Types of Care: Acute Care Measures
Types of Care: Chronic Care Measures
Settings of Care: Hospital Care Measures
Settings of Care: Ambulatory Care Measures
Settings of Care: Nursing Home Care Measures
Settings of Care: Home Health Care Measures
Care by Clinical Area: Cancer Care Measures
Care by Clinical Area: Diabetes Care Measures
Care by Clinical Area: Heart Disease Care Measures
Care by Clinical Area: Maternal and Child Health Care Measures
Care by Clinical Area: Respiratory Diseases Care Measures
Clinical Preventive Services
Appendix II: U.S. Census Region and Division Definitions Used in the 2011 State Snapshots
AcknowledgmentsThe 2011 State Snapshots were developed from the 2011 National Healthcare Quality Report through a team effort including the Agency for Healthcare Research and Quality (Ernest Moy, Karen Ho, Karen Migdail, Morgan Liscinsky, Biff LeVee, Doreen Bonnett, Roxanne Andrews), Thomson Reuters (Healthcare) Inc. (Rosanna Coffey, Jillian Dudek, Minya Sheng, Kathy Hickey, Anika Hines), ML Barrett, Inc. (Marguerite Barrett), Social & Scientific Systems (Xiuhua Chen, Ram Khadka, Anil Koninty, Atlang Mompe, Barbara Barton, Jeffrey Schinckle, Po-Lun Chou, Janette Walters, Srini Guruswami, Janet Pagán-Sutton). These State Snapshots have built on work of earlier years and contributions of the above individuals and others: Agency for Healthcare Research and Quality (Edward Kelley, Dwight McNeill, Jeffrey Brady, Marybeth Farquhar, DonnaRae Castillo, David Atkins, Christine Williams, Sandi Isaacson, Mary Nix, Kathy Crosson, Gerri Michael-Dyer, Marjorie Shofer), Thomson Reuters (Healthcare) Inc. (Craig Hunter, Julia Nisbet, Jim Blakley, Mirjana Milenkovic, Angela Fulmer), Social & Scientific Systems (Laurie MacCallum, Dale Byington, Paul Gorrell, Mikki Hall, Debbie Machen), ECRI (Vivian Coates, Steve Rhoads, Evan LeGault, and Pamela Nash),Kenney IS Consulting (Tim Kenney), the National Governors Association, the National Conference of State Legislators, the Council of State Governments, the Association of State and Territorial Health Officials, and the Federal Interagency Workgroup for the National Healthcare Quality Report. Additional support was provided by AcademyHealth (Enrique Martinez-Vidal, Amanda Brodt), the Lewin Group (Tim Dall, Sarah Stout), and the Madison Design Group (Russ Surles, Anne Kerns, Darin Ruchirek). Top of PageEndnotes1 Bureau of Labor Statistics. Quarterly Census of Employment and Wages, 2004. Available at: http://www.bls.gov/cew/home.htm.2 Bureau of Labor Statistics and U.S. Census Bureau. Current Population Survey, Annual Social and Economic Supplement, 2003, 2004, 2005. Available at: http://www.bls.gov/cps/cps_aa2003.htm. 3 U.S. Census Bureau. Census 2000 EEO Data Tool. Available at: http://www.census.gov/eeo2000/index.html. 4 U.S. Census Bureau. Population estimates by State, 2004. Available at: http://www.census.gov/popest/data/historical/2000s/vintage_2004/state.html. 5 Claritas, Inc. 2001 Demographic Data and the Claritas Update: Demographics Methodology. San Diego, Claritas: 2001. 6 More information on data from the Medical Expenditure Panel Survey is available at: http://www.meps.ahrq.gov/mepsweb/data_stats/data_overview.jsp. 7 U.S. Census Bureau. Table ST-F1-2000: Average number of children per family and per family with children, by State: 2000 Census. Available at: http://www.census.gov/population/socdemo/hh-fam/tabST-F1-2000.pdf. 8 Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey data, 1998, 1999, 2000. Available at: http://www.cdc.gov/nchs/nhis.htm. 9 The Health Benefits Simulation Model (HBSM) is a microsimulation model of the U.S. health care system. HBSM is based upon a representative sample of households in the United States, which includes information on the economic and demographic characteristics of these individuals as well as their utilization and expenditures for health care. The HBSM household data are based on AHRQ's 1999 through 2001 MEPS, which were used together with the March 2004 Current Population Survey. The data were adjusted to show the amount of health spending by type of service and source of payment as estimated by the Office of the Actuary of the Centers for Medicare & Medicaid Services (CMS) and various agencies. More information on the HBSM data and methods are available in Sheils J, Haught R. Covering America: cost and coverage analysis of ten proposals to expand health insurance coverage. Appendix A: Health Benefits Simulation Model (HBSM): uniform methodology and assumptions. October 1, 2003. Available at: http://www.rwjf.org/files/research/costCoverageMethodology.pdf. 10 ACCRA Cost of Living Index. Arlington, VA: Council for Community and Economic Research, 2005. Available at: http://www.coli.org/. 11 National Association of State Budget Officers. Table 19: Total State employee health expenditures, fiscal 2002 and 2003. In: 2002-2003 State Health Expenditure Report. New York, NY: Milbank Memorial Fund, 2005. Available at: http://www.milbank.org/reports/05NASBO/nasbotable19.pdf. 12 Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey data. Available at: http://www.cdc.gov/nchs/nhanes.htm. 13 Shojania KG, Ranji SR, Shaw LK, et al. Diabetes mellitus care. In: Shojania KG, McDonald KM, Wachter RM, et al. Closing the quality gap: a critical analysis of quality improvement strategies. Vol. 2. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Technical Review 9. AHRQ Publication No. 04-0051-2. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap2/qualgap2.pdf. 14 The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. New Engl J Med 1993;329(14):977-986. 15 Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. UK Prospective Diabetes Study Group. Br Med J 1998;317(7160):703-13. 16 Gilmer TP, O'Conner PJ, Rush WA, et al. Predictors of health care costs in adults with diabetes. Diabetes Care 2005;28:59-64. 17 Testa MA, Simonson, DC. Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: a randomized, controlled, double-blind trial. JAMA 1998;280:1490-96. 18 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2004-2006. Available at: http://www.cdc.gov/brfss. Top of Page Internet Citation2011 State Snapshots: Methods. Derived from 2011 National Healthcare Quality Report. May 2011. Rockville, MD: Agency for Healthcare Research and Quality. http://statesnapshots.ahrq.gov/. This page has links to PDFs that can only be read or best viewed in Acrobat Reader, please download Acrobat Reader. |


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text: bacon By John Riggs January 31, 2011 5:40 PM Share on Facebook Share on Twitter Category: Share on Facebook Share on Twitter More Leave a comment Send to a friend! Print this page Pin it! Reddit This! Share on Tumblr! More from katsfm.com What Bobby 'The Brain' Heenan Looks Like Today Gamer Comes to Aid of Bullied 10-Year-Old Last Good Tooth, 'What's What I Do' – Free MP3 Download Child Eats Dog Poop in Most Disgusting Ad You'll Ever See Best of the Web ZergNet


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1. Sweet-Pea Canapes Gourmet, May 2007
2. Crostini with Lump Crab Salad and Extra Virgin Olive... Reprinted with permission from Fantastico!, November 2007
3. Smoked Salmon Chips Perfect Parties, May 2008
4. Scandinavian Ceviche Perfect Parties, May 2008
5. Mini Chocolate Sandwich Cookies Gourmet, December 2004
6. Asian Avocado Salsa Bon Appétit, August 2008
7. Tiramisu Affogato Gourmet, August 2008
8. Mini Lobster Rolls Gourmet, August 2007
9. Crab-and-Pork Spring Rolls Gourmet, June 2006
10. Kir Royale Epicurious
11. Crostini with Beef Tartare and White Truffle Oil Reprinted with permission from Fantastico!, November 2007
12. Pissaladiere Strips Gourmet, July 2007
1. A Menu Inspired by Argo Epicurious
2. A Menu Inspired by Django Unchained Epicurious
3. A Menu Inspired by Life of Pi Epicurious
4. A Menu Inspired by Beasts of the Southern Wild Epicurious
5. A Menu Inpired by Lincoln Epicurious
6. A Menu Inspired by Zero Dark Thirty Epicurious
7. A Menu Inspired by Silver Linings Playbook Epicurious
8. A Menu Inspired by Les Misérables Epicurious
9. A Menu Inspired by Amour Epicurious
10. A Menu Inspired by Hugo Epicurious
11. A Menu Inspired by The Tree of Life Epicurious
12. A Menu Inspired by War Horse Epicurious
1. Movie Menus: A Grand Great Gatsby Party Throw a Champagne-fueled bacchanal inspired by F. Scott Fitzgerald's classic New York novel, now a Baz Luhrmann movie
2. Oscar Party Recipes and Drinks Host a Hollywood-style affair with our movie-themed menus, classic cocktail recipes, and Champagne picks—plus popcorn, brownies, and easy hors d'oeuvres
3. Oscars 2013: Movie-Themed Menus The year's Best Picture nominees, including Django Unchained, Les Misérables, Zero Dark Thirty, and Amour, inspire nine award-worthy feasts
4. Oscars 2012: Movie-Themed Menus The year's Best Picture nominees inspire nine award-worthy feasts
5. Kevin Lee's Oscar Party Tips A star of the Real Housewives of Beverly Hills offers advice on throwing a glamorous Hollywood-themed Academy Awards party
6. Oscars 2011: Movie-Themed Menus Recipes and drinks inspired by the year's Best Picture nominees
7. Taste Test: Microwave Popcorn Which brand would make the perfect movie companion? Read on to find out
8. Celebrate the Super Bowl Five of our favorite chefs share their ultimate football-party recipes
9. Salsa Taste Test Our taste test of 19 brands of salsa revealed three winners
10. Tortilla Chips Taste Test Out of 31 varieties, which tortilla chips are the best?
11. Brownie Mix Taste Test 21 store-bought brownie mixes were tested by our editors only three truly satisfied our chocolate craving
12. Oscars 2010: Movie-Themed Menus Meals inspired by this year's ten Best Picture nominees
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This butcher block table's beautiful maple cutting surface looks excellent, displayed with an edge-grain construction
Call or email our John Boos experts with any questions you have. We're happy to help you. We answer our phones M-F, 9 to 6, EST. 888-892-9911, firstname.lastname@example.com.
The John Boos Town House 42 x 24 inch butcher block table provides you with all the kitchen prep space you'll need. This hard maple butcher block table from John Boos would look great in any kitchen. The cutting surface displays its beautiful hard maple with an edge-grain construction. Additionally, the slatted maple shelf provides you with some extra storage room. This John Boos butcher block will last for a long time because John Boos' premium maple is hard and durable. Also, the food-safe beeswax finish protects the table from damage like cracking or warping.
If you found this item at a lower price, call us at 888-892-9911 or send us the form below. Give us the details on the lower price so we can match it!
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Patterned - All Over Bathroom Vinyl Flooring
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Softstep Collection - Vinyl Flooring
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Superbly priced vinyl in classic, natural looking designs, this collection really does add a touch of class to any space. Easy to clean and maintain, with a 5 year wear warranty. Available in store to take away or call our dedicated team to order by phone.
Titan II Collection - Vinyl Flooring
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Rhino Step Collection - Vinyl Flooring
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Rhino Champion Collection - Vinyl Flooring
After Event Price £45.99 m2 Was £22.99 m2Now £18.39 m2
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The Olympus vinyl range is a strong and durable range that is almost indistinguishable from wood and tile floors.
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Our Atlas range combines classic wood and tile effects with some stunning contemporary looks – all designed to bring any room you choose to life.
Bounce Collection - Vinyl Flooring
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As the name suggests, Bounce is a vinyl which has a great feel underfoot. In this collection of stunning vinyl's there are some brilliant real stone and wood effects.
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Little boy holding a banner isolated on white
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Alienware (a Dell Inc. subsidiary) begins offering its first Ubuntu-powered PC targeted at gamers.
Image from alienware.com
The Intel Linux Graphics Installer provides a friendly way for downloading the latest Intel Linux graphics software stack.
Firefox 20 has all the goodies and it is already available for stable Ubuntu releases such as Ubuntu 12.10 and Ubuntu 12.04. But what about Ubuntu 13.04? Ubuntu "Raring Ringtail" is already on beta and the final release will happen in a few weeks time. And it is yet to receive Firefox 20 update. It will be coming anyways before the final release.
Dell has launched Alienware X51 Ubuntu gaming desktop. Alienware customers can now choose either Windows or Ubuntu when buying a new X51.
Following on from its release last week, GNOME's default web-browser is now available for users of Ubuntu 13.04 to install.
The Ubuntu team is pleased to announce the final beta release of Ubuntu 13.04 Desktop, Server, Cloud, and Core products.
Codenamed "Raring Ringtail", 13.04 continues Ubuntu's proud tradition of integrating the latest and greatest open source technologies into a high-quality, easy-to-use Linux distribution.
The Ubuntu team is pleased to announce the final beta release of Ubuntu 13.04 Desktop, Server, Cloud, and Core products.
There were some confusions regarding the release of next Ubuntu release. But overtime, all the apprehensions were laid to rest. Ubuntu 13.04 "Raring Ringtail" will be released as per schedule. User Interface Freeze is already a done deal. Final beta release should also be arrived by now. And the final release will happen on April 25th. In plain language, Ubuntu 13.04 is almost ready.
We're here with cake and an interview. We're Alan Pope, Mark Johnson, Tony Whitmore, and The Podcats. We're here in Studio A for the sixth episode of Season (Series) Six of the Ubuntu Podcast from the UK LoCo Team!
At the GPU Technology Conference, Valve recently talked about their experience of porting Source Engine to Linux.
Microsoft's long-held dominance over the computing sector is coming to an end, say market experts Gartner.
The industry analysts expect Microsoft's roost to shrink by over 7% this year alone. And, in further research they've conducted, go as far as as to predict the Windows' makers share slipping as little as 14% by 2017.
New items have been added to the official Ubuntu Shop, including the obligatory 'new release' t-shirts.
Canonical update their range of branded goods around one every 6 months, typically before the release of the latest Ubuntu version.
QupZilla is a new and very fast QtWebKit browser. It aims to be a lightweight web browser available through all major platforms. This project has been originally started only for educational purposes. But from its start, QupZilla has grown into a feature-rich browser.
QupZilla has all standard functions you expect from a web browser.
Ubuntu 13.04′s Unity desktop will not ship with a new in-Dash payment feature as originally proposed.
I'm going to mention a certain infamous social networking site and I don't want you to pelt me with rotten fruit for doing so. Agreed? Awesome. Yes, it's Facebook app time again.
In-Dash App Purchase Transaction. Image credit: alecu83
Ubuntu 13.04 wants to let users buy music from the Ubuntu One Music Store directly from the Dash – no web-browser transactions needed.


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text: Have a beach party or just a beach themed party. Put up summer beach decorations and put Fun in the Sun balloons everywhere. Serve punch and a summer cake, and when you do use the Fun in the Sun Standard tableware kit. This kit provides you with place settings for up to eight guests. You'll get eight Fun in the Sun cake plates, which are 7 inches square and feature a colorful beach ball image on a sea background. There are sixteen matching 2-ply beverage napkins that are 5 inches square. The kit also includes eight lime green 9 ounce cups and a 24-piece set of bright blue plastic cutlery. You'll get eight knives, eight spoons, and eight forks. kit Includes:


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Open Source is powering the New York City Tech Scene. Please join us on March 30 to celebrate open source technology in New York.
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Hunter's Point Plaza
47-40 21st St
New York,
Saturday, March 30, 2013 from 9:00 AM to 8:00 PM (EDT)
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Results 1-15 of 33
Browse and compare 33 Norfolk Mimes (and those who serve Norfolk, Nebraska)
251 miles from Norfolk
Charlie Chaplin Impersonator / Mime
A man of many faces, actor Damian Blake has delighted young and old across the globe with his classic characters and assorted silly bits of business. He has appeared on stage, in print, on film, as a variety entertainer, character actor, fashion model,…
Serves Norfolk
Corporate Comedian / Mime
Funny Business is a national entertainment agency with 30 years experience in booking comedians and variety acts for corporate events, colleges, nightclubs, high schools and more. We work with over 3,000 entertainers nationally and book comedy in over…
Serves Norfolk
Variety Entertainer / Mime
We are full-service creative professionals - fine art, performance art, art instruction and art entertainment. Our popular entertainment services include: Caricatures; Face painting; Balloon art; Faux tattoos - henna or airbrush; Silhouettes; Novelty…
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Juggler / Mime
Russ Sharek has been described by reliable sources as a zen fool, benevolent supervillain, misanthropic community leader, clown father figure and Impish Cabaret Rasputin. He's a teacher known for empowering people to challenge their fears, teaching hat…
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Comedian / Mime
Marty Pollio is a versatile and hilarious comedian and variety act. His set includes fast paced, high energy physical comedy (choreographed to music) along with stand-up that is clean, funny and original. Marty's multiple appearances on the Tonight Show…
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Circus Entertainment / Mime
Bacchanal Promotions is a fully insured entertainment company specializing in fire and circus arts. Based in the Detroit area, Bacchanal Promotions offers fire performance and other circus entertainment throughout the United States and Canada. We strive…
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Circus Entertainment / Mime
acrobats & circus artists —a highly trained group of acrobatic performers—add fun and flourish to any occasion. The wide range of offerings (from aerial silks to stilt walking) allows you to choose the elements that will most enhance your event.…
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Jerry Lewis Impersonator / Mime
A spot on impersonation of a young Jerry Lewis, paying tribute to such classic acts as "The Typewriter", "Chairman of the Board" and many others -- all with that signature Lewis voice!
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Magician / Mime
Whether your guests be 8-80 years old, everyone will love Haydini's breathtaking magic, illusion, mind reading and comedy. The show can be seen by adults, teens, and children alike! Haydini includes several audience members in each routine. Haydini is…
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Children's Party Entertainment / Mime
Balloons With a Twist has everything you need for your party or event! We do balloons twisting, face painting, temporary tattoos, and magic shows. We host princess, Jedi, pirate, dress-up, and tea parties. We provide pony rides, petting zoos, bounce…
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Magician / Mime
Make your next event stand out with Professional entertainment. From close-up to Stage from corporate to private parties! Over 25 years experience performing for hundreds of private as well as some of the biggest companies national and international,…
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NY Pearl the Mime is skilled in classic & modern mime, roving improvisation, clown & character antics, silent story telling, living statue, and living mannequin. Services provide for but are not limited to PRIVATE/SOCIAL/CORPORATE EVENTS, CELEBRATIONS-BIRTHDAYS…
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Children's Music / Mime
In his live show, kids bark like a dog; make music like a trumpet and beatbox like a drumset! Kids of all ages will have an "Electric" time making music on the spot and going on spontaneous adventures with Shock as he teaches the basics to…
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Balloon Twister / Mime
Balloon Artist? Only the most POPular! Stilt Walker? Tall and Proud! Face Painter, Juggler, Magician, Statue Artist, Clown, Characterist and Mime ... The brightest entertainers in the business will make your event shine. Based in NYC, IGE Entertainment…
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Face Painter / Mime
Miz Liz is an extraordinary Face Painter, Body Painter, Airbrush Tattoo and Glitter Tattoo Artist. She is also a Variety Entertainer, Juggler, Circus Artist, Fire-eater, Magician and performs exciting children's and family Stage Shows. She also produces…


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Product DescriptionSingapore Math Home Instructor Guides were created specifically to give homeschoolers' a teacher's guide that works in an individualized environment. Work on explaining concepts as you bridge the gap between the textbook and workbook with unit concepts, pages to reference, numerous reinforcement and practice exercises and detailed solutions laid out step-by-step. Suggestion-only timeframes for each unit are included, though not organized by "daily lesson", allowing the parent to determine how much time to spend on a particular concept. This Home Instructor's guide may be used for either the 3rd Edition or Primary Math Textbook 3B U.S. Edition. 167 pages, spiralbound softcover.
This guide contains: The "Manipulatives" section on page vii of this Home Instructor's Guide refers to an appendix. However, the pages for this appendix were inadvertently left out; a link is provided to access the manipulatives section on Singapore Math's website. Product Information
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Metro 1.0
It's easy to get up and over the hills on your super comfortable Metro 1.0 with 21 speed gearing.
It's easy to get up and over the hills on your super comfortable Metro 1.0 with 21 speed gearing.
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The ultimate urban assault bike. Smooth, stylish and superbly simple. We've upped things again here with an 11-speed internal geared hub powered by a Gates CDC belt drive.


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Catch Cheating Spouse With Amac Keylogger
You may be looking for methods and resources to discover a cheating spouse in the act. One method that you may want to take involves installing a Mac Keylogger to catch your spouse cheating on you by monitoring his/her online activity, as the Internet makes it to some extent undemanding to people to begin abnormal relationships online. A Mac Keylogger can benefit you to verify if your companion is using the Internet to hoodwink you. What a Mac Keylogger will do is to record and store all keystrokes that are typed on a Mac OS X.
If you think your wife is having an affair with others or your husband is cheating on you, a Mac Keylogger will help you uncover the real truth. Install it and know what your spouse is up to. The Mac Keylogger from Amac, which is specially designed for Mac OS X users, allows you to see what your spouse does online and build a record of his/her online activities.
- Mac Keylogger logs both-side chat conversations in Skype, iChat, Adium, MSN and AIM to let you know which one your spouse is talking to and what he/she is talking about.
- Mac Keylogger records websites visited in Safari, Firefox, Chrome and passes information to you on what kind of websites your spouse is visiting.
- Mac Keylogger takes screenshots of the computer desktop to let you know whether your spouse is video chatting and what they are doing.
- Mac Keylogger delivers reports to a preset email address so that you can check logs easily at any time.
It is foolish to blindly trust your spouse. You never know what they do online. It's often easier for you to work through the process if you turn to some outside help. Apply a Mac Keylogger as that's what it is in the business of doing. This is a tried and truly helpful tool that will help you to get the details that you require in this situation.


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Attorney Profile
Edward Sharkansky was a prosecutor with the Plymouth County District Attorney's Office prior to opening his current practice in 1997. Over the past five years, he has transformed his felony criminal practice to one which specializes in representing individuals charged with Operating Under the Influence and other related motor vehicle offenses. Mr. Sharkansky has tried hundreds of OUI cases in courts throughout the Commonwealth.
- expert witness testimony to suppress blood alcohol analysis
- cross-examination of breath test operator regarding operation of breath test machine and accuracy of breath test results
- cross-examination of police officer regarding field sobriety testing
He is a member of the following organizations:
- National College for DUI Defense
- National Association of Criminal Defense Attorneys
- Massachusetts Association of Criminal Defense Attorneys (Member of the Board of Directors)
- Massachusetts Bar Association
- Plymouth County Bar Association (Member of the Board of Directors)
Edward Sharkansky has transformed his felony trial practice into a DUI/DWI specialty practice thus offering an unmatched level of knowledge and trial experience to clients arrested for DUI/DWI. He has proven success in license recovery and acquittals for clients arrested for DUI or OUI.
- Edward Sharkansky has been invited to speak at numerous seminars sponsored by the Massachusetts Bar Association, Massachusetts Continuing Legal Education and Suffolk University School of Law.
- He is a graduate of the George Washington University and received his Juris Doctor from the Northeastern University School of Law.
Hire the best Massachusetts attorney and fight your DUI charges in court.


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GGP Names Cushman & Wakefield to Lease, Manage 1.5M SF Maryland Office Portfolio4 Aug, 2011, New York
Cushman & Wakefield announced today it has been named Leasing and Management Agent of a 1.5
million-square-foot General Growth Properties office portfolio in Maryland.
A Cushman & Wakefield team, led by Vice Chairman Jonathan Serko and Executive Vice President Barry Zeller in New York, will oversee the leasing efforts for the office properties in Columbia, Baltimore and Owings Mills, while providing property management for the properties in Columbia and Owings Mills. The portfolio includes: - Columbia Corporate Center, a seven-building office complex in Columbia Town Center totaling 876,475 square feet. Located adjacent to The Mall in Columbia with 250 shops and eateries, the office complex also offers views of Symphony Woods Park and Lake Kittamaqundi, as well as easy access to major thoroughfares. Cushman & Wakefield Senior Director Hayes Merkert, Director Danielle Schline and Director Karen Cherry will be the team members dedicated to Columbia Corporate Center. - Harborplace Tower, a 261,780-square-foot class-A office building overlooking Baltimore's Inner Harbor and located adjacent to Harborplace & The Gallery, the city's premier shopping, dining and entertainment destination. Cushman & Wakefield Senior Director Tim Jackson and Associate Director Kyle Durkee will be the team members dedicated to Harborplace Tower. - Owings Mills Corporate Center, comprised of two office buildings totaling 330,736 square feet, with close proximity to major highways and access to multiple restaurants and the Owings Mills Mall. Cushman & Wakefield Senior Director Tim Jackson and Associate Director Kyle Durkee will be the team members dedicated to Owings Mills Corporate Center. "We are extremely pleased to have been appointed by GGP to maximize the value of their Maryland portfolio," said Mr. Serko. "Utilizing Cushman & Wakefield's full-service platform, our Leasing and Property Management teams will work seamlessly together to maintain these buildings at the highest standards, while bringing new leasing opportunities to market." * * *


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I love these stools, the legs extend more than expected, but that's okay, would have liked to know weight limitation of 250 lbs prior to buying, need to think how to not get people over 250 to sit in them tactfully :( but overall, absolutely love these, if I had a bigger apartment I'd buy 2 more, oh, and they were packed very well, nice surprise
I love these stools and I'm definitely keeping them, however, I was expecting an "unfinished" galvanized metal stool. This is instead painted a metallic silver with a shiny topcoat. It's kind of like a car's paint. They look as pictured from a distance and everyone who has seen them loves them. Just make sure you know what to expect.
Perfect mid-century Tolix reproduction stools for my modern kitchen. Great value, same price as much crummier, boring stools. Much more affordable than the real thing from France, and a great reproduction. Packed beautifully. They stack, w/little rubber protectors under seat so they won't get scratched. Good quality and value.
These stools are nicely made and sturdy....Very similar to the look of the original french made Tolix version without the steep price....The finish is a platinum-like powder coat (not clear coated raw metal )....The powdercoat has a few flaws, but don't affect the look. Fully assembled.
love these stools to go around our kitchen island... perfect compliment to our stainless steel appliances... love the color... super sturdy.... and the stack-ability is a plus!
Very happy with these stools. I use them as extras when we have guests. The best part is when they are not in use they just stack and store in a small unused corner of my kitchen. I bought four and I am very happy. For the price you can't beat them.
Great quality, classic stools, exactly what I was looking for for my kitchen bar. I was dabbling between white, graphite, black and I'm thrilled I went with this color. Great classic lines and great product.
Sturdy, stackable, medium weight. Modern feel, easy to pack/move. My husband was worried that the stools would be uncomfortable, but when they arrived he instantly overcame his fears and uses the stools daily. Great purchase and good value for money.
Exactly what i wanted at the right price.....packed well
I needed an updated look for casual seating at bar height kitchen counter. These are perfect! I bought 4. Not great for prolonged seating, but perfect to have a bite to eat or a couple of drinks.
Usually leaves our warehouse in 1-2 business days. *
Items must be returned in new or unused condition and contain all original materials included with the shipment. More details
FINAL SALE EXCLUSION: Items marked as FINAL SALE are not returnable unless the problem you experience is the result of our error.
This item cannot be shipped to Alaska or Hawaii.
More details
Our standard shipping method is ground shipping. We also offer expedited shipping for most items. Your final shipping cost and estimated delivery timeframe will be available at checkout.
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* For your safety, some orders go through our loss prevention department. If we select your order for this process, we will immediately notify you that there may be up to a 3-day delay on your order.
** Most Oversize orders are delivered within 1-4 weeks. Some orders may take 6 weeks to be delivered.
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SUPERSEDED (see Active link, below)
1. Scope
1.1 This specification covers 0.177 in. (4.50 mm) diameter metallic-coated carbon steel marcelled tension wire for use with chain-link fence. The 0.177 in. (4.50 mm) diameter metallic-coated wire shall be produced in accordance with Specification A817.Three types of coatings are covered:
1.1.1 Type I--Aluminum-coated (aluminized),
1.1.2 Type II--Zinc-coated (galvanized), and
1.1.3 Type III--Zinc-5 % Aluminum Mischmetal (Zn5Al-MM) alloy-coated.
1.2 The values stated in inch-pound units are to be regarded as the standard. The values given in parentheses are for information only.
2. Referenced Documents (purchase separately) The documents listed below are referenced within the subject standard but are not provided as part of the standard.
ASTM Standards
A700 Practices for Packaging, Marking, and Loading Methods for Steel Products for Shipment
A817 Specification for Metallic-Coated Steel Wire for Chain-Link Fence Fabric and Marcelled Tension Wire
A902 Terminology Relating to Metallic Coated Steel Products
chain link fence; marcelled wire; metallic coated steel wire; steel wire; wire ;
ICS Code
ICS Number Code 77.140.65 (Steel wire, wir ropes and link chains)
ASTM International is a member of CrossRef.
Citing ASTM Standards
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Standards Tracker
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The Laser® SL graphite rod series disproves the old adage that if something seems too good to be true, it probably is. In this case, Lew's® has indeed constructed a new series of graphite rods made with superior components, attractive styling and unmatched performance – while keeping the sticker price under the $100 mark.
2012 Woods & Water®, Inc. - All Rights Reserved.


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Style #: 13W3809, 13W3814, 13W3808, 13W3813
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Color(s): Green-Pink-Yellow, Peach-Light Grey, Black-Grey-Rose, Blue-Violet-Grey
Price: $100.00
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Click the questions to toggle answers on or off.
- Can I receive continued education credits for attending Adam's workshops?
- We provide proof of attendance for those who want to apply for Continued Competency credits at their professional organization. After attending a workshop, members can apply on-line to: firstname.lastname@example.com to receive a certificate of completion indicating the participant name, with date and registration # in Adam's workshop. Credits given are at the discression of your affiliated organization.
- What is your mailing address?
DreamHealer 442 - 6540 E. Hastings St
Burnaby, BC V5B 4Z5
- Should I change my medication for Adam's treatment?
- Absolutely not. Any changes to your medication should be discussed between you and your doctor. It is not necessary to change medications in order to use your intentions for healing. Your thoughts and intentions can be used in conjunction with any medical treatment.
- How do I know if I am doing visualizations the right way?
- Adam suggests some specific visualizations in DreamHealer 2, Path of the Dreamhealer, Intention Heals and explains them further in both of his DVDs. These are guides for you and he encourages that you personalize them for your specific purpose and condition. It is best if you fully understand your condition and what your body has to do to heal. As long as you are using positive intention to heal, there is no wrong way to do visualizations. .
What visualization is best for my illness?
- Some of the possible visualizations are clearly outlined in DreamHealer 2 and also in both DVDs. Let your feelings and imagination guide you to the best visualization for your situation. It is also recommended that you consult with your doctor for more details as to where to focus your visualizations. Doctors are the best resource for this information. The more you understand about your illness the better you can visualize and tackle the problem.
- What are some of the rules for attending a workshop/conference?
- No photography or recording devices allowed during the workshop.
Refrain from using perfumes or colognes at the workshop as some people with certain illnesses are sensitive to them.
All cell phones must be turned off during the workshop.
Please wear loose comfortable clothing.
If you feel that you are sensitive to subtle energies please sit on the outside perimeter.
You cannot bring noisy medical equipment into the workshop as it will interfere with the treatments.
If you have a persistent cough you will not be permitted to attend the workshop as it will also interfere with the treatments.
Between now and the workshop date you should be practicing all the steps outlined in Adam's books including the visualizations from both DVDs.
Know how to ground your energy and visualize merging auras as outlined in the second book. Adam will be going over this, but if you have an idea what to expect then the treatments will be more powerful.
Understand that you do have the power to improve your own health, starting now.
You should have a visualization specific to your own illness when you arrive at the workshop. You can find general visualizations in both DVDs and information on how to customize your visualizations in the book "Intention Heals".
Know as much as possible about your illness. I.e. where exactly it is located; what it is called; know what the organ looks like that might be affected, etc…the more information you have, the more effective and targeted your visualizations will be. Take visualizations seriously as they do work.
Positive thoughts only at the workshop: Have a picture in your mind, of you being somewhere or doing something you love to do. Think about this before attending the workshop and you will have a much easy task of staying positive. This is very important as your thoughts and intentions play a major role in your health. - I have registered for a conference that I am not able to attend. Can my friend attend in my place?
- You can transfer your registration to someone else if you aren't able to use it. Since we sign you in for the conference by name, you need to update your online registration account to indicate that there has been a name change. It is your responsibility that all personal information is updated so that we can correspond with the person who would be attending in your place.
- Will Adam's books and DVDs be for sale at the workshops?
- Yes, they will be for sale at the workshops. It is highly recommended to read books and review the DVDs prior to attending the as preparation.
- When I register online for a conference, will I receive a ticket in the mail?
- No. You receive your proof of registration by email which you should bring to the workshop.
- When I attend a workshop and participate in the energy healing, can I "catch" someone's illness if they have bad energy?
- No. Energy is directed through our intentions and when your intention is to heal, then only positive results can occur. Also one theory is that a person's illness has a specific frequency to that person and cannot be attracted by another person. Adam gives more details on this at his workshops.
- What should I do to prepare myself for a workshop/conference?
- In order to get the most out of your conference experience, you should read the books and view the 2 DVDs. Practice your visualizations at home in preparation for the workshop.
What can I expect from a workshop?
- The conference experience will vary from person to person. There are many factors involved with your healing. Adam will instruct you on how you can become involved in your own healing process and continue the healing after the conference. Adam never recommends that you change any of your medical protocol. You can use these techniques in conjunction with any medical treatment. Become familiar with your illness and take charge of your own healing process. Some people with pain issues often notice changes immediately after or during the conference. That does not mean that everyone with pain issues will notice a change immediately, or at all. We have had emails a year later from some conference attendees letting us know that their pain issues are no longer with them and had vanished after a conference. You have to learn that you can make a difference in your own health. Those with serious issues such as cancer have to look at the conference as a turning point in their healing journey. Results vary from individual to individual.
Typical Email Questions
- Can I get a private or one on one treatment by Adam?
- Due to the excessive demand and Medical School Adam does not do any individual sessions. He does 2 group energy treatments at his workshops which can be very powerful . The workshop events often create an energy shift for a person, as a jumpstart to their healing. You can create an intentional energy event for the person receiving the healing energy from others. He plans to be a fully licensed Naturopathic Doctor in Fall 2013.
- Can I connect remotely to a workshop healing?
- Not everyone can make it to a Dreamhealer workshop. So I have put a short description for you to remotely connect to the healing at one of these workshops. Please go here for more details:Remote Healing Connection


text: "This is Nomad 6-4, asking for landing permissions Foxtrot Actual. " "Roger that Nomad 6-4. This is Foxtrot Actual. Landing bay is open for a brief period of time." The helicopter landed softly onto the landing pad and the doors quickly closed behind it to avoid detection. A squad of soldiers stepped out, and after them, was a menacing figure, who slowly stepped out of the helicopter. He got a few looks from those who caught a glimpse of him... He didn't blame them. After all, He was "Akula", which was the shark in Russian. They respected, yet feared the man. He had been helping with the resistance movement, but had never stated why. After all, one supporting such a group took considerable risk, and that made them more suspicious of him. Akula saw a captain come up to him. "..Akula. Fancy meeting you here. I suppose you are here to glance at the new arrivals?" "Yes captain. Show me the way." The captain walked him towards a window overlooking a large area, and the captain pointed over in the direction of a group. "That's them Akula. Now, if you excuse me, I have other matters to attend to." The hulking figure of a man stared down at the group. They seemed unaware to his presence. If only they were smart enough to look up.. Akula chuckled to himself as he watched the group interact with each other.


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Mr. Roger Pittman, 88, of LaGrange, passed away Monday, January, 14, 2013, at Hospice LaGrange.
Mr. Pittman was native of Troup County and was born December 15, 1924, son of the late Wallace B. Sr. and Hettie Ruth Powers Pittman. He retired from Civil Service, United Postal System. Mr. Pittman was a member of the River of Life Prison and Jail Ministries and devoted to the prison and jail ministries for more than 20 years. He was a U.S. Navy veteran of World War II.
Survivors include his wife of 71 years, Audie Lamerle Pittman of LaGrange; son and daughter-in-law, Charles Owen and Irene Pittman of Franklin; brother, Rev. Wallace Bonner Pittman of LaGrange; sisters, Carol J. Meacham of Huntsville, AL, Ilene J. McClure of Montgomery, AL, J. Irene Ketchum of LaGrange, brother, Jerry s. Pittman of Stockbridge; sisters, Cleo R. Gafford of Columbus, and Linda L. Shelnutt of Franklin. He was preceded in death by a son, Richard Wayne Pittman and three sisters.
Funeral services will be at 11:00 Wednesday at the Hunter-Allen-Myhand Chapel with Minister Billy Colquitt and Rev. Harry Leverett officiating. Interment will be at Shadowlawn Cemetery. The family will receive friends from 10:00 until 11:00 before the service. In-lieu of flowers contributions may be made in memory of Mr. Pittman to the River of Life Ministries, 105v Brittney Lane LaGrange, GA 30240.
Condolences may be shared or expressed at hunterallenmyhand.com.


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Perhaps Biden will find forgiveness from President Barack Obama, who once slipped up and offered Biden the same promotion to the top of the ticket.
When he introduced Biden as his running mate in August 2008, Obama called Biden "the next president of the United States," then quickly corrected himself.
Republican presidential nominee Mitt Romney made the same mistake last year when introducing Rep. Paul Ryan to his ticket. The music played and Ryan walked out waving. Once the applause subsided, Romney stepped back to the microphone to correct the mistake.
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