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Bullsbay, who began his racing career at Hollywood Park, was back at his old stomping grounds Wednesday morning for the $700,000 TVG/Betfair Hollywood Gold Cup Saturday after nine months in the East.
"He knows his way around here," said Alice Clapham, assistant to trainer H. Graham Motion, from Barn 53 North after the 5-year-old horse was shipped here Tuesday from Motion's headquarters at Fair Hill, Md.
"He was vanned from Fair Hill to Newark, flown here Fed Ex and arrived here at 8 p.m.," said Clapham. "He's a good shipper. He galloped a mile this morning."
Bullsbay, a Kentucky-bred son of Tiznow, made his debut here in November, 2007, for trainer Eric Kruljac and finished in a dead-heat for second in a six-furlong sprint but was disqualified for interference and placed ninth. He raced here again on the Gold Cup undercard June 28 last year and finished second in a seven-furlong allowance race.
Bullsbay was transferred to the Motion stable last autumn and developed into a leading stakes horse. He won the Grade III Alysheba Stakes and finished fourth in the Grade I Stephen Foster Handicap in his last two starts at Churchill Downs.
Bullsbay defeated Californian Stakes winner Informed in the Alysheba and was beaten by only 1 ¼ lengths in the Stephen Foster, in which he was edged in a photo for third by Einstein.
"Everyone who works with him at Fair Hill has been overjoyed at the way he's been training," said Clapham. Jeremy Rose, who has ridden him in his last four starts, retains the mount.
Motion will be here to saddle Bullsbay in the Grade I test at 1 ¼ miles on Cushion Track. Bullsbay will leave from post four in a field of 13.
Bullsbay is one of three shippers for the Gold Cup. Parading was shipped here June 29 from New York by trainer Shug McGaughey in quest of his third straight graded stakes victory. Berkeley Handicap winner Autism Awareness was shipped here from Golden Gate Fields by trainer Genaro Vallejo.
Parading, a Phipps Stable homebred, will carry actual high weight of 119 pounds and be ridden by Kent Desormeaux, seeking his second $700,000 stakes victory here in six days after scoring with New York invader Gozzip Girl in the American Oaks Sunday. The 6-year-old horse was made the tepid 4-to-1 morning-line favorite.
Life Is Sweet, a multiple stakes-winning 4-year-old filly, seeks to become the first female to win the Gold Cup since Princessnesian in 1968. She was listed as the 9-to-2 second choice.
Dan Ward, an assistant to trainer Jerry Hollendorfer who supervises his division here, hopes for good luck with Dakota Phone in the $700,000 TVG/Betfair Hollywood Gold Cup, which goes as the eighth race Saturday.
A victory by Dakota Phone would make up for the disappointment Hollendorfer suffered last year when Heatseeker, the morning-line favorite for the Gold Cup, was scratched with an ankle injury the day before the race. The 5-year-old horse was subsequently retired to stud duty.
"Heatseeker was just getting good," said Ward, shaking his head. "He just drew off in the Californian." A 5 ¼-length romp in The Californian in his previous start established Heatseeker as a short-priced favorite for the Gold Cup.
Dakota Phone, a 4-year-old gelding co-owned by Hollendorfer and Halo Farms, was a closing third in The Californian in his last start, beaten by three-quarters of a length. "Dakota Phone never runs a bad race," said Ward. "There should be a decent pace in front of him. He's real honest and runs hard every time."
Dakota Phone worked four furlongs here Wednesday in 50.40 seconds with jockey Rafael Bejarano.
Ward had been through Gold Cup heart-ache similar to the Heatseeker saga before. "I was a groom for Bobby Frankel in 1979," recalled Ward. "Johnny's Image was training so good I think he would have beaten Affirmed."
Affirmed won the race that year under 132 pounds. "Johnny's Image had just won the Hollywood Invitational Turf Handicap," said Ward. "He got into the Gold Cup with 122, and Laz (Barrera, trainer of Affirmed) was furious. But Johnny's Image broke a splint bone just before the race, almost the same timing as Heatseeker."
Trainer Jim Cassidy will rely on Irish-bred Meydan Princess in the $250,000 Royal Heroine Mile Saturday after Diamond Diva, who won the race last year when it was called the CashCall Mile, was forced to pass because of an injury.
"She's leaving tonight for the farm," said Cassidy Wednesday from Santa Anita of Diamond Diva, an English-bred who nipped Ventura by a nose last year. "It's the same problem as last year, a suspensory. She will probably need six months off." Diamond Diva was out for nine months following her victory last year before returning for two starts, most recently a third-place finish in the Gamely Stakes.
Meydan Princess will be ridden by David Flores, who won the CashCall Mile aboard Diamond Diva. Cassidy expects a big effort in the Grade II test for females at one mile on turf.
Meydan Princess won three of nine starts for trainer Jeremy Noseda in England before she was obtained by Forging Oaks Farm and transferred to Cassidy at the end of last year.
"Meydan Princess is doing real well, and I had planned to run her in this race anyway," said Cassidy. "She's a different type of horse than Diamond Diva, more up and coming, and I'm real happy with her.
"She's run three times for me, and two of the races have been really good," said Cassidy of a pair of closing seconds in allowance races on turf. "She can't train any better than she has trained. We'll find out where she fits Saturday."
Meydan Princess drew post five in a field of eight in the Royal Heroine, which will go as the 10th race on an 11-race card.
On Sunday, one day after Life Is Sweet seeks to become the first female in 41 years to win the Gold Cup, another filly takes on males in the $100,000 Hollywood Juvenile Championship.
Necessary Evil, who set a track record of 56.68 for five furlongs while recording a 3 ¾-length victory in a spectacular debut May 31, seeks to become the first filly since champion Althea in 1983 to win the six-furlong Hollywood Juvenile.
Trainer Doug O'Neill will send out a powerful one-two punch in the Grade III test with Necessary Evil (Joel Rosario) and unbeaten Willard Proctor Memorial Stakes winner Classical Slew (Garrett Gomez).
Other probable starters are Really Uptown (Victor Espinoza), Zip Quik (Joseph Talamo) and Coo Cachoo.
The Sunday card will also include the $100,000 Landaluce Stakes, the meet championship for 2-year-old fillies at six furlongs. Unbeaten Cinderella Stakes winner Well Deserved (Rosario) heads a lineup also expected to include Repo (Corey Nakatani), Champagne d'Oro (Gomez), Ballistic Sue (Tyler Baze) and Washington invader Feeling Fancy (David Flores).
FINISH LINES ─ Rafael Bejarano, who has ridden 1,999 winners, has seven mounts on the Thursday card to reach the 2,000 plateau. Bejarano, who has led the last six meets on the Southern California circuit, trails Joel Rosario, 67-61, with eight days left in a hotly contested race…Trainer Jeff Mullins said that multiple stakes winner Battle of Hastings would return to Colonial Downs for the Virginia Derby July 18 after working on the turf here Sunday. He also said that Hollywood Oaks winner Carlsbad would try grass for the first time in her career at Del Mar. "She loved it here Sunday," said Mullins of an encouraging turf work…Hall of Fame trainers celebrate birthdays this week: Bobby Frankel turns 68 Thursday, and Ron McAnally 77 Saturday.
Copyright © 2009-2014, Hollywood Park. All rights reserved.


text:
Lenovo has won more than 100 international awards for forward-thinking design.SEE MORE REASONS
Starting at
Lenovo Erazer X510 Desktop Specs
|User Guide
|Lenovo Erazer X510 Desktop
4th Generation Intel Core i7-4770K Processor( 3.50GHz 1600MHz 8MB)
|Operating System
Windows 8.1 64
|Hard Disk Drive
|Optical Drive
20.3" x 7.2" x 17.5"
Up to 16GB DDR3- 1600Mhz (Support Dual Channel)
7.1 channel surround sound support
28 lbs
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Ethernet - 10/100/1000M LAN, Broadcom 802.11b/g/n Wi-Fi
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625 watt
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|Skullcandy Hesh 2 Over Ear Headphones with Mic (78004420)
|Lenovo Speaker M0520 (57Y6360)
Quiet mechanical keys deliver gaming-grade responsiveness and tactile feedback that's easy on the ears. Easily find WASD and arrow keys - even when playing in low light.
G602 redefines the laws of wireless gaming. From the pinpoint accuracy of exclusive Delta Zero sensor technology to high durability primary switches to 11 programmable controls, G602 offers true gaming performance. Count on G602 to dominate boss after boss.
What do you do when you have created one of the most iconic over-ear headphones on the planet? You make it better. This is the case with Skullcandy's original headphone, the Hesh. The product was beloved for its huge cans, thumping bass, and having a large canvas for Skullcandy's original artwork. In what might be seen as a radical uprising, the Hesh 2 has arrived as an innovative upgrade from its iconic predecessor. It's an elevated audio experience housed in a sleek and simplified aesthetic. Complete with Supreme Sound, the Hesh 2 proves that even the rebellious evolve.
Lenovo Mini Speakers deliver crisp, clear sound without taking up too much space. They connect with a single USB 2.0 cable, so they're easily compatible with many different devices.
|Protect Your Erazer Desktop With Lenovo Services
Why Lenovo Services?
Enjoy the Convenience of In-Home Repair
Protect Your PC Beyond the 1-Year Base Warranty
Convenient Remote Support When You Need It Most
Lenovo Services Premium Support provides access to expert technicians when you need them most, from the comfort of your home, with convenient over-the-phone or remote session support. We offer you a one-stop solution for issues beyond your standard hardware warranty, including:
Lenovo has won more than 100 international awards for forward-thinking design.SEE MORE REASONS
Limits: Limit 5 per customer. Offers valid from Lenovo in the US only.
Availability: Offers, prices, specifications and availability may change without notice. Lenovo will contact you and cancel your order if the product becomes unavailable or if there was a pricing or typographic error.
General: Review key information provided by Microsoft that may apply to your system purchase, including details on Windows 8, Windows 7, and potential upgrades/downgrades. Lenovo makes no representation or warranty regarding third-party products or services.
Trademarks: Lenovo, ThinkPad, ThinkCentre, ThinkStation and the Lenovo logo are trademarks of Lenovo. Microsoft, Windows, Windows NT, and the Windows logo are trademarks of Microsoft Corporation. Ultrabook, Celeron, Celeron Inside, Centrino, Centrino Inside, Core Inside, Intel, Intel Logo, Intel Atom, Intel Atom Inside, Intel Core, Intel Inside, Intel Inside Logo, Intel Viiv, Intel vPro, Itanium, Itanium Inside, Pentium, Pentium Inside, Viiv Inside, vPro Inside, Xeon, and Xeon Inside are trademarks of Intel Corporation in the U.S. and other countries. Other company, product or service names may be trademarks or service marks of others. www.intel.com/go/rating
Warranty: For a copy of applicable warranties, write to: Lenovo Warranty Information, 1009 Think Place, Morrisville, NC, 27560. Lenovo makes no representation or warranty regarding third party products or services. The Lenovo Limited Warranty applies only to Lenovo hardware products purchased for your own use, and does not transfer upon resale.
Battery: These systems do not support batteries that are not genuine Lenovo-made or authorized. Systems will continue to boot, but may not charge unauthorized batteries. Attention: Lenovo has no responsibility for the performance or safety of unauthorized batteries, and provides no warranties for failures or damage arising out of their use. Battery life (and recharge times) will vary based on many factors, including system settings and usage.
Pricing: Does not include tax, shipping and handling, or recycling fees. Reseller prices may vary. Savings referenced off regular Lenovo web prices.
**Ship date: An estimated ship date will be posted on our order status site after your order is placed. The date reflected above does not determine when your order will ship since inventory status may change before your order is final and because items may be held until all products on the order are ready to ship. To obtain the latest information about the availability of a specific part number, please call the phone number listed in the masthead at the top of this page. A flat charge for shipping & handling may apply for certain orders, as indicated on the Checkout page.

subset: commoncrawl


text:
It's about time. We've been writing about the new Boston office of Latham & Watkins for weeks now (here and here), revealing a number of their top lateral hires.
On Wednesday, Latham made its official announcement — and confirmed the accuracy of our prior reporting. All of the partners we previously named as Latham-bound, taken from such top firms as WilmerHale, Proskauer Rose, and Bingham McCutchen, are mentioned.
Let's take a closer look at the L&W crew, and also learn about additional attorneys who are joining up (including associates)….
Continue reading "Latham Officially Launches Its Boston Office"


text:
Nightmare overhanging darkly: essays on African American culture and resistance
Third World Press, Jun 1, 1992 - Social Science - 261 pages
Writings of the Black heroes and musicians and the intellectual and physical environment that shaped their lives and those of the Black community.
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32 pages matching South in this book
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Review: Nightmare Overhanging Darkly: Essays on Black Culture and ResistanceUser Review - Greg - Goodreads
Classic, visionary and terribly useful. Read full review
Black on Black Homicide
Black Culture in the Early Forties
6 other sections not shown
Common terms and phrases
52nd Street Acklyn Lynch African American Archie Shepp argued Assata Shakur become Billie Holiday Black artist Black community Black culture Black homicide Black music Black students Black women blues brothers Bud Powell centers century challenge Charlie Parker color confront consciousness creative critical cultural apparatus dance decade Dizzy Gillespie downtown drugs Duke Ellington economic entertainment ethos experience fight forces Frantz Fanon freedom George Jackson Harlem historical human Ibid Institute integration Interviewer jazz Jimmy Kenny Clarke labor leadership liberation live Malcolm Malcolm X Martin Luther King Max Roach move Nation of Islam Negro never North Number oppression organized Paul Robeson percent person play political President prison problem reality recognize responsibility revolution Richard Wright sense sixties social society song South spirit struggle television theatre things tion uptown urban violence voice W.E.B. DuBois workers writes wrote York young
References to this book
Race Music: Black Cultures from Bebop to Hip-Hop
Guthrie P. Ramsey
Limited preview - 2003


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Jorge Aragao - voo de paz.mp3
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Customer Reviews for Purple Stripes Semi-Opaque Roller Window Shades
"Great Roller Shade"
By customer from Jasper, GA
I bought this Roller Shade for my daughters play room. The colors are true to the picture and even though I bought a large shade it is really easy to lower or raise. The design with the birds is so cute and matches perfectly. I installed them myself with no problem at all. I love it! The price is really great and the quality of the shade is excellent!View this product
"Great Buy"
By Berto from Cayman Islands
Did our entire house with these and opted for the motairized verion for everything. We love it! One click and you can open up a specific blind in your room or all of them if you want.View this product


text:
The Screaming Eagles had a very strong showing at the NEAC Championships this past weekend, finishing with 302 points, good enough for 5th place.
The Eagles got things started on Sunday, when Veronica Lubsen got a 3rd place finish in the 100 freestyle with a time of 1:00.28, just being edged out by 2nd by less than .3. Jennifer Scully took home a second place finish in the 200 butterfly, touching the wall in a time of 2:42.61. Carleigh Gallardo also competed and took home a 6th place finish in the same event with a time of 3:20.72.
CSE ended the 2014 NEAC Championships with a 6th place finish in the 400 freestyle relay, when threlay team of Alexandra Budd, Carleigh Gallardo, Caitlin Potter, and Jennifer Scully finished in a time of 4:34.90.
Wells College won their 3rd straight women's NEAC Championship with 444 points. CSE finished in 5th place with 302 points.


text:
3CX Phone System Standard & Pro Editions (Software PBX)
Get your 3CX phone system software editions with The Telecom Spot, an authorized 3CX reseller, so you can rest assured you're getting the best service, product, price and expertise. 3CX Phone System is licensed based on the number of simultaneous calls (internal & external) that your company makes. All editions support an unlimited number of extensions. As a software based IP phone system, 3CX offers you many benefits:
- • Easily install and manage via web-based configuration interface
- • Less expensive to purchase and expand than a hardware-based phone system
- • Get improved productivity with presense, desktop based call control and extension management
- • Forget separate phone wiring - with 3CX your phone can use cmputer network, easy hot desking!
- • Enable mobility - staff can work from home using remote extension
- • SIP interoperability - choose from popular IP phones instead of being locked into one brand
- • You can receive and make calls using VoIP gateways/cards via standard PSTN
- • Additional saving on your monthly phone bills by utilizing SIP trunks, VoIP providers or Skype gateway!
Key features of 3CX Pro Edition (Previously Call Center Module) has:
- • Call center features
- • Synchronize Microsoft Exchange Server contacts with 3CX Company Directory
- • Ability to synchronize 3CX Company Directory with any LDAP services - coming soon
- • Ability to view presence of remote offices
- • More powerful reporting features
Due to manufacturer MAP policy, please contact us or log in for our sales pricing.
3CX Phone System Pro Edition - 1024 SCSKU: 3CXPSPROF1024$59,065.00


text:
Photo Courtesy of Walter S. Judd
Photo Courtesy of Walter S. Judd
|Rocky slopes and woodland margins
|Naturalized in northern part of United States and eastern Canada
|Spring to summer
|Perennial or biennial herb
|Branching from base, with yellow-orange sap
|Alternate, simple, deeply lobed or dissected into 5-7 segments, the terminal segment usually 3-lobed, the other coarsely-lobed or toothed along margin, segments 1-3" long or wide
|Round, orange or yellow, about 1" in diameter, held in few-flowered clusters
|Flowering Season:
|Spring to summer
|Allergenic Components:
|All parts
|Allergenic Properties:
|Dermatological, ingestion
|The yellow-orange sap of this naturalized herb can cause burning and blistering of the skin. May be highly toxic if ingested, although the plant is considered unpalatable because of its acrid taste and pungent, fetid smell. Chelidonine is the major alkaloid found in greater celandine. At least 20 additional alkaloids have been found in this plant. The concentration of these alkaloids varies in various plant organs, depending upon the stage of growth. The plant is suspected in the death of a child. Cattle were poisoned and died in Britain after ingesting the ripe fruit of this plant. Has long been used as a folk medicine for liver, lung, gastrointestinal problems and rheumatism as well as an external treatment for warts. General symptoms of poisoning for humans: diarrhea, drowsiness, headache, coma, death. General symptoms of poisoning for cattle: drowsiness, staggering gait, salivation, convulsions, death.
Minnesota Allergen Index | National Map
Back to Allergies & Pollen Welcome


text:
- $4.99 Flat Rate Shipping. Any Size Order! -
- Easy 365-Day Returns -
HOME New York Giants Gear New York Giants Mens New York Giants Mens T-Shirts $40 to $60 (31 items) Product ID: 691964
Main Content
On February 5th, 2012, two teams will scrape, grapple and fight their way to the top of their conferences for a shot to bring home the coveted Vince Lombardi trophy. It's never too early to get pumped up for this explosive finale of America's Game. This double layer tee from Reebok will showcase your excitement for the biggest game of the year! It features a printed Super Bowl XLVI logo cloth applique on the front, raw seams on the front and back yoke, distressed stripes on the sleeves and sewn-in thermal sleeves for added warmth and style.
- 100% Cotton fabric
- Cloth applique with screen print graphics
- Distressed screen print stripes on sleeves
- Imported
- Long sleeve double layer T-shirt
- Officially licensed NFL product
- Raw seams on front & back yoke
- Reinforced taped collar seam
- Rib-knit collar & cuffs
- Sewn-in thermal sleeves
- Tagless collar
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Special event items are produced by manufacturers only after the outcome of a game or event. These are advanced sale items and will ship immediately after they are received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


text:
Leather Therapy Wash - 8 oz
Leather Therapy Wash™ lifts out embedded dirt leaving both natural and synthetic leather clean, strong, supple and soft. This wash won't harden or darken leather so your boots and tack will always look as great as they did when they were brand new. Read more...
Leather Therapy Wash™ easily cleans even the toughest dirt and grime without hardening or darkening leather. Cleans mold, mildew and sweat without leaving behind any greasy residue. Concentrated micro-suds lift out embedded dirt leaving leather clean with a wonderfully soft feel.
Safe on natural and synthetic leather. Cleans without hardening or darkening leather. Beneficial lubricants leave leather strong and supple. Does not need to be rinsed, just wiped off. A biodegradable, earth friendly product. 8 oz.
100% Satisfaction Guaranteed - Your Money Back Any Time, for Any Reason.
Smith Brothers is proud to offer a 100% satisfaction guarantee on all of our products. We stand behind the quality of our products, and should you not be satisfied with your purchase, simply return it and we will refund, replace or exchange it for you.


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Bridgegate Panel Subpoenas Four, Including Christie's Spokesperson
Four witnesses are subpoenaed by the New Jersey Legislature committee investigating last fall's closure of local access lanes to the George Washington Bridge in Fort Lee.
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The hangbag clips over your stroller handle for storage at your fingertips! This storage caddy accommodates one or two standard size bottles, plus wallet, keys & phone - all the essentials covered!
hangbag stroller caddy is HOT! because:
Geschreven door: Fliss
vrijdag 24 mei 20135/5
The tip I have is to purchase a pushchair hang bag and store the pump & small raincover in it, this way you will never be caught short and it provides you with somewhere to store your mobile & keys & tissues. It is one of the best purchases I have made and I am always organised now.
Geschreven door: Malissa
vrijdag 24 mei 20134/5
This is not for hot drinks or drinks in cups at all. We use this often and it is nice that you can fold the buggy with it attached. This works best with bottles or drinks that can be capped because of how it sits when attached. We only use our buggy with the second seat right now because of the ages of our children and the drinks sit above the head of our baby which means that we can't put any hot drinks in here incase they might spill. If you are using this only as a single buggy this might be easier to use.
Bedankt %user_name%
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Cable vs. Satellite
Compare the differences and get the right service for you.Compare Now
Are bundles bogus?
Nope, they can save youSee How
a bundle of cash.
See the provider map.
You want cable, you need cable, but who is your cable provider?View Now
It's easy to get cable. Call 1-866-921-5828
Why Cable TV in Latham, MO
If you are looking for an affordable TV service that is packed with entertainment and easy to use, then choose cable TV in Latham, MO. Whether you watch dramas, comedies, sitcoms, news reports, cooking shows or documentaries, you will find programming that entertains you on cable. With hundreds of HD channels, movies, premium networks and On Demand entertainment, cable TV offers hours of entertainment. And cable TV is available in bundles with high-speed Internet . Cable offers Internet that is faster than DSL, and installation that is easier than satellite. Plus cable is:
Cable TV offersmore HD choices
Snow may mess up satellite, but itdoesn't faze cable
Cable can beinstalled virtually anywhere
How Latham Watches TV
If you thirst for cable TV knowledge, we can help. CableTV.com has cold-filtered cable data on tap and ready for consumption. Try this (it's on the house): almost everyone, or 97% of Americans, watches television as it is aired and roughly 33% of those TV viewers have at least four televisions in their homes. Upwards of 50% of people also stream video content online. Among those with cable TV, almost three-fourths bundle their service with high-speed Internet. Cable's ubiquitous national presence also helps explain how DVRs account for about 7% of America's total TV viewing.
All those stats mean that if you don't own at least one TV for every room in your house, chances are your neighbor to the left or right of you does. It also means that almost everyone you meet today will watch a TV tonight, and 57% of them will use either their DVR or their Internet to do so.
Latham Cable Internet
Cable providers have so much more to offer than TV. That is why so many Latham residents bundle cable services. Cable Internet is faster than most DSL services, providing downstream speeds 25%-100% faster than the national average. People who choose cable bundles also save money, roughly $400 every year they bundle TV and Internet. Both are very good explanations why cable Internet subscribers represent 32% of households, and how broadband penetration in Missouri grew to 64% by 2010. Enter your zip code to find out more about cable Internet, bundles and providers in Latham.
It's easy to get cable, Call 1-866-921-5828
CableTV.com Loves Latham Actors
According to our research, Latham, MO residents love Mark Harmon. Mark Harmon is a well-loved actor and holds the number one spot on the Most Popular actors list. His role as Agent Leroy Jethro Gibbs in "NCIS" has captured the public. He played a carpenter in his first acting role on "Ozzies Girls" in 1973. His career solidified when he took the role as a handicapped veteran in "Eleanor and Franklin: The White House Years." You can find Mark Harmon on CBS in your area.
Find Cable TV in Latham
We hope by now that you figured out that we know television like Mr. Burns knows how to release the hounds. That being said, our knowledge includes finding you the best cable option in your area. Because of local licensing regulations, there is usually only one cable provider in a region. Call up the number above to find your Latham cable provider.


text:
To perform a search, enter a keyword, phrase or item number in the search field and click "search."
We offer two ways to locate information:
Persistent mousse, with fine bubbles rising slowly. Pale salmon pink in color, with a shade of gold. A nose of red fruits and fresh pear. Delicate fruit on the palate, elegant, and showing great finesse.
"The currently available Brut Rose is based on the '09 vintage, with significant contributions from '08 and '07; 43% is chardonnay, 57% pinot noir and pinot meunier, with a light dosage of 7-8 g/l. It has a perfumed, red-fruits bouquet and a palate full of richness and flavour, balanced by notes of chalk and mineral ex the acidity. I cannot remember ever having a glass of Billecart rose that disappointed me."
94 Points
Australian Wine Companion
"Bright and elegant, this offers appealing flavors of ripe black cherry, raspberry and orange peel that show hints of toasted raisin bread, anise and sweet smoke. Offers a beautiful texture, with a long, mouthwatering finish. Drink now through 2015."
92 Points
Wine Spectator
"A dry rosé, freshly tasting of red currant fruits, laced with beautifully refreshing acidity. The wine has some weight, but it has more of an elegant, dancing lightness."
92 Points
Wine Enthusiast
"Light orange. Tangerine, pear and flowers on the nose, which is complicated by a note of fennel. Broad and sappy but dry, with lively orange and strawberry flavors and a subtle note of spice cake. Weightier on the finish, which features an exotic note of spicy herbs. This Champagne's delicate touch will make it work well with simple seafood dishes or even sashimi."
92 Points
International Wine Cellar
Champagne is both a region and a method. The wines come from the northernmost vineyards in France and the name conjures an image like no other can. An 18th Century Benedictine monk named Dom Perignon is said to be the first to blend both varietals and vintages, making good wines not only great, but also special and unique to their winemaker. Today, nearly 75% of Champagne...Read More About Champagne
Pink Bubbles
Some Champagne and sparkling wine is pink. It's more rare, and more robust, and sometimes more expensive. But
one of those wines that is just deliciously appealing. The pink color in a rose sparkler comes from the skins -
means that the wine must include at least one of the red grapes of the traditional method -
Pinot Noir or Pinot...Read More About Rosé
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text:
Helios ArrayTalk0
this wiki
The Helios Array is a solar concentrator configuration that is suited for a Village-scale (or medium scale commercial) solar oven design.
It's strong attraction is the fact that it is made with off the shelf materials, available in most countries, and the power in Watts it can produce.
Formally named the Helios Array.
- Mirror Area: 54 square feet (5 sq. M.).
- Performance: equal to large (3,500 Watt) oven element.
- Cost: under $500 Cdn. if it is made locally. (Compare this model to Villager Sun Oven at $10,000-plus (for only twice the collection area) fabricated in a United States factory).
The Helios Array is suitable for medium scale commercial enterprises. It has been developed with a rotary grain roaster, a conventional-type oven and a water purification attachment.
Helios arrays are currently roasting cacao and coffee on a commercial scale in Mexico. They are also baking bread, pizzas, cookies and roasting peanuts.
Helios array have been constructed in Mali (bakery) and India (peanuts roasting). After her trip to Mali, Marie Testud created the Helios Construction Guide available for free on the Solar Fire website.
The Solar Fire is currently working on spreading solar concentrator Helios and SFP32 (for steam engines).
News and recent developments
[[Video:Solar Cooking |thumb|350px|left|A restaurant in Thailand grills with a Helios Array, October 2010.]]
- January 2010: Constructing the Helios in Texas by Ray Mencke
Construction plans
See also
External links
- Construction plans for the Helios
- Blog describing project of Marie in Mali (2009) (Includes video)
- Blog of Lorin Symington in Mali (2008) and Mexico (2010)
Eerik Wissenz : info (at) solarfire.org
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Presented at the VA Health Services Research and Development Annual Meeting, Baltimore, February 16, 2011.
Received Nov. 2, 2011; revisions received Jan. 20 and Feb. 29, 2012; accepted March 12, 2012.
Drs. Bauer and Kilbourne receive royalties for published treatment manuals relevant to the bipolar collaborative chronic care model from Springer (Dr. Bauer) and New Harbinger (Drs. Kilbourne and Bauer). All other authors report no financial relationships with commercial interests.
Supported by NIH grant R-01-MH-079994 (Dr. Kilbourne); the VA Health Services Research and Development Centers of Excellence at the Boston VA Medical Center and the Ann Arbor VA Medical Center and the VA Health Services Research and Development grant IIR-10-314 (Dr. Bauer); and the Vivian A. and James L. Curtis School of Social Work Research and Training Center, University of Michigan (Dr. Grogan-Kaylor).
This paper has been designated as an Editors' Choice Award Lecture by the Scientific Program Committee of the Institute on Psychiatric Services. Dr. Bauer will present this paper at the 64th IPS in New York City, October 6, 2012.
Address correspondence to Dr. Bauer (email@example.com).
Copyright © American Psychiatric Association
2, 2011; Revised
20, 2012; Revised
29, 2012; Accepted
12, 2012.
Collaborative chronic care models (CCMs) improve outcome in chronic medical illnesses and depression treated in primary care settings. The effect of such models across other treatment settings and mental health conditions has not been comprehensively assessed. The authors performed a systematic review and meta-analysis to assess the comparative effectiveness of CCMs for mental health conditions across disorders and treatment settings.
Randomized controlled trials comparing CCMs with other care conditions, published or in press by August 15, 2011, were identified in a literature search and through contact with investigators. CCMs were defined a priori as interventions with at least three of the six components of the Improving Chronic Illness Care initiative (patient self-management support, clinical information systems, delivery system redesign, decision support, organizational support, and community resource linkages). Articles were included if the CCM effect on mental health symptoms or mental quality of life was reported. Data extraction included analyses of these outcomes plus social role function, physical and overall quality of life, and costs. Meta-analyses included comparisons using unadjusted continuous measures.
Seventy-eight articles yielded 161 analyses from 57 trials (depression, N=40; bipolar disorder, N=4; anxiety disorders, N=3; multiple/other disorders, N=10). The meta-analysis indicated significant effects across disorders and care settings for depression as well as for mental and physical quality of life and social role function (Cohen's d values, 0.20–0.33). Total health care costs did not differ between CCMs and comparison models. A systematic review largely confirmed and extended these findings across conditions and outcome domains.
CCMs can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration.
Organized care management processes—the systematic use of guidelines supported by clinical information systems and care management—are the cornerstone of quality improvement in both primary care and multispecialty group practice (1–3). They are a key component (2) of patient-centered medical homes (4, 5) and accountable care organizations (6, 7). Multiple randomized controlled trials have indicated that care management processes, such as collaborative chronic care models (CCMs), improve outcomes for various chronic medical illnesses. These models, originally articulated by Wagner et al. (8) and Von Korff et al. (9) and subsequently included as part of the Robert Wood Johnson Improving Chronic Illness Care initiative (http://www.improvingchroniccare.org/), represent a framework for care that consists of several or all of the following six components: patient self-management support, delivery system redesign, use of clinical information systems, provider decision support, linkage to community resources, and health care organization support (10, 11). The effect of CCMs and related disease management strategies for treatment of chronic medical illnesses has been the subject of both qualitative reviews (11–13) and meta-analyses (14–17).
Disease management strategies, including CCMs and other care process innovations, have been used to enhance depression treatment in primary care. Two meta-analyses of disease management programs (broadly defined) have a demonstrated beneficial effect of such programs on symptoms (18, 19) as well as satisfaction with care (18) and treatment quality (18), accompanied by greater service utilization and health care costs (18). A more recent review has underscored these findings (20). A meta-analysis of cost-effectiveness assessed in eight randomized controlled trials of disease management for depression in primary care found that compared with the control condition, the care management model was more effective but cost more (21). The investigators concluded that data on costs and effects in settings other than primary care are needed before care management models can be widely implemented.
Addressing the needs of individuals with serious mental health conditions in addition to depression is critical, since mental disorders affect more than 25% of the U.S. population at any one time (22), and the lifespan of individuals with serious mental illness is 25 years shorter than the U.S. average (23). CCMs are being applied to treatment for various mental health conditions across a variety of care settings and have been entered into clinical practice guidelines for the treatment of some chronic mental illnesses (24, 25).
However, treatment for mental health conditions presents more complex clinical and organizational challenges than primary care treatment for medical illnesses. For example, individuals with serious mental health conditions may at times have impaired executive or decision-making capability; at the same time, participating effectively in a care system that is fragmented across mental health and medical sectors demands substantial motivation, organization, and persistence in order for clinical needs to be met comprehensively (26). If CCMs do have a beneficial effect on a wide variety of mental health conditions across various settings, these models could provide a coherent approach by which to structure care for patients with mental illness, integrating with patient-centered medical homes that use CCM-based approaches (2).
We therefore conducted a systematic review and meta-analysis of randomized controlled trials to determine the comparative effectiveness of CCMs relative to other care conditions for individuals with mental illness. If broad-based effects are demonstrated across conditions and care settings, two effects could result. First, these findings could lead to mechanism and moderator studies, as has been done previously for primary care management of depression (19) and medical CCMs (11), in order to support further model development. Second, these findings could guide the efforts of policymakers and administrators to incorporate the needs of individuals with mental health conditions into new models stimulated by U.S. health care reform (3–7).
This investigation represents several innovations. First, CCMs were identified a priori based on the presence of explicitly defined operational components, regardless of whether their conceptual "lineage" was derived from the Improving Chronic Illness Care (8–11) model. Second, in order to provide the most comprehensive analysis of CCM effects on mental health conditions, we included all trials that measured effect on a mental health outcome, regardless of the targeted underlying physical or mental disorder or care setting. Third, to provide the most comprehensive assessment of effect, we extracted not only symptomatic outcomes but also other outcomes relevant to mental health outcomes, including social role function, overall quality of life, physical quality of life, and health care costs. Fourth, we systematically identified analyses across these outcome domains using a priori decision rules to include only those analyses that contributed nonredundant information. Fifth, we complemented the meta-analysis with a systematic review to ensure consideration of informative data that did not meet the restrictive requirements for meta-analysis. This review provides a comprehensive assessment of the comparative effectiveness of CCMs on a broad group of outcome domains across various mental health conditions treated in a wide variety of care settings.
Relevant randomized controlled trials that were either published or in press through August 15, 2011, were identified via MEDLINE, PsycINFO, Embase, Scopus, Cochrane Library, and clinicaltrials.gov; this search was supplemented by review of article bibliographies plus contact with investigators in the field. The MEDLINE MeSH terms, or equivalent terms for other databases, were as follows: case management, combined modality therapy, continuity of patient care, cooperative behavior, mental health services, primary health care/organization and administration, patient care team, practice guidelines, and delivery of health care/methods. The search was continued until no new articles were identified. Candidate article titles and abstracts were screened by one or two authors (H.G., M.S.B.), and full-text reviews were independently extracted by two or more authors (E.W., A.G.K., B.P., H.G., M.S.B.) for relevant outcome analyses.
CCM was defined a priori as an intervention with at least three of the following six components according to criteria from the Improving Chronic Illness Care initiative (10, 11): patient self-management support, delivery system redesign, use of clinical information systems, provider decision support, health care organization support, and linkage to community resources (Table 1). The intraclass coefficient across raters for the number of CCM criteria met was 0.93, and the kappa for CCM identification was 1.00. The threshold of three criteria was chosen for two reasons. First, to require only two criteria would yield many psychotherapy studies that included only self-management support plus work-role redesign (the addition of a therapist). Second, the earliest articulations of the model (8, 9) consisted of four (12) rather than six elements, so including studies with three rather than all four original criteria would provide a more stringent test of the model and allow for future dose-response analyses.
Collaborative Chronic Care Model (CCM) Core Elementsa
a Adapted from references 10 and 118.
Trials were included if the intervention met these explicit operational criteria, regardless of whether the investigators cited criteria from the Improving Chronic Illness Care initiative or explicitly considered the intervention to be a CCM. It is important to note that not all disease management programs included in other reviews (for example, references 18, 19, 21) met CCM criteria, and therefore not all such programs are included in this model-driven study.
Trials were required to compare an intervention meeting the CCM definition with another intervention or with treatment as usual. Trials that compared two or more interventions that met CCM criteria were excluded (for example, reference 27), since such trials could not provide information on the comparative effectiveness of a CCM. Because CCMs are frameworks applied to the outpatient clinic setting, interventions that included a mobile treatment team component and other comprehensive rehabilitation programs (for example, reference 28) were excluded; similarly, trials in schizophrenia were excluded because this disorder is typically treated by these more intensive interventions. Both parallel-group and within-subject randomized controlled trials were considered for inclusion, although none of the latter were identified. Among identified trials, all articles reporting CCM effects on any mental health symptom or on mental quality of life were included, whether or not the sample primarily consisted of individuals with formally diagnosed mental disorders.
Study characteristics and outcome analyses were extracted as noted earlier, with differences reconciled by consensus. Outcome analyses were included regardless of whether they were identified as primary outcome analyses and regardless of their reported power. In addition to analyses of mental health symptoms and mental quality of life, we extracted other analyses relevant to mental health effects, including those of social role function, physical and overall quality of life, and health care cost. We did not include analyses of guideline concordance or other quality indices given the uncertain relationship of such measures to health outcomes in mental health (29) and medical-surgical (30–32) conditions.
CCM trials often report multiple outcome analyses at multiple time points. Therefore, an a priori strategy was developed to ensure that an exhaustive but nonredundant set of analyses was identified. First, we extracted only one measure per domain (e.g., depressive symptoms, physical quality of life). Second, we chose continuous variables over categorical variables (e.g., the raw symptom score over the percentage of participants who achieved remission); if an outcome domain was represented only by categorical data, then the analysis was extracted. Third, when the same variable was reported over time, the measure from the longest time point during active treatment was chosen. Fourth, for cost outcomes, the most inclusive measure was chosen, and among these measures, we used the longest outcome interval (e.g., total direct treatment costs over 2 years rather than ambulatory treatment costs over 1 year). Fifth, analyses were excluded if they examined subsamples of a larger sample for which data were already reported (e.g., an analysis of depression in diabetic patients was not included if depression data for the overall sample were reported elsewhere). Last, we excluded analyses for which the variable represented a subset of previously reported items from a higher-order scale (e.g., an analysis of sleep was not reported if sleep was represented by an item on a depression scale analysis that was included).
The aforementioned outcome analyses established the data set for systematic review. Meta-analyses consisted of the subset of analyses that reported continuous variables as unadjusted means plus the sample size and a measure of dispersion (typically the standard deviation or confidence interval). A meta-analysis was carried out for each outcome domain for which at least two analyses were available. Since outcome variables from different studies are often measured in different units, we used Cohen's d (33), calculating the standardized mean difference between the treatment and comparison groups using the difference in means divided by the pooled standard deviation. For each qualifying outcome domain, an overall meta-analytic estimate of the combined effect of the included analyses on the outcome of interest was calculated using the random-effects estimator described by DerSimonian and Laird (34; also see reference 35). A check for systematic bias (36) in reporting was performed by constructing a funnel plot of each trial's effect size against its standard error and applying Begg and Egger tests (37) and by computing a Spearman's rank correlation coefficient between the study effect sizes and respective sample sizes (38).
To provide a more comprehensive assessment of CCM effects than that which could be achieved by meta-analysis alone, we also performed a standardized assessment of all analyses that met inclusion criteria for the review. We categorized each qualifying analysis from each trial as favoring the CCM, favoring the control condition, or exhibiting no difference between the CCM and control condition based on the statistical significance (p value) reported by the authors. To identify overall effect, analyses were then summarized as percentages across mental health conditions and across outcome domains.
The search yield is summarized in Figure 1 in the data supplement that accompanies the online edition of this article, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (39) conventions. For the overall systematic review, 57 trials were described across 78 articles, yielding 161 qualifying analyses (140 assessed clinical outcomes; 21 assessed economic outcomes). Trial characteristics are summarized in Table 1 in the online data supplement (40–94). The earliest qualifying trial was reported in 1994 (40), predating the seminal conceptual study by Wagner et al. (8).
All but one trial (63) included only adults, and three trials (51, 57, 85) focused on adults over age 60. The mean age of sample participants was 49.4 years (SD=10.8; range=17.2–77.6). The mean percentage of women enrolled in trials was 63.1% (SD=25.5; range=3.5–100), and three trials included only women (52, 64, 68). The mean percentage of participants from minority groups was 37.3% (SD=26.7; range=2.7–100), and four trials examined only participants from minority groups (64, 68, 76, 77). Seven trials (12.3%) took place outside the continental United States (43, 52, 69, 76, 91, 92, 94). Forty trials (70.2%) examined depression. There were also trials examining bipolar (N=4; 7.0%), anxiety (N=3; 5.3%), and multiple/other (N=10; 17.5%) disorders. Notably, 12 trials (19.3%) were designed for populations with combined behavioral health and medical disorders or risks, including diabetes (60, 74, 75), cardiovascular risk (75, 81), cancer (64, 68), pain (71), and various other conditions (85, 86, 90, 93).
Regarding organizational setting, 16 trials (28.1%) took place in staff model health maintenance organizations (HMOs), 11 (19.3%) in U.S. Department of Veterans Affairs (VA) facilities, 27 (47.4%) in nonintegrated systems, and three (5.3%) across multiple types of organizations. Thirty-nine (68.4%) trials took place in primary care settings, nine (15.8%) exclusively in behavioral health settings, and nine (15.8%) in medical specialty or multiple settings.
Regarding trial design, sample sizes ranged from 55 to 2,796 participants (mean=387.3, SD=437.3). Most trials were randomized at the patient level, with a mean of 3.9 [SD=0.6] CCM components for the intervention. Five trials delivered the patient intervention predominantly or exclusively via telephone (61, 66, 67, 70, 72). The most common control condition was usual care (N=33; 57.9%); however, there were trials comparing the intervention with a variety of enhanced usual care conditions (e.g., clinician notification or patient education) or with less integrated models, such as consultation-liaison.
Outcome analyses (N=161) are summarized in Table 2 in the online data supplement (40–117). Follow-up intervals typically paralleled active treatment intervals, with a mean length of 13.7 months (SD=9.8; range=3–36) of treatment. Eight analyses also investigated residual CCM effects or costs months to years after the cessation of active treatment (103, 106, 111–115, 117).
Forty-six of the 163 analyses (28.2%) qualified for meta-analysis (33 assessed clinical outcomes, 13 assessed economic outcomes) (Figure 1, Figure 2). These analyses derived from 30 trials reported across 28 articles. Moderate (33) beneficial effects of CCMs were seen in trials for depression, the only clinical symptom for which there was more than one qualifying analysis (Cohen's d=0.31; 95% confidence interval [CI]=0.16–0.47; 14 analyses). Beneficial effects were also observed on mental quality of life (Cohen's d=0.20; 95% CI=0.04–0.36; six analyses), physical quality of life (Cohen's d=0.33; 95% CI=0.17–0.49; six analyses), and social role function (Cohen's d=0.23; 95% CI=0.02–0.44; three analyses). Estimates for the effect size of CCMs on overall quality of life (two analyses) yielded wide confidence intervals (Cohen's d=0.20, 95% CI=–0.02 to 0.42), and differences between CCMs and control conditions did not reach statistical significance. Estimates for the effect of CCMs on global mental health (two analyses) also did not reach statistical significance (Cohen's d=0.09, 95% CI=–0.17 to 0.35). The CCM effect on total health care costs did not differ from the control condition effect on total costs (Cohen's d=0.05; 95% CI=–0.02 to 0.12).
Meta-Analysis of Clinical Outcomesa
a The individual comparisons extracted for these meta-analyses reflect data from the longest time interval for a given trial (see the Method section). The individual comparisons at these longest time points may or may not have been significantly different but were extracted for meta-analyses as the most rigorous test of the model. In complementary fashion, the systematic review results (see Table 2; also see the online data supplement) report the planned analyses as reported in each given trial, which typically included repeated-measures analyses that incorporated tests of change over time between the chronic care model and the control condition.
b Weights are from random-effects analysis.
Meta-Analysis of Economic Outcomes
a Weights are from random-effects analysis.
Bias statistics were calculated separately for clinical and economic domains. All clinical outcomes were aggregated for this analysis. Funnel plots revealed no significant evidence of bias for either clinical or economic outcomes (37). In line with previous meta-analytic research on psychosocial interventions for mental disorders (38), we also tested for publication bias by calculating a Spearman's rank correlation coefficient between sample size and effect size. Correlation for each outcome was nonsignificant, providing evidence that studies with larger effect sizes in one direction were no more likely to be published than studies with smaller effect sizes (36).
Of 140 clinical analyses, 133 (95.0%) reported p values (Table 2, Table 3). Of these, 66 (49.6%) favored the CCM, one (0.8%) favored the control condition, and 66 (49.6%) revealed no significant difference between the CCM and the comparison model. Among 21 analyses reporting economic outcomes, 10 (47.6%) reported p values. Of these, nine (90.0%) reported no difference in costs between the CCM and the control condition, while one (10.0%) favored the control condition.
By-Diagnosis Tabulation of Systematic Review Clinical Analyses Comparing the Chronic Care Model (CCM) With the Control Condition
a Each qualifying analysis from each trial was categorized as favoring the CCM, favoring the control condition, or exhibiting no difference between the CCM and the control condition. Percentages reflect the proportion of total informative analyses (e.g., for depressive disorders, 41 of 88 informative analyses [46.6%] favored the CCM).
b Percentages reflect the proportion of analyses that were informative compared with those that were indeterminate (trials that did report the significance level explicitly compared with those that did not) (e.g., 88 of 92 analyses [95.7%] for depressive disorders reported significance).
Tabulation By Outcome of Systematic Review Analysis Comparing the Chronic Care Model (CCM) With the Control Condition
a Each qualifying analysis from each trial was categorized as favoring the CCM, favoring the control condition, or exhibiting no difference between the CCM and the control condition. Percentages reflect the proportion of total informative analyses (e.g., for anxiety disorders, five of five informative analyses [100.0%] favored the CCM).
b Percentages reflect the proportion of analyses that were informative compared with those that were indeterminate (trials that did report the significance level explicitly compared with those that did not).
Trials enrolling individuals with depressive disorders included 88 analyses reporting significance across all clinical outcome domains; of these, 41 (46.6%) favored the CCM. Results favored CCMs in trials enrolling individuals with anxiety disorders (10/12; 83.3%), and the effect was somewhat lower overall in trials enrolling individuals with multiple/other disorders (10/21; 47.6%) and bipolar disorder (5/12; 31.7%).
Systematic review of the less restrictive set of analyses confirmed the meta-analytic findings. Among depression analyses, 29/53 (54.8%) favored the CCM, with none favoring the control condition. Among mental quality of life analyses, 11/21 (52.4%) favored the CCM, with none favoring the control condition. Among social role function analyses, 8/15 (53.3%) favored the CCM and one (6.7%) favoring the control condition. Overall quality of life analyses, for which there was a nonsignificant meta-analysis with only two qualifying analyses, revealed beneficial CCM effects by systematic review methodology using a larger sample size, with two of four outcomes (50%) favoring the CCM and none favoring the control condition. Similarly, global mental health was typically a secondary outcome measure and was also represented in the meta-analysis by only two analyses; systematic review indicated that two of six analyses (33.3%) favored the CCM, while none favored the control condition. For physical quality of life, in contrast to positive meta-analysis findings, significance counts indicated that six of 21 outcomes (28.8%) favored the CCM, with none favoring the control condition.
Additionally, systematic review identified a broader variety of symptom outcomes than those represented in each meta-analysis, including measures of anxiety, cognition, global mental health, mania, substance abuse, and suicidality. Of symptom domains with more than one nonredundant analysis reporting significance, five of five anxiety disorders analyses (100%) favored the CCM, and one of two mania analyses (50%) also favored the CCM.
Systematic review results across mental health conditions and outcome domains are summarized in Figure 3 in comprehensive analysis displays (CADgrams), which allow for graphical inspection of the data across both mental health condition and outcome domain simultaneously. For example, for mental quality of life, it can be seen that while the majority of analyses derived from studies of depressive disorders, a similar pattern of results was obtained for populations with bipolar, anxiety, and multiple/other disorders.
Comprehensive Analysis Displays (CADgrams) for Specific Outcome Domains Across Diagnosesa
a The bar graphs depict comprehensive analysis displays, which summarize chronic care model (CCM) significance across outcome domains. These comprehensive analysis displays appear in an order consistent with that of Table 2 for domains with four or more informative analyses, with each outcome categorized by disorder. The horizontal axis represents the raw count of informative analyses according to the number of analyses that favored the CCM, revealed no significant difference between the CCM and control condition, or favored the control condition. The dimension of the horizontal axis varies by the number of informative analyses in order to accommodate the length of the bars, ranging from 4 (overall quality of life) to 133 (total clinical outcomes).
In this most inclusive analysis to date of CCM comparative effectiveness for mental health conditions, meta-analysis of unadjusted outcomes for continuous variables demonstrated significant small to medium (33) effects of CCMs across multiple disorders with regard to clinical symptoms, mental and physical quality of life, and social role function, with no net increase in total health care costs. In some cases, meta-analysis identified significant effects even though the majority of individual meta-analyzed comparisons were negative (e.g., for mental quality of life). In complementary fashion, systematic review of the less restrictive set of analyses largely confirmed and extended the meta-analytic findings.
This study has several strengths. First, we included CCMs based on a priori operational criteria, regardless of stated conceptual "lineage," thereby allowing us to comprehensively identify and assess interventions consistent with the Improving Chronic Illness Care model. Second, we examined CCM comparative effectiveness across multiple disorders and care settings. Third, we employed a meticulous method to ensure exhaustive, yet nonredundant, identification of all relevant outcome analyses. Fourth, we included all qualifying analyses, regardless of whether they represented primary outcomes or were reported to have adequate power. Fifth, we complemented powerful but restrictive meta-analytic techniques with more inclusive but still standardized and quantitative systematic review.
Several patterns in the results deserve note. The majority of analyses derive from studies of depressive disorders treated in primary care; however, the number of trials for populations treated outside of primary care is growing quickly. Importantly, an increasing number of trials now address mental disorders that are by definition chronic (which may or may not be the case for depression) and treated in specialty care settings. Not surprisingly, compared with primary care trials for depression and anxiety, trials for chronic conditions, such as bipolar disorder, show a somewhat more variable effect. This is likely due to several factors. Specifically, such disorders are by definition chronic and typically accompanied by multiple comorbidities (118). Additionally, mental health treatment settings may represent more complex organizational challenges (26) than primary care for implementation of care management models.
It is interesting that no substance abuse interventions that were identified qualified as CCMs, although several candidate trials were identified (119–124). These trials typically focused on collocating or coordinating primary care with ongoing psychosocially oriented substance use programs, suggesting that these already integrated specialty programs identified and attempted to address a focal quality gap (i.e., lack of primary care) rather than reorganizing care more extensively. Among CCM trials, only two (86, 88) included qualifying substance use outcome analyses, with one of three analyses (33.3%) favoring the CCM. Our search also identified only one CCM trial for schizophrenia (125), which yielded indeterminate results according to our systematic review criteria (see the Method section) for overall, mental, and physical quality of life as well as for depression.
In aggregate, meta-analyses of unadjusted continuous outcome measures were congruent with the more comprehensive systematic review. For outcome domains in which only two studies qualified for meta-analysis (overall quality of life, global mental health), meta-analysis indicated substantial heterogeneity (Figure 1), and the larger sample of systematic review analyses may provide a more stable estimate of effect. For physical quality of life, the meta-analysis of six studies indicated a CCM advantage, while significance count in the 24 systematic review studies revealed no difference between CCMs and control conditions in a majority of studies.
There have been three other meta-analyses of broadly defined disease management trials for depression in primary care (18, 19, 21) and none, to our knowledge, for other mental health conditions or settings. None of the previous reviews used an established model to identify interventions, nor did they complement meta-analysis with systematic review to address limitations entailed in using a more highly selected sample of trials or analyses. Nonetheless, it is notable that two previous meta-analyses (18, 19) also demonstrated beneficial effects of disease management, albeit at some increased costs (18). One meta-analysis of costs from a smaller number of trials (21) also demonstrated increased total health care costs, with cost per quality-adjusted life years ranging from $21,478 to $49,500 and cost per additional depression-free days ranging from $20 to $24. Our economic meta-analysis across conditions and care settings revealed no net difference in the total health care cost difference between CCMs and control conditions. Importantly, net costs were not consistently higher for CCMs targeting chronic conditions treated in specialty settings (81, 82) than for CCMs treating depression in primary care settings (Figure 3). These findings address earlier recognition of the need for more comprehensive data on CCMs regarding costs and effects in settings other than primary care (21).
Several questions remain to be answered. A better understanding of mediators, moderators, and mechanisms is essential to further development and application of the model. Four potential applications of mediator, moderator, and mechanism research may be particularly helpful in developing and deploying the CCM for maximum public health effect.
First, patient clinical and demographic characteristics can help to identify target populations that will benefit from the model. For instance, minority participants in the VA primary care setting responded better to a depression CCM than did Caucasian participants (126). Our work in bipolar disorder, in both the VA (127) and a staff model HMO (80) provides the good news that comorbid substance dependence does not reduce CCM effect, nor do anxiety disorders (127).
Second, it is not clear how many, or which, of the CCM components are necessary. The multicomponent model evolved out of the recognition that single-component interventions are not sufficient to improve health outcomes that depend on the complex interaction of multiple organizational components (8, 12, 20). For medical CCMs, circumstantial evidence indicates that self-management support is important, as 19 of 20 positive trials included this component (11). A meta-analysis of depression care management effects identified staffing and training characteristics associated with positive effect, but it was not designed to identify specific CCM components (19).
Third, while early CCM work took place in the staff model HMO setting, CCMs for mental illnesses have now been applied across a wide variety of care organizations. However, it is not yet clear whether CCMs have equal effects in less integrated care settings. To provide a compelling framework for care on a policy level, CCMs should demonstrate benefit across the broad spectrum of care settings represented in U.S. health care.
Fourth, scrutiny of other aspects of study design will provide data relevant to CCM dissemination. For example, assessment of the effect of duration of treatment and follow-up evaluation on CCM effects can provide an indicator of the time frame for return on investment for providers and payers who implement CCMs.
Another critical issue is the identification of the most effective implementation strategies by which to establish and sustain the model. Case studies of depression care management in the VA (128, 129) and a recent quasi-experimental implementation study of community health centers (130) provide some lessons, and a randomized controlled trial of two implementation strategies for a bipolar disorder CCM in community mental health centers is currently under way (131).
How can these results support further research that responds to the exigencies of the current health care environment? Clearly, there is a need to integrate care for patients with mental health conditions into new organizational models emerging under health care reform. Additionally, since it is increasingly unlikely in the current health care climate that multiple diagnosis-specific care management programs can be deployed to treat multiple conditions in a single individual or population, cross-diagnosis CCMs and CCMs that address highly comorbid populations will have to be a particular focus, and results from our review indicate that such models can be effective. Similarly, development of population- and health plan-level CCMs will be important to reach individuals treated in venues too small to mount practice-based care management strategies (132).
Several lessons can be drawn from our results to guide CCM implementation in the current health care environment. First and most fundamentally, the potential benefit of CCMs for mental health conditions extends beyond depressive disorders and beyond the primary care setting. Second, CCMs designed for mental health conditions can improve physical as well as mental health outcomes. Third, CCMs can address the needs of populations with multiple chronic conditions, an emerging focus of the U.S. Department of Health and Human Services (133). Fourth, it should be recognized that as one moves from disorders treated in primary care to more chronic or severe disorders requiring specialty sector treatment, it becomes more challenging to achieve an effect, as noted earlier with regard to bipolar disorder. However, the fact that even highly comorbid chronic disorders benefit from CCMs (80, 127) is reason for optimism. Finally, it should be recognized that most of the CCMs tested to date have been clinic-based models, which require a sufficient critical mass of patients with a given condition, as well as local infrastructure, for implementation. However, promising results with CCMs that are implemented primarily or exclusively via telephone (61, 66, 67, 70, 72) indicate that population- and health plan-level implementation of CCMs may indeed be feasible, thus extending CCM benefits to settings in which a CCM cannot be applied independently (132).
Thus, CCMs are effective in a broad group of outcome domains across mental health conditions treated in a variety of care settings at no net increase in overall health care treatment costs. These findings have important implications for improving outcomes for individuals with mental illnesses. As stated in one national practice guideline, CCMs can serve as a "foundation of management" (24, p. 722) for such conditions.
Given the dual potential of CCMs to improve both physical and mental health outcomes in a wide variety of mental health conditions, the CCM model can serve as a framework for patient-centered medical homes (2–5) and support management of quality and risk in accountable care organizations (6, 7). The effectiveness of these models in populations identified as having dual mental and physical disorders (60, 64, 68, 71, 75, 81, 85, 86, 90, 93) is particularly important in this regard. Additionally, the utility of CCMs particularly for chronic mental disorders takes on greater importance in light of the Patient Protection and Affordable Care Act, which allows state Medicaid programs to establish reimbursement models to manage individuals who have a "serious and persistent mental health condition" and chronic medical conditions. The development of state-level health care exchanges and accountable care organizations, which involves bundled payments to providers, can facilitate utilization among care managers in providing CCM-related services.
Given their broad applicability to complex mentally ill populations, the potential benefit of CCMs for the Medicaid population is clear. Additionally, CCMs for serious mental illness can have potential for substantial effect for the Medicare population, since as individuals with serious mental illnesses (such as bipolar disorder) grow older, they consume an increasingly disproportionate share of both behavioral health and medical resources (134, 135).
Health care cost reductions are critical in each of these settings. Importantly, CCM benefits are associated with no net increase in health care costs (Figure 3). We as well as other investigators have pointed out the limitations of economic analyses derived from clinical trials (136). These concerns, particularly germane to efficacy trials, are mitigated somewhat in effectiveness-oriented health services designs. Nonetheless, it is critical to determine the economic outcomes of CCM implementation in the more heterogeneous environments encountered in policy-based or other roll-out efforts (137). Meanwhile, creative modeling efforts using research trial results have been employed to propose viable insurance benefit designs to support the sustainability of CCMs in the current health care environment (138).
The most notable limitation of this comprehensive analysis is that the bulk of the evidence reviewed was derived from studies of depression treated in primary care. However, the evidence base across other disorders and care settings is growing quickly, and our results support the robustness of CCM effects in broader populations and more diverse care venues. A second limitation is that we defined CCMs as interventions with at least three of the six components of the Improving Chronic Illness Care model (10, 11), and thus some heterogeneity of effect may be attributable to the use of different components across interventions. Further analyses of this and other data sets can address this issue. Third, the study likely underestimates CCM effects by including analyses that were not primary trial outcomes and thus not necessarily adequately powered. Finally, the meta-analyses included a selective sample of published analyses that reported unadjusted continuous outcomes. However, no evidence of reporting bias was found quantitatively, and the more inclusive yet highly structured quantitative systematic review largely corroborated our meta-analysis results.
Our systematic review and meta-analysis yield what is likely a lower bound for CCM effects. Despite this conservative approach, CCM effects were robust across populations, settings, and outcome domains, achieving effects at little or no net treatment costs. Thus, CCMs provide a framework of broad applicability for management of a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.
A recent commentary (139) argued that policymakers have championed many foci for cost savings that amount to "false cost control." The author argues that the major focus of health care cost reduction efforts must be in reducing avoidable complications of chronic illnesses, which account for up to 22% of all health care expenditures. Reducing these complications could realistically result in a $40-billion per-year savings. Such tertiary prevention has been the orienting focus of CCMs since their inception (8), and our analyses indicate that these benefits can extend to patients with a wide variety of mental health conditions, including those with chronic or highly comorbid disorders.
The authors thank Heidi Frankenhauser, Donna Li, and Sarah Marsella for assistance in the development and formatting of the evidence tables and article counts.


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HOME San Francisco 49ers Gear San Francisco 49ers T-Shirts San Francisco 49ers T-Shirts Mens Sale Items (17 items) Product ID: 1124484
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