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i won't give any more away, but you will find out the origin of the name "The Eagles." You'll find out how Glen Frey summed up the trinity of rock and roll in one sentence. You'll also see the rare footage and audio of Glen Frey literally threatening Don Felder with fisticuffs, on stage in 1980, a key moment leading to the breakup. This movie is pure rock and roll.
Rated PG-13
In the midst of the first quarter film releases stands a gem of a film that is endearing and romantic...and includes zombies.
Warm Bodies is your basic teenage love story. Zombie boy meets girl, and spends the length of the film wooing her despite the odds. The odds are high, considering what we know about the zombie-human relationship dynamic. I was curious about this movie because the process of how a zombie might turn back into a human is really undiscovered country.
We don't know why our zombie hero R (Nicholas Hoult) became the way he is, or why he begins to change. He has a running dialogue in his head and seems to know that he needs to eat brains, but seems to yearn for something better. He hasn't given up completly on his humanity like the scarier and creepier Bonies (zombies that have lost all humanity?) who seem to be the bullies of the zombie population.
In this zombie scenario, zombies who eat human brains somehow gain the memories of their victims. How Highlander of them! On one brain eating mission, R encounters Julie (Teresa Palmer) and eats the brains of Julie's boyfriend. Seeing the beauty that Julie's former boyfriend saw, R falls into love with Julie in true Romeo & Juliet style.
Feuding families. Balcony scenes. Forbidden love. It's all there, but not only do you see the genesis of blossoming love, there is a sweet message about healing humanity.
The plot takes it's time to develop, but it fits situationally and I felt like I spent a worthwhile 90 minutes with this one.
Credit goes to Comedian Rob Corddry who play's R's best zombie friend M. It was more of a dramatic role for him, but he ate it up...like so many human brains.
Rated R
Once again, Director Kathryn Bigelow has brought us an extremely intense movie watching experience.
Zero Dark Thirty is a film based on the CIA's real life, sometimes moment-by-moment hunt from Osama Bin Laden. The intensity is turned up to ten right from the opening scene showing us a dark screen with 911 call soundbites from the victims of the World Trade Center towers.
Jessica Chastain plays Maya, a CIA newbie who develops something of a bloodlust for capturing Bin Laden. The story begins with some explicit and controversial scenes depicting the torture off suspects with the intent of getting information to capture terrorists.
That information leads to a lengthy investiation by Maya, who believes she's found the main courrier of Bin Laden, with hopes it will lead her to the leader of al-Qaida. The final act of the film details the elite team of American soldiers who raid a compound in Abbotabad, Afghanistan believing its where Bin Laden is hiding out. They are methodical, exacting and deadly.
The true test of the movie, is that we know how it all ends. Still, the development to get there kept my eyes solidly glued to the screen. Surely a film like this makes you reflect your own thoughts about the treatment of our fellow human beings, patrtoisim, bloodlust and whether ends justify the means. That's what great film should do, and this is a great film.
It was also refreshing to see that this thriller of a story is based on the strength and tenacity of a strong female lead.
It's literally the last day of the year, so let's fit one more discussion about film in.
I felt as if 2012 was not a great year for film. There was a LOT of trash. A LOT of uninteresting sequels. A LOT of superheros who quite frankly were not all that super in my opinion.
There were a few diamonds in the rough though, and I wanted to share them with you. Here's my Top 10 Movies of 2012 with a note why.
#10 - Prometheus: The supposed Alien prequel was disappointing in the way that it was very vague as to what was actually going on. I wasn't all that impressed on my first screening, until my mind started asking questions about how this futuristic sci-fi flick was woven together. The more I thought about it, the more i liked it. (Sign of a good movie)
#9 - Goon: Some might say this was a foul mouthed, comically violent film that only a hockey fan could appreciate. Well. I am that hockey fan. This film marks the best performace I've ver seen from the typically low-brow Sean Williams Scott. It has heart.
#8 - Marley: I am a sucker for films about music. I love the music of Bob Marley, so this was a natural fit.
#7 - Bernie: Jack Black gets honors for doing that magic film trick, where the character transforms from the person you expect into an all new character. (another sign of a good movie) A plucky Shirley MacLaine helped this funny, quirky and mostly true tale stick out amongst the rest.
#6 - Sleepwalk With Me: Comedian Mike Birbiglia brought this psuedo-documentary to life about his own trials and tribulations about sleepwalking. He's a funny man and he makes a funny movie.
#5 - The Cabin In The Woods: Watching this one about a group of unsuspecting teens retreating to a remote cabin was like eating candy for this and just about any sci-fi/horror film fan. So many layers of witty, smart and gory goodness.
#4 - Looper: Joseph Gordon-Levitt and Bruce Willis tie together the best use of science fiction in 2012.
#3 - Silver Linings Playbook: Bradley Cooper plays a recently released patient dealing with his own mental issues, while coming to terms with the consequences of his actions. Jennifer Lawrence continues to grow as an actress with this performance. Cooper is likeable once again following his crude sequel to The Hangover.
#2 - Skyfall: Much like 2008's The Dark Knight was a brilliant action-drama-thriller, which happened to include superheroes, Skyfall is a masterful action-thriller that just happens to be a James Bond movie too.
#1 - Moonrise Kingdom: I fell in love with this quirky Wes Anderson film early in the year and this tale of young love on the run simply set the bar too high for anyone to top.
Still on the list to see are: Les Miserable, Zero Dark Thirty and The Impossible.
Honorable mention: Life of Pi, Django Unchained and Total Recall (2012) which only gets a mention because i watched it in a theater in Harrogate, UK where the local folk were so kind, they offered to share their popcorn, candy and soda with me. Quite proper!
Christopher Nolan Calls 'Man of Steel' "The Biggest Possible Movie Version" of Superman
Rated PG-13
The greatest thing that can be said about The Twilight Saga: Breaking Dawn- Part 2 is that it's over. No more movies, no more books, no more Bella's dirty looks.
Once again we are subject to poor acting, and weak story lines that circle around the romantic notion of getting what you cannot have. This one is unique though, because Bella (Kristin Stewart) is no longer a human yearning for the forbidden love of Edward (Robert Pattinson.) Her newfound vampings have put her at the center of a scandal in the vampire world, which lead to a showdown over the legitimacy of her half-human half-vampire child.
That amount of riducilousness is only matched by Bella's dialogue shouted to Jacob: "Nessie!? You named my daughter after the Loch Ness Monster?"
Now lets not be competely negative. We do get a couple treats. For example, Dakota Fanning is limited to just one word of dialogue and Michael Sheen lets out a vampire cackle that will almost guarantee that I won't ever take him seriously as an actor ever again.
Truth be told, I didn't mind watching this Twilight, because I knew it would be the last. It must have tapped a nostalgiac vein in me.
Alas, I was completely disappointed with the resolution of the film. It made the blood drain from my face, as if a vamp was taking one final drink.
Glad we are done here. Best of luck to this crew of actors in finding other work that does not cast them as brooding supernatural creatures.
Who Will Like This Film:
All Twilight fans looking for closure
Any significant others of Twilight fans who were dragged to the other Twilight Films, because its finally over
Humans considering the vampire lifestyle
All Twilight fans looking for closure
Any significant others of Twilight fans who were dragged to the other Twilight Films, because its finally over
Humans considering the vampire lifestyle
Who Won't Like This Film:
Everyone else
Everyone else
Rated PG-13
A solid argument could be made that this is the greatest James Bond film ever made. I like to think they are all pretty entertaining, so I'll just say this.
Skyfall is a really good action-spy-thriller, that just happens to be a Bond movie too.
Daniel Craig once again makes a human being out of James Bond. He is no longer just the super suave, internationally known, super intelligent ladies man. He's also a human, who has parents, a childhood, bleeds when cut and has feelings.
I still have a bit of difficulty adjusting to the new style, but I still like it.
Javier Bardem appropriately earns the title supervillian with his role as Silva. The bad guys are always better when you like them, and as dastardly as Silva is, you still feel for him.
My sole criticism of the film is that it repeatedly grinds on the theme of old vs new. Ad nauseum. I get it. James Bond needs to build a new audience and appeal to a younger demographic. You don't need to hit me over the head with it.
Go see this movie in the theater.
Who will like Skyfall:
Any/All James Bond Fans including the Bond Super-Nerds
Grown ups looking for a solid evening of entertainment
Hungry Komodo dragons
Any/All James Bond Fans including the Bond Super-Nerds
Grown ups looking for a solid evening of entertainment
Hungry Komodo dragons
Who won't like Skyfall
Kids under 13 - long run time, significant character development
Kids under 13 - long run time, significant character development
People who like watching Love Actually
People looking for cheesy James Bond gadgetry
People who like watching Love Actually
People looking for cheesy James Bond gadgetry
I would like to say that my thoughts are with the victims and families of those affected in Aurora, Colorado.
I'm still not sure what motivates an individual to commit such heinous crimes, but I do know the difference between the fiction we see on screen and the reality that we live in.
Film is supposed to be an escape. We watch and suspend our reality for the sake of storytelling and entertainment. Done properly, film is art with a cathartic effect, and help us shape the way we look at the world.
We are each meant to interpret the information we see. My hope is we use that information to make the world a better place for all of us.
- Adam
Rated PG-13
There are a lot of moving parts in the third chapter of Director Christopher Nolan's take on the Batman franchise. I found they fit together well, although I saw several repetitive film ideas come into play.
The Dark Knight Rises takes place eight years after The Batman (Christian Bale) takes the blame for Harvey Dent's crimes. Now, a ruthless thug named Bane has ambitions to destroy Gotham City with a nuclear weapon. Batman has to come out of retirement to fight the baddies again.
Bane (Tom Hardy) is an especially well played bad guy because of seemingly present sense of wanton destruction. Because of a partial mask, you only see a portion of his face. The distraction only increased my fear of him as the film went on.
There are at least five subplots running alongside teach other: 1. Will Batman return. 2. Will Catwoman (Anne Hathaway) do the right thing? 3. Who is Officer Blake (Joseph Gordon-Levitt) 4. What's with the nuclear power thingy. 5. Why is Alfred crying so much. They go on and on.
Paying attention pays off for this one. Paying attention to Anne Hathaway really pays off.
I enjoy all the darkness from Nolan. Not just the story, but the setting, mood and lighting are all dark. A brilliant use of strobe effect in the dark I especially liked as Batman advances on a bad guy in the sewers under the city. It's well done action.
The symbolic theme of leadership and responsibility pop back up again. Revealed as Batman, Bruce Wayne has to explain to Officer Blake his reasons for becoming a caped crusader. It's been a while. The symbol of justice, the any-man nature of the mask, the hope for our future. It's great superhero material., but it also adds to the really long 2h 45min run time.
If any of these plot points sound familiar, that's because they are in every movie ever made. Will the hero return? Will those sitting on the fence choose the right side? Are things darkest before the light? You know the answers. It's just whether you're surprised when they happen.
For The Dark Knight Rises. I was surprised 75% of the time. While I don't think this is the greater film of the trilogy, I will say I was left wanting more.
Rated PG-13
It's only been 10 years since Sam Rami delivered Tobey Macguire as the Marvel action hero Spiderman. The world moves fast these days, so maybe that's why we have a reboot of that 2002 story, this quick.
Does this version of Spiderman improve upon the trilogy from the 2000s? In some ways, it does with better character development, action that you can follow and pretty decent acting performances. In other ways, this Spiderman fell like a web of repetition.
Peter Parker (Andrew Garfield) is an emo high school teenager, in search of clues about his parent's death. Ike most teenagers, their overriding theme, and the theme of the movie is self-discovery. That leads him to Oscorp and the lab of Dr. Curt Connors (Rhys Ifans.) This is where Spider-man's origin story is retold and altered to fit the modern day setting. Parker courts Gwen Stacy (Emma Stone) as Spider-man moves closer to a showdown with Dr. Connor's alter ego, The Lizard.
The relationship between Peter and Gwen is what drives the quality of this movie. Garfield and Stone are pretty decent actors who have believable chemistry. The rest of their backstory is useless. Not for one second did I believe that either were high school students, and it was enough of a problem that it distracted me from the story. Come on! Gwen is a high school student, who is also a lead representative of a bio-genetics firm? Garfield has youthful tendencies, but too advanced intellectually. (Apologies to teens of today)
Much like the introduction of Daniel Craig as the latest James Bond, Garfield is a grittier version of Spider-man. Rough around the edges and nervy, with a youthful carelessness. Throw in a Footloose-like solo barn dance scene with a skateboard and you've got something perfectly marketed to the youth of today.
Dennis Leary also plays Gwen's father, New York Police Captain Stacy. He was actually my favorite character. His Leary-like frustrations carried the otherwise useless plotline of Spider-Man being chased by the Police as a vigilante.
I do hold all superheroes to a higher moral standard. The Amazing Spider-Man shows us how the young Spidey may be on the road to righteousness, but he's not there yet. For that, I was disappointed. Since we're in fantasy land already, I also expect my superheroes to have super powers. This Spider-Man was more like a regular guy who's really good at parkour.
This movie is also another example of poor use of 3D technology. One more critical note: if Peter Parker/Spider-Man relies so much on a cell phone is this one, why does he use a camera that has film? Go digital already. Most of the movie is CGI anyway.
1. Why would the Engineers create humans, only to want to destroy them? Seems like waste of time.
2. Android technology in the original 1979 Alien seemed sketchy. That film took place in 2122. Prometheus takes place around 2090. The androids here seem to be operating fine, even contemplating complex human emotions like freedom. Did we take a step backwards in their tech?
3. Where was the DVR? While two crew members have to fend for themselves, the captain takes an, ahem, "break" with Charlize Theron. While they meet a horrible fate, with video cameras entact, the captain returns and wonders what happened to the two guys. Well…check the tape!
1. Why would the Engineers create humans, only to want to destroy them? Seems like waste of time.
2. Android technology in the original 1979 Alien seemed sketchy. That film took place in 2122. Prometheus takes place around 2090. The androids here seem to be operating fine, even contemplating complex human emotions like freedom. Did we take a step backwards in their tech?
3. Where was the DVR? While two crew members have to fend for themselves, the captain takes an, ahem, "break" with Charlize Theron. While they meet a horrible fate, with video cameras entact, the captain returns and wonders what happened to the two guys. Well…check the tape!
While hordes of acid-reflux inducing questions are asked, few answers are given. That left me with a bit of an empty feeling, like I just watched a setup for the next Prometheus film.
Dear Hollywood,
It's OK to tell a story from beginning to end in one film.
Rated PG-13
For goofy superhero fun, The Avengers is not a bad ride at all, but I still prefer Director Joss Whedon's other work from this year "Cabin In The Woods."
The Avengers is the summation (but by no means the end of the franchise) of several movies based on Marvel comic book superheroes. Faced with the certain destruction of earth, by the outcast Viking god Loki (Tom Hiddleston,) Nick Fury (Samuel L. Jackson) brashly assembles a motley crew of fighters to battle the oncoming threat.
While at first their egos and talents don't mix, they learn through strife their combined unit is much stronger than the evil facing them.
Robert Downey Jr; Mark Ruffalo; Chris Evans; Scarlett Johansson; Chris Hemsworth and Jeremy Renner are respectively Ironman; The Hulk; Captain America; Black Widow; Thor and Hawkeye. We've seen all the characters separately in films to varying degrees of success except for master archer Hawkeye and super spy Black Widow.
The first act drags. Vocal yawns could be heard while Nick Fury spends much time setting up the conflict and garnering his superteam. The all out battle to follow is a respectable reward for the exposition and rising action.
It's easy to fall victim to superhero cliché, and while The Avengers does in order to appeal to the masses, there is still pleasure to be taken from the stellar eye candy special effects.
If not for the comic relief of The Hulk, this would have been a much lesser film. Captain America handing Hulk the simple command to "smash" makes up for just about all the missteps.
Here's another quick way of looking at The Avengers franchise. If I were to rank the films in this series so far, it would go like this:
Stick around through the end credits for the culinary payoff. Avengers need to eat too.
Did I just watch a documentary on American Idol, where instead of voting the losers off, they just kill them? Possibly, but Idol was never as entertaining.
The Hunger Games is set in a post-war dystopian future, where the United States is now a country called Panem, and split into districts instead of state, two commoners from each district are chosen to savagely fight to the death for the entertainment of the ruling class. It's a form of punishment to keep the common people in line, which the upper class have spun, now calling it a national tradition.
These chosen children, range in age from their late teens to a disturbingly young age. This is perhaps the darkest element of this dark film. Watching the upper class celebrate the fact that they are sending kids out to the slaughter makes it pretty easy to cheer for their downfall.
Katniss Everdeen (Jennifer Lawrence) is the heroine, who has to live up to her potential. The one
thing that really drives this movie is Jennifer Lawrence. She's a young actress, but you can tell there is something behind her eyes and in her face. Her honesty on-camera makes you believe her. She's the opposite of a blank slate, even if she hasn't realized what her potential is yet. The future is bright for her.
The supporting cast is surprisingly strong. Woody Harelson plays Hamish, an alcoholic former Hunger Games winner that mentors the fresh meat. Lenny Kravitz surprises with a passionate performance, despite the gold eyeliner. Stanley Tucci is the Hunger Game emcee and his fake teeth were basically a character to themselves.
The Hunger Games falls into the new franchise-category of movies that include Harry Potter and Twilight. It's also pretty hard not to make comparisons to the aforementioned similar films. There is a lead character destined for greatness. There is a love triangle forming. There is a greater evil hovering over the lives of the characters.
The film is not without its faults. There was part of me that wanted to cast off this movie series as just another brick in the wall, but there is an impressive level of achievement here, which cannot be denied.
Rated R
If not for the predictable and unnecessarily long ending, which includes a sad attempt as creating it's own R-Rated "you had me at hello" tag line, I might have really liked Friends With Kids.
The movie is the brainchild of beautifully adorable indie actress Jennifer Westfeldt, who wrote, directed and stars as the lead female. (She's also notably the long term girlfriend of Jon Hamm, who is also in the film.) The story involves a late 30's couple with a platonic friendship between Jason (Adam Scott) and Julie (Westfeldt) who decide they want a child. They don't want the attachment of marriage to weigh down their relationship, seeing how it's changed their two pairs of friends for better and worse (Hamm & Kristin Wiig and Maya Rudolph & Chris O'Dowd.)
Jason and Julie's strength in friendship and their adult attitude about the situation they've chosen for themselves is quite impressive. I really can't say I know a couple that might be able to pull off their platonic-parenting status, but maybe that's because the idea seems to be something only the guys in the movie understand. They get the companionship and the family but they also get to sleep with other people.
With the New York setting and the open conversations about the relationship, you can't help but feel in Woody Allen influence. It was quite entertaining, until they dive into the pool of predictable romance-comedies.
Still, Friends With Kids deserves more credit. The ensemble cast is very strong and believable. The story and tension between the characters is true to life. I liked Scott with the lead role. He's thought out and engaged in the "now" of the film.
Without being preachy, the film also makes arguments, pro and con about the alternative family situation that's developed. To my dismay, it ends making a rather traditional decision. That third act is nearly painful to watch. Considering how unusual the relationship between Jason & Julie is, it doesn't seem believable that they start acting like people do at the end of a typical rom-com.
I didn't appreciate that and frankly felt a little cheated. It was like getting a present wrapped in a giant box, only to find the gift is actually the size of a coin and not that valuable.
Rated PG
It doesn't quite live up to my childhood memory of my favorite Dr. Seuss book, but the Hollywood version of The Lorax isn't an updated fail.
The reason this family friendly movie doesn't fail is because it passed my kid-friendly test in the theater. Basically, when you watch the film, it's whether you hear kids getting restless. It was silent for the showing I attended, which means it kept kids engaged.
The story of The Lorax, Once-ler, Truffula trees, Swanny Swans and the thneeds that we all need is familiar with some add ons. The main character Ted (Zac Efron) is a young boy trying to win the affections of a girl who wants to see a tree. (The things guys will do to get the girl.) The rest of the cast is as colorful as a handful of candy. Danny DeVito, Betty White & Ed Helms all deliver likeable performances. Helm's musical numbers stand out as favorites.
The introduction of Mr. O'Hare (Rob Riggle) as a greed hungry corporate power monger who sells clean air to the residents of their cordoned off home town was extraneous. Maybe they needed a villain beyond the Once-ler for everyone to hate, but I felt it muddied the plot.
I caught the film in 2D, although it's also being shown in the 3D format. You can tell what scenes are meant to pop out at you, but I felt the vibrant colors and animation stood out plenty in the base format.
Loving the book, I also enjoy the message of The Lorax, which is basically that we should care about each other. That, and the dangers of unchecked corporate greed in a capitalist society. It also doesn't hit you over the head with the message. It's a nice family treat.
Rated R
In the land of raunchy comedies, Wanderlust roams somewhere in the middle of the pack, but with a steady flow of medium sized jokes, it can still entertain.
Produced under the Judd Apatow house, Wanderlust stars Paul Rudd and Jennifer Aniston as a newly unemployed New York couple. Forced to move to Atlanta and stay with a rude brother in law, they instead decide to join a hippie commune.
If not for the obvious direction of the plot, Wanderlust may have been a better film. It's not a bad movie, just medium funny.
The fish out of water routine manages to stay fresh thanks to a cast of oddballs living at the commune including Alan Alda and the now grown-up teenager from Six Feet Under, Lauren Ambrose. The jokes flow through the outsiders response to the free love, extreme openness and quirky habits of the tribe, but none really draw the burst out laughter that the similarly raunchy Bridesmaids delivered in 2011.
The humor is in the playing off stereotypical things you think a hippie commune might do. The characters act silly while hallucinating on drugs. The newbies get real uncomfortable with the free love sexual dynamic and watching people squirm while their personal space is constantly invaded is just fun. You can also appreciate the satire on yuppie culture.
Considering the cast was mostly made from the alum of the comic troupe The State, later turned Reno911!, you can expect the same level of alternative comedy.
Sidenote: Wanderlust means a strong impulse to travel. These characters are more in search of themselves. Bad title
Rated PG
If you're really going to take the kids to an adventure movie, journey back to the box office and buy two tickets to the whale movie "Big Miracle." It will be far more worth your time.
I simply do not enjoy watching disjointed kids movies that make incredibly ridiculous jumps of logic, while trying to maintain their credibility with the youth by spouting out trendy catch phrases of the day.
Journey 2: The Mysterious Island is the equally pathetic follow up to 2008's Journey To The Center Of The Earth. Josh Hutcherson is the leftover from the first film, and is joined by Michael Caine, Luis Guzman, Dwayne Johnson and Vanessa Hudgens. I would imagine none of them will be listing this film on their resume.
Sean (Hutcherson) discovers a secret message from his grandfather (Caine) and convinces his stepfather (Johnson) to fly him to an island in the South Pacific on a school day. The stepfather-son relationship is stereotypically strained and Mom decides it's an OK idea to help them bond.
Once there, they meet up with a willing, but low-rent tour guide (Guzman) and his daughter (Hudgens) who take them on a three-hour tour (sing it!) in search of the lost island.
They find a hidden place of beauty, only to discover they are in danger and need to flee. That's a pretty crappy vacation indeed.
It's annoying to me when characters who are clearly supposed to be human are allowed superhuman powers. The fantasy of this kid's movie is supposed to be the magic they encounter and it's wonder. Jump-starting a submarine with a giant electric eel is magic. The Rock singing a soothing song while playing a ukulele is not magic. At least carrying around the ukulele pays off somehow.
Journey 2 may all be entertaining for tweens, with all the elephants the size of small dogs and bumble bees the size of horses. The overabundance of poop jokes, bad puns and general mediocrity will be enough to allow Mom or Dad to take a brief nap during the film. Just ask the guy who dozed off sitting a few seats away from me.
Save this as a rental for the kids. Press play and leave the room. There is nothing useful for anyone over the age of 13 here.
Rated R
Its said that youth is wasted on the young. Just think how bad it might be if they had superpowers too.
Chronicle is a finely tuned example of the found footage film genre. In it, three teenage boys, Andrew, Matt & Steve, come upon a mysterious hole in the ground, inside which is an even more mysterious object. They enter the hole as your typical teens. They exit with the power of telekinesis. The squirrelly-emo one of the three is documenting the events with his video cam.
This is like handing teenage boys $1,000,00 cash and telling them to have fun.
The second act, where our teens discover how to harness their new-found power is brilliant. It's exactly how you expect three guys to act. At first they skip stones with their mind. Then while playing at the table, they figure out how to block a fork from stabbing their hand. Then they fly, all while manically giggling about how cool it is.
A nice design element of the film is the subtext of how these guys don't seem quite mature enough to handle their power. Then, you think of what could go wrong. Then, things go wrong. The third act mayhem is typical and less interesting.
While this downward spiral is palpable, Chronicle works because you believe how these guys are living in the moment.
I was pleasantly surprised how well the film gels. I was tired with found footage style the moment The Blair Witch Project came out. This breathed some new life into it.
Rated R
Call me paranoid, but I love a good survival story. What would I do in the situation? How would I handle it differently? Exactly how long could I survive after my iPhone battery drains?
Liam Neeson's new film The Grey is a chilled action story, filled with pending doom, survival of the fittest and wild wolves that carry a grudge. Ottaway (Neeson) and a crew of grungy oil workers are aboard a plane that goes down in the frozen middle of nowhere, Alaska. The survivors even reference the 1993 movie Alive and fend for their survival. A pack of hungry wolves, upset that a plane lands in their turf, make for a particularly bad three days.
The Grey has a plot very similar to a number of other movies (Predator, Anaconda, even Jaws) where a creature starts picking off members of a group, one by one. The thing that makes this stand out is Neeson's believability in a survival situation. In one dramatic and heavy scene, Neeson shouts to the heavens for help. Not like Captain Kirk shouting at Kahn. More like a man's final desperate attempt to spare his life. It's still weighing on me as I write this. I still don't know how Neeson turned from an eloquent actor to an action hero, but it works.
Still, Ottway is kind of a lousy guy. He's hired as a sharpshooter to kill wolves at an oil refinery. In Alaska, we can assume that most people are there to get away from everyone else. Ottway has a interesting backstory, but come on. Your job is to shoot wolves who are just looking for food? Can't you just put up a fence?
At first, you feel sympathy for the wolves. They are just animals surviving. Then you start to wonder how you might defend yourself from a pack of wolves. Then you fear them, basically because you want to keep on living.
Interestingly enough, the well-placed dark turn towards the end of the film helps out a theory of mine on this movie. With just a little bit of editing, the creatures stalking this group could have just as well been supernatural. You really only see small moments of wolves and when they do attack, the camera work is so blurry that you can't really tell what is going on.


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Sony STR-DN1050
The Sony STR-DN1050 is a great deal that offers almost everything you could want in a midrange receiver.
Pricing not available
Roku Streaming Stick ( 2014)
Unless you have very little to spend, this is one of the best streaming devices you can buy in the UK today.
Pricing not available
Samsung Shape M7 ( black)
The Samsung Shape M7 is a versatile streaming speaker that sounds better than the Sonos Play:3 but lacks a rich ecosystem of products and supported services.
Roku 2
The Roku 2 offers tons of content sources and an innovative remote with built-in headphone jack for just $80, but the Roku 3 is still our favorite pick.
Pricing not available
Sonos Play:1 ( black)
Ideal for first-timers or people with existing Sonos systems that want to expand it into smaller rooms, the Play 1 is a great way into wireless audio. If you've been dithering about getting Sonos, now is the time.
Apple TV ( 2012)
While it's still a step behind the Roku 3, the Apple TV is an excellent streaming box, especially for those invested in the Apple ecosystem.
Typical price: £99.00
Sky Now TV Box
A streaming TV box for £10 is astonishing value, although if you can afford an extra £40 you should pick up a Roku Streaming Stick instead.
Typical price: £10.00
Google Chromecast
Technically, the Chromecast is a wonder to behold. If all you want is a cheap way to get iPlayer and Netflix, it's a good choice, but it needs more content before it becomes a must-buy for most.
Pricing not available
Roku 3
The Roku 3 is quick and easy to use for accessing online video services but it's pricey. It's also disappointing that it lacks support for key movie and catch up TV services including 4oD and Lovefilm.
Sonos ZonePlayer ZP90
The Sonos Connect brings effortless wireless media streaming to existing hi-fi owners, but it's not the first Sonos system we'd recommend.

subset: commoncrawl


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JC Penney leaving Salisbury Mall, closing doors in Rowan
SALISBURY — Another original anchor at the Salisbury Mall is pulling out of the troubled shopping center.
J.C. Penney will leave the mall in August and close its doors in Salisbury, the company confirmed Wednesday.
The retail giant's departure from the mall has been rumored for months, following plans by Belk and Big Lots to leave the shopping center at the corner of Jake Alexander and Statesville boulevards. Both Belk and Big Lots will relocate near Interstate 85 this year.
But J.C. Penney, which has struggled financially since the failure of a new marketing strategy, will close the Salisbury location in early August and not relocate. The store employs about 35 people, most part-time.
"Each year, we evaluate our store portfolio to determine whether there's a need to close or relocate underperforming stores," spokeswoman Sarah Holland said.
J.C. Penney is positioning itself for future growth, she said.
"While it's never an easy decision to close a store, especially due to the impact on our valued team members and customers, we would not have moved forward with this difficult decision if we did not believe it was absolutely necessary," Holland said.
With J.C. Penney's departure, the mall loses three original anchor tenants, including Belk and Rose's.
Mall owner Igal Namdar did not respond to questions from the Post. His Namdar Realty Group, a New York real estate company, bought the mall for $2.5 million last year after it went into foreclosure.
Badcock Furniture recently signed a 10-year lease to fill the long-vacant Goody's location in the mall (originally Rose's), scheduled to open this summer. The Mulberry, Fla.-based company with about 40 stores in North Carolina could not be reached for comment about J.C. Penney's departure.
Previously, a Badcock spokesperson told the Post the company wasn't deterred by Belk and Big Lots' impending departures.
"We think the mall is still viable," said Bill Pou, Badcock's executive vice president of retail operations.
Mayor Paul Woodson agrees.
"I think the mall will survive," Woodson said. "But I think the mall is going to have to transform itself into more of a discount-type mall and get away from the high-end stores like Penney's and Belk."
Debt service on the mall must be quite low because Namdar bought the property at such a bargain price, Woodson said. He can afford to charge less in rent than someone who paid $13 million or $14 million for a mall, Woodson said, which should help him attract new tenants.
Woodson also predicted J.C. Penney will return to Rowan County, possibly in a proposed retail development in Summit Corporate Center.
Hutton Growth One has reserved property at the county-owned business park on Interstate 85 for 18 months. It plans to use that time to court retailers, including a "well-known" anchor store, for a new shopping center.
Chattanooga, Tenn.-based Hutton is building the nearby expansion of the Wallace Commons shopping center at Klumac Road and I-85, where Belk plans to relocate this fall.
Rowan County residents spend an estimated $271 million a year outside the county on retail and consumer services. Called "retail leakage," the statistic proves huge demand for retail in Rowan, said Robert Van Geons, executive director for RowanWorks Economic Development Commission.
"There is enough demand to fill every vacant retail space that we have here," Van Geons said.
Van Geons said he's optimistic the mall owner can land more tenants like Badcock.
In addition to the furniture store, Namdar's leasing director announced last week that he's signed leases with a martial arts studio, arcade, snack shop, cell phone accessory kiosk and an expansion of an existing clothing store.
"Anytime we lose an employer, that's something that we hate to see in Rowan County," Van Geons said. "I for one will miss having J.C. Penney here."
J.C. Penney's decision to close its doors in Salisbury comes after a one-two punch of falling mall attendance and the corporation's financial struggle.
The Plano, Texas-based department store chain reported a net loss of $552 million for its fiscal fourth quarter.
Total sales for the fourth quarter decreased 28.4 percent to $3.884 billion. Comparable store sales declined 31.7 percent. Internet sales through jcp.com were $315 million in the fourth quarter, decreasing 34.4 percent from last year.
For the full fiscal year ending Feb. 2, J.C. Penney reported a net loss of $985 million or $4.49 per share.
Many longtime customers abandoned the store when new CEO Ron Johnson, the former retail guru at Apple, took over and began to transform the company to appeal to a younger demographic. He did away with coupons, discounts and doorbusters, and by late February, the company's stock had fallen 46 percent.
Despite the losses, Johnson remains at the helm and struck a positive tone in a recent earnings report.
"Sales and customer traffic were below our expectations in 2012, but as we execute our ambitious transformation plan, we are pleased with the great strides we made to improve J.C. Penney's cost structure, technology platforms and the overall customer experience," he said.
Looking ahead, "we are working towards reconnecting with our core customer while attracting new customers to J.C. Penney," Johnson said.
Contact reporter Emily Ford at 704-797-4264.


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CME Disclosure
Kelli Jane K. Harding, M.D., Department of Psychiatry, Irving Institute for Clinical and Translational Research, Columbia University Medical Center, New York State Psychiatric Institute, New York Presbyterian Hospital, New York, NY.
Reports no competing interests.
Harold Alan Pincus, M.D., Department of Psychiatry, Irving Institute for Clinical and Translational Research, Columbia University Medical Center, New York State Psychiatric Institute, New York Presbyterian Hospital, New York, NY and RAND, Pittsburgh, PA.
Address correspondence to Dr. Kelli Harding, Columbia University, Department of Psychiatry, 1051 Riverside Dr., Unit 125, New York, NY 10032; e-mail: email@example.com
The aim of this article is to assist psychiatrists in meeting their responsibilities to better understand their patients and improve the quality of medical care that they receive. The importance of quality, the state of health care quality, and health care aims and expectations are reviewed. In addition, integration of strategies to build a stronger infrastructure to support the delivery of high-quality mental health care is discussed at both the clinical and systems/policy levels. At the systems/policy level the following are addressed: 1) how to achieve consensus and greater specificity on standard elements, methods, assessment tools, and treatment guidelines and provide applications to implement them in clinical practice using health information technology; 2) how to establish methods to measure the quality of mental health care delivered to patients and provide support and incentives for clinicians and organizations to adopt care improvement strategies, including building the measurement and monitoring infrastructure, designing improvement incentives, providing training/support for organizational improvement methods, and updating clinical training/accreditation/certification standards; and 3) how to develop leadership and resources to expand the evidence base to have a direct impact on health care decision making by patients, clinicians, and policymakers (i.e., comparative effectiveness research). Although the 2010 health care reform legislation (Patient Protection and Affordable Care Act) emphasizes health care insurance coverage issues, it contributes further strategies to help transform U.S. health care delivery system to improve quality and reduce cost. This article offers aid to clinicians for navigating and participating in the professional changes ahead.
The passage of the landmark 2010 Patient Protection and Affordable Care Act (ACA) and its provisions for supporting quality drew attention to ongoing health care value trends in the United States; however, quality issues in health care are not new. More than a decade has passed since the national dialogue on shortfalls in care delivery began with the landmark Institute of Medicine (IOM) series To Err Is Human: Building a Safer Health System (1) and Crossing the Quality Chasm: A New Health System for the 21st Century (2). These initial reports documented the "chasm" between the medical care that should be and is given in the United States, including how nearly 100,000 people die each year as a result of presumably preventable medical errors (1). In addition, the series highlighted significant gaps between research, policy, and practice, with a disappointing 17-year lag in the translation of biomedical research into actual clinical practice, the so-called "bench to bedside" delay (2).
Despite having the most expensive health care system in the world, accounting now for 17.3% of the gross domestic product (GDP) (3), health care in the United States repeatedly falls short on expected results (4). For instance, a World Health Organization (WHO) report in 2000 found that the United States ranked 37th on health care quality (France ranked first) using measures such as health equality, life expectancy, fairness in financial contribution, health performance indicators, and health expenditures per capita (5). A 2007 Commonwealth Fund Report ranked the U.S. health care system last or next-to-last on five dimensions of a high-performance health system (quality, access, efficiency, equity, and healthy lives) compared with that of five other developed nations—Australia, Canada, Germany, New Zealand, and the United Kingdom (4). As former WHO Director-General Dr. Gro Harlem Brundtland said, "the health and wellbeing of people around the world depend critically on the performance of the health systems that serve them. Yet there is wide variation in performance, even among countries with similar levels of income and health expenditure" (6).
The disparity between optimal and actual medical care is widespread across conditions (preventive, acute, and chronic), health care settings (inpatient and outpatient), patient populations (age, ethnicity, and socioeconomic status), and geographic areas (7–9). Variations in health care delivery, as shown in the Dartmouth Atlas of Health Care, are not simply due to how sick people are or how much medical care they receive. In other words, more care does not equal better care (10). Chronic diseases are particularly vulnerable to variation: patients are susceptible to underuse, overuse, and inappropriate use of medical services, with an estimated chance of only 55% of getting recommended care (8). Quality shortfalls demonstrate the need for fundamental change of health care delivery in America. As noted in the IOM Crossing the Quality Chasm report, "Quality problems occur typically not because of failure of goodwill, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized." In essence, problems are so widespread that trying harder within the current system is not enough. System-wide change is needed (2).
In the United States it is unclear who has primary responsibility for health care quality. A fragmented "alphabet soup" of stakeholder agencies and organizations, including private insurers, the government, and consumer groups, use a variety of performance measures to examine quality from each of their unique perspectives. Despite much activity in the development of health and mental health quality indicators, efforts in the United States lack coordination. At present no single entity oversees or coordinates health care quality improvement efforts or organizes incorporation of best practices based on performance findings (11).
No matter how the quality improvement effort is organized, physicians hold a key leadership role from their own practices to the national arena. The Accreditation Council for Graduate Medical Education (ACGME) core competencies of professionalism, practiced-based learning and improvement (PBLI), and systems-based practice (SBP) (12) redefined physician proficiency beyond biomedical research alone. Understanding and improving the current state of health care quality in their own practices is the first step in integrating expectations across these competencies.
The IOM Crossing the Quality Chasm report listed six key aims for improvement in health care quality (2). These key aims, that health care should be safe, timely, effective, efficient, equitable, and patient centered, are central to health care quality improvement:
Safe , meaning avoiding injuries to patients from the care intended to help them.
Timely , indicating reduced waits and harmful delays for both those who receive and those who give care.
Effective , implying the provision of services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (i.e., avoiding underuse and overuse, respectively).
Efficient , demonstrating the importance of avoiding waste, including waste of equipment, supplies, ideas, and energy (i.e., duplication of services).
Equitable , meaning providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Patient-centered , signifying the importance of providing care that is respectful of and responsive to individual patient preferences, needs, and values.
[Adapted from Institute of Medicine: To Err Is Human: Building a Safer Health System. Washington DC, National Academy Press, 2000; and Berwick DM: A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood) 2002; 21(3):80–90.]
As is true in medicine in general, a disparity exists between the mental health care people could receive and the care they actually do receive. For instance, evidence-based approaches for treating depression, such as the chronic care model described below, are effective (13), yet are rarely used in practice (14). Furthermore. the rate of improvement on quality measures in mental health trails behind gains made in other areas of medicine, such as controlling high blood pressure and β-blocker treatment after a heart attack (7). The Institute of Medicine's 2006 Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series identified several key areas of quality problems in mental heath. These included 1) failure to provide care consistent with scientific evidence, 2) unnecessary variations in care (including disparities in care associated with race/ethnicity), 3) lack of access to care, and 4) unsafe care (15, pp 4–6, 32–36).
Failure to provide care consistent with scientific evidence
A review of studies from 1992 to 2000 demonstrated across conditions, such as depression, bipolar disorder, panic disorder, schizophrenia, and alcohol withdrawal, only 27% clinician adherence to established clinical guidelines (16). In 2003, patients with alcohol dependence were found to receive only 10.5% of recommended care (8). The yearly Health Plan Employer Data and Information Set report on the state of U.S. health care quality, developed by the National Committee for Quality Assurance and used by more than 90% of America's managed health care plans, measures performance on important dimensions of care and service. Their 2010 report indicated that the majority of patients with commercial insurance in whom a first episode of major depression was diagnosed and who were given antidepressant medication were about as likely to receive appropriate initial treatment (i.e., taking antidepressant medication for at least 12 weeks) in 2009 as in 1999 (62.9% in 2009 versus 58.8% in 1999). In addition, the percentage of Medicaid recipients with newly diagnosed depression receiving effective ongoing treatment (i.e., taking antidepressant medication for at least 6 months) also was little changed from 2001 (30.0%) to 2009 (33.0%). Furthermore, it is known that the number of days between hospital discharge and a follow-up visit is a significant predictor of treatment nonadherence (17) and identifies patients in need of additional interventions before they reach a crisis point or need for rehospitalization (18). Among Medicare recipients discharged from psychiatry hospitalizations in 2009, only 37.3% had an outpatient follow-up visit within 7 days (the same rate as in 2001), and 54.8% had a visit within 30 days (decreased from 60.6% in 2001) (7).
Unnecessary variations in care
Unnecessary variations in care, particularly relating to race, ethnicity, and age have been known to exist in psychiatry for some time. For instance, misdiagnosis is more likely to occur in black Americans, and they are more likely to receive antipsychotic medications at higher doses without clear indications (19–21). Schizophrenia is more likely to be overdiagnosed and depression underdiagnosed in black individuals; however, when diagnoses are based on more structured clinical interviews, rates of these illnesses were similar to those in their white counterparts (22). Other ethnic minority groups and children also appear vulnerable to inappropriate variations in care, including widespread use of antipsychotic medications for off-label purposes (23–25).
Lack of access to care
Accessing help for mental health problems remains problematic for many Americans. In the United States, more than 15% of the overall disease burden is attributable to mental illnesses (26), and the economic burden of serious mental illness, including the cost of health services, loss of earnings, and disability benefits, is estimated to be $317 billion (27). Major depression alone accounts for nearly half of lost productive time, costing more than $30 billion per year (28). However, mental health care is not readily available to those in need (29–31). Factors beyond health insurance and ability to pay are involved in the inability to access mental health care (32, 33), including structural barriers (uncertainty of how to access services) and attitudinal barriers (i.e., the belief that the problem would get better on its own, concerns about efficacy, the stigma/shame of mental illness, fears of hospitalization, or fears of being forced to take medication) (30, 34).
Race and ethnicity are two factors that illustrate the complex nature of issues relating to access. A large epidemiologic study showed that black adults are roughly two times less likely than white respondents to receive treatment for mood and anxiety disorders, even after adjustment for differences in income, education, and severity of illness. The study also showed that white respondents with drug use disorders were significantly less likely than black respondents to receive treatment for a drug problem (35). Considering that barriers to access are particularly important given 2009 data showing that 20.9 million people, or 8.3% of the U.S. population aged 12 years or older, had an unmet need for treatment for an illicit drug or alcohol use problem (31).
Unsafe care
Unsafe care, such as medication errors or interventions with a high risk of harm (i.e., restraints), is known to cause significant morbidity and mortality in general health care; however, few studies have looked at the incidence, nature, predictors, and prevention of errors that occur in mental health treatment settings (36, 37). The limited available data suggest that medication errors and adverse drug events are common in psychiatric hospitals and occur with the same frequency as they do in general hospitals (38). What little is known about psychiatric medical errors primarily relates to inpatient services and the use of seclusion and restraint (36, 39). The lack of data in itself is cause for concern and in part may relate to the failure to properly educate practitioners in the mental health field (40). As noted by Grasso et al. (41), "Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture."
Lucian Leape, in his landmark 1994 JAMA article on medical errors, called for the end of the "guilt culture" approach to mistakes, i.e., focusing on who made the error, and instead advocated an approach to determine what system failure allowed a well-trained and well-intentioned professional to make a mistake (42). Reframing errors as "bad systems, not bad people" has dramatically reduced errors in industries such as commercial aviation and nuclear power generation, and there is some evidence that this paradigm is taking hold throughout medicine (43). In psychiatry, the state of Pennsylvania reframed use of seclusion and restraint as a "treatment failure" indicator for its state hospital system and through quality improvement initiatives was able to dramatically reduce use of these interventions (from 107.9 hours per 1,000 patient days in 1993 to 2.72 hours per 1,000 patient days in 2000) (44). Implementation of these types of innovations indicate that quality improvement is feasible in mental health.
The 2006 IOM report recommended a five-part strategy to build a stronger infrastructure to support the delivery of high-quality mental health and substance use (MH/SU) care. This includes 1) more coordination in filling gaps in the evidence base, 2) a stronger, more coordinated, and evidence-based approach to disseminating evidence to clinicians, 3) improved diagnosis and assessment strategies, 4) a stronger infrastructure for measuring and reporting the quality of MH/SU care, and 5) support for quality improvement practices at the sites of MH/SU care (15). In this article we discuss the integration of these strategies first at the clinical level and second at the systems/policy level.
Whether in outpatient or inpatient specialty mental health or general medical settings, psychiatrists and other mental health professionals must learn and apply 1) evidence-based strategies for assessment and treatment in the care of their patients and 2) quality improvement methods at the locus of care. These approaches provide a strategy for improving the quality of patient care directly at the clinical level.
If mental health care is to hold to the industry principle, "You can't improve what you can't measure," standardized measures need to be introduced for clinical evaluations and treatment. Systematic measures help clarify treatment goals, track patient progress over time, and adjust interventions continuously based on results to optimize outcomes (45). For example, the management of chronic medical conditions, including hypertension, asthma, congestive heart failure, and MH/SU conditions (i.e., major depression, bipolar disorder, alcohol abuse, and schizophrenia) requires systematic longitudinal clinical measurement and adjustment of treatment strategies based on the findings from those measures (i.e., measurement-based care) (46).
Despite routine use of measurement-based care in psychiatric research, the use of measurement has not permeated day-to-day patient care to assist with diagnosis and monitor treatment response, decreasing the likelihood of scientific knowledge being applied to practice (46). Reliable instruments for identifying and assessing psychiatric conditions are available but are not widely applied. For instance, structured interviews increase the detection of psychiatric conditions (47). Furthermore, even though a diligent step-by-step approach to depression treatment produces better outcomes and prognoses than usual care (48, 49), validated measures for tracking depressive symptoms, such as the clinician-guided Patient Health Questionnaire (PHQ-9) or self-report Beck Depression Inventory (BDI), are not typically used to guide care.
In addition to the incorporation of standard measures, to improve the quality of care, the practice infrastructure for mental health services needs strengthening. One such strategy is incorporation of the principles of the chronic care model or "mental health home" (50) in existing practices. The patient-centered chronic care model (51–53) (Figure 2) is a conceptual framework used by numerous health organizations for implementation of quality improvement initiatives (53). The model seeks to achieve better treatment outcomes through improved interactions between prepared patients/families and a proactive care team that is patient centered, coordinated, longitudinal, efficient, safe, and evidence based. These relationships are supported by a practice infrastructure that includes self-management support, clinical information systems, decision support, and delivery system design for chronic illness care, which are in turn supported by policies and leadership at the health system level. Further elaborations on this concept, the "patient-centered or advanced medical (or health) home" (54), are incorporated into health care reform strategies and are also being applied to mental health care (55).
The Chronic Care Model
Chronic care models encourage adapting evidence-based guidelines into routine clinical decision making to help assure that consumers are getting the best possible care with currently available treatments. Although there are electronic tools to facilitate this practice (discussed below), one immediate practice clinicians can adopt is engaging in shared decision making and self-management with patients. In these frameworks, patient and provider are both considered experts, a concept that has been shown to have positive mental health effects (56). Not unlike home blood pressure monitoring (57), people with psychiatric conditions can systematically follow their own symptoms on self-report measures for discussions with providers during visits. Consumers and their families can lead the change with their doctors, starting now by downloading and filling out self-report measures [see http://www.depressionprimarycare.org/clinicians/toolkits/ (MacArthur Foundation) or http://impact-uw.org/tools/ (Project IMPACT)].
Also incorporated into these concepts is the use of team-based care management (58) to coordinate care activities between appointments, such as phone calls, e-mail reminders, and monitoring measures. With physician oversight, the implementation of nonphysician care managers has shown to significantly improve control of depression and other medical diseases, as well as patient satisfaction (59), which has been shown to predict enhanced self-care and more favorable outcomes (60).
Although hiring a care manager is a financial challenge for solo-practice psychiatrists, partnering with other practices could facilitate a quality infrastructure with shared personnel and resources. As an alternative, solo practitioners could contract with an outside Web- or phone-based care management service. For instance, the Veterans Affairs system uses remote behavioral health telephone care coordinators to regularly check in with depressed patients and relay information back to practitioners (61). The use of care managers along with electronic medical records (EMRs) or even simply a spreadsheet is particularly helpful for organizing and maintaining a patient registry, a system that allows tracking of patient outcomes with similar diseases, such as depression (62).
It is also critical that psychiatrists take a leadership role in applying systematic quality improvement methods at the point of care. Approaches such as Plan–Do–Study–Act (PDSA), Lean Manufacturing, Six Sigma, and the Toyota Production System (63) adapted from fields such as systems engineering, aerospace, and manufacturing, are being applied across medicine to change care processes and improve care. For example, PDSA (or Deming) cycles (64, 65) are based on the scientific method (hypothesis–experiment–evaluation) and involve a systematic Plan (a proposition for improvement), Do (actions taken toward the improvement), Study (use of measurement to determine the effects of the intervention), and Act (applying knowledge to further improve). PDSA cycles are an iterative process that allows clinician and practices an opportunity to improve the quality of care and become intimately familiar with the process of quality improvement through practice (66). There are a number of policy/systems level changes on the horizon that will encourage and support physicians in implementing improvement methods in their own practices.
Improving the quality of mental health care is going to require initiation of a robust set of complementary policies aimed at multiple system levels (Figure 3).
(Reproduced with permission from Pincus HA: Crossing the quality chasm. Schizophr Bull 2010; 36:109–111. Copyright © The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.)
Achieve consensus and greater specificity on standard elements, methods, assessment tools, and treatment guidelines and provide applications to implement them in clinical practice using health information technology (HIT).
There is no agreement on a standard set of mental health "vital signs" or of which clinical measures to use in routine practice. Imagine seeing an internist who did not check blood pressure regularly for hypertensive care. Because this is considered a standard care expectation, something would seem amiss. Yet, what constitutes an expected mental health examination? Practice components, such as specific measures for clinical assessment, clinical decision algorithms and evidence-based interventions have not been specified and standardized in psychiatry.
Evidence-based guidelines in mental health, as developed by professional associations or other groups, will need to include measurement as an expectation with explicit guidance on which assessment tools or treatments to use for whom and when. Psychiatric treatment guidelines (67), in part because of the current limited evidence base, are not specific and recommend that clinicians monitor treatment responses without sufficient detail about what this involves. Defining terms such as "moderate improvement" or "relapse" more specifically on a standard scale, such as a 35%–50% symptom reduction or 20% change in baseline, would reduce variability. Conservative initial parameters could be adjusted over time to reflect the growing evidence base, as is done with other chronic conditions such as hypertension, (68) and could help determine minimal remission and recovery standards for mental disorders.
Mental health guidelines will also need to be more explicit about what constitutes adequate treatment with standardized protocols and preidentified decision points. For instance, in depression care, how long and at what dose is an adequate trial of an antidepressant before augmenting or switching? Structured guideline implementation, with clear algorithms and fidelity expectations, have been shown to improve the quality of provider performance and patient outcomes in depression care in both the Texas Medication Algorithm Project (TMAP) (49) and Sequenced Treatment Alternatives to Relieve Depression (STAR*D) studies (48).
As is true in the rest of medicine, once measurement tools and clinical algorithms/guidelines are specified in mental health, they must be readily available to clinicians in a workflow-friendly way as part of EMRs, a building block of standardization. Clinical decision support systems (CDSS) built into EMRs can disseminate up-to-date clinical information required to deliver high-quality care at the point of contact. When created with user input, CDSS can facilitate incorporation of evidence-based guidelines into clinical practice. In the information age with thousands of medical journals available, keeping up on the literature on one's own is daunting. CDSS, if done correctly, can help, along with other technological aides. Computerized physician order entry (CPOE) and e-prescribing assist in minimizing errors and make it easier for clinicians to "do the right thing" (69).
Another important potential advantage of applying HIT is the capacity to have all the necessary information about a patient's past history available at the point of care when critical decisions are made. For example, readily available information (e.g., on a secure Web site or credit card-like chip) could prevent repeat brain imaging and radiation exposure for patients presenting with psychosis in emergency department settings. In addition, easily accessible information about medication doses and laboratory findings could facilitate handoffs and minimize disruptions in care with transition between mental health providers or inpatient to outpatient psychiatry settings. At the same time, although medical information should be available when and where it is needed, it is essential that distribution of such information (and especially information related to mental health) be under the patient's control and be fully protected and secure.
The American Recovery and Reinvestment Act of 2009 (ARRA) created a national agenda for HIT across medicine by designating $19 billion toward the adoption of HIT and EMRs into U.S. practice settings by 2014. In addition, physicians using a "certified" EHR, meaning it meets standards of meaningful use toward improving patient care (i.e., not for billing alone), are eligible for substantial incentives as of 2011 (70). A report released in January 2011 showed that 41% of all office-based physicians across specialties and 80% of the nation's hospitals intend to take advantage of federal incentive payments for adoption of certified EMRs (71). Unfortunately, nonphysician mental health providers and mental health and substance use clinical organizations were excluded from receiving the ARRA incentive payments. Mental health will need to be fully integrated into this information infrastructure.
Establish methods to measure the quality of mental health care delivered and provide support and incentives for clinicians and organizations to adopt care improvement strategies.
More specific guidelines not only need to be developed and integrated into tools to apply them at the point of care, but they also need to be translated into a quality measurement and monitoring infrastructure at the levels of consumers, clinics, health systems, health plans, and populations (72). Organizational support and quality improvement incentives reinforce learning to use measures and implementing quality care initiatives.
Building the measurement and monitoring infrastructure
Ultimately, the nation needs a comprehensive quality measurement and monitoring system across all of health care including strategies that are adapted to the needs of mental health care. A blueprint for such a system is provided in the 2010 IOM report on Provision of Mental Health Counseling Services under TRICARE (73), which went somewhat beyond its formal charge to recommend implementation of a quality measurement and monitoring system across all military mental health services. (TRICARE is the Department of Defense's health care benefits program that serves all of the uniformed services and their families, comprising more than 9 million beneficiaries.) The report recommended development and application of quality measures to assess provider performance, monitoring of results, processes, and outcomes of care at all levels, and systematic and focused continued professional education.
The overall recommendation for a comprehensive quality management system clearly extends well beyond TRICARE and is consistent with those suggested previously by the IOM as the components of a national quality measurement and reporting infrastructure. Identified care measures need translation into specific performance measures that are then piloted for their validity, reliability, feasibility, and cost. These performance measures would ideally be composed of data gathered during routine processes of care (e.g., electronic health records and insurance claims) rather than through a separate data collection process (74). The data would then need to be submitted to a repository, allowing for auditing to confirm that the performance measures were calculated accurately as specified. The results would then need to be analyzed and displayed in a format appropriate for intended audiences such as consumers, physicians, health systems, health plans, and quality oversight organizations. Although various disparate organizations in the public and private sector currently perform some of these functions, there are numerous gaps and redundancies that require a much more coordinated national approach.
Designing improvement incentives
Organizations, such as government, health plans, accreditation/regulatory agencies, coalitions of employers, and professional groups, can use a variety of incentives (e.g., financial and public reporting) to further motivate physicians to incorporate evidence-based practice models and standards of care (75). Across health care in general there are numerous initiatives linking the use of structure, process, and outcome measures to incorporate quality into the payment system. For instance, there are numerous "value-based" initiatives incorporated in the ACA that link payment to a bundling of services with adjustment for quality and efficiency that will need to be tailored for mental health care. These include the expansion of existing initiatives for Medicare value-based purchasing, such as physician self-reporting on designated quality measurements as well as nonpayment for iatrogenic hospital complications or services deemed not clinically necessary on chart review. Other value-based initiatives include bundling payments and the use of "accountable care organizations" to pay for a person's care needs over a period of time (76). Importantly, these initiatives apply funding models that have much greater flexibility than fee-for-service, allowing, for example, support of care and quality management activities.
Other financial incentives include pay for performance (P4P) models that have developed throughout medicine using measures in areas such as inpatient/outpatient care, medication management, monitoring, consumer perceptions, and outcomes (77). Mental health lags behind the rest of medicine in P4P with one study in 2008 finding 24 existing programs in behavioral and mental health. Most of the programs identified primarily focus on depression care in a primary care setting (78). A particularly interesting P4P model is being implemented in Minnesota: the DIAMOND (Depression Improvement Across Minnesota Offering a New Direction) Project (79). Participating medical groups are initially rewarded for establishing a structure for applying evidence-based care and in the second phase are rewarded for actually implementing systematic longitudinal clinical measurement. In the third phase, an increasing proportion of rewards is based on improved outcomes for patients. Although P4P models are promising for implementing widespread adoption of quality measures and continuous improvement, as demonstrated by the ambitious and successful National Health Service program in England (80), there are limitations to the models of P4P. Evidence indicates that P4P often rewards those who have higher baseline performance (75) and if removed may cause a decline in quality (81). Therefore, it is important to link these efforts to enduring provider education and support.
Training/support for organizational improvement methods
Individual providers and organizations will need to learn how to implement improvement strategies at the locus of care and throughout the organization. Organizational readiness for change in specialty mental heath settings is influenced by leadership to shift the organizational climate and motivate staff for change (82). Making quality improvement a top organizational priority with dedicated resources is a common element of success in quality improvement (83). Training and financial support for organizational improvement methods help reduce variations in care and increase effective care delivery (84).
Organizations such as the not-for-profit Institute for Health Care Improvement (IHI) have worked to "ensure the broadest possible adoption of best practices and effective innovations" (85) through identifying and testing new models in general health care. There is need for an organization such as the IHI to spearhead organizational change for mental health. One example in behavioral health is the University of Wisconsin-Madison's NIATx network, created in 2003, which aims to improve the "cost and effectiveness of the care delivery system" for people with mental illness and/or addiction and "remove barriers to treatment and recovery" for payers and providers (86).
Updating clinical training/accreditation/certification standards
The current mental heath workforce needs training to gain comfort using the tools of measurement and quality improvement. Unless they are involved in clinical research, practicing doctors and trainees are unlikely to have learned to incorporate measurement into routine care. Quality and measurement training, both cognitive (tested on examinations) and practical (application to practice), demonstrate the ACGME core competencies of professionalism, PBLI, and SBP. Educators across the spectrum from undergraduate, graduate, and continuing medical education need to incorporate training in these areas for future and current doctors. The American Board of Psychiatry and Neurology is actively moving this agenda forward by incorporating quality improvement programs into revised Maintenance of Certification by 2012, including best practice and guideline adherence by chart and patient/peer review and improvement plan implementation (87).
Develop leadership and resources to expand the evidence base to have a direct impact on health care decision making by patients, clinicians, and policymakers (i.e., comparative effectiveness research).
Comparing the benefits and harms of two approaches or interventions directly in actual practice is known as "comparative effectiveness research" (CER) or "patient-centered outcomes research" (88). CER incorporates strategies for designing and promoting research that contributes to both identifying and filling in knowledge gaps at both clinical and health systems levels. It also involves evaluation of quality improvement strategies and policies and rapidly synthesizing updates in knowledge to help clinicians, consumers, and policymakers make informed decisions.
As part of the national ARRA, the IOM was asked to develop a list of initial national priorities for funds dedicated to comparative effectiveness across health care. Topics for mental health and substance use conditions constituted one of the largest "buckets" of the "top 100" national priorities. Among top national priorities were comparing the effectiveness of pharmacological treatment and behavioral interventions in managing major depressive disorders in diverse treatment settings, as well as comparing atypical antipsychotics and conventional pharmacological treatment for different indications. The IOM prioritized comparison of management strategies after a suicide attempt (e.g., inpatient psychiatric hospitalization, extended observation, partial hospitalization, or intensive outpatient care), in addition to different treatment approaches (e.g., integrating mental health care and primary care, improving consumer self-care, and a combination of integration and self-care) in avoiding early mortality and comorbidity among people with serious and persistent mental illness. Furthermore, the report stressed the importance of developing a CER framework capable of continuously incorporating new evidence as diseases and interventions evolve.
The passage of the 2010 health care reform legislation, including the 32 million Americans who are poised to gain access to health care in 2014, is creating a huge push to improve quality and value in general and mental health care. With this paradigm shift comes challenges unique to mental health as well as a great opportunity to provide better care and involve patients more in their own care. Furthermore, the focus on quality and value in health care delivery will expand and further redefine the general competencies of professionalism, problem-based learning and improvement, and systems-based care. The competencies were, in fact, created to ensure a professional's ability to practice "in the rapidly changing health care environment" (89). Their evolving use will enable clinicians to fully participate in quality improvement initiatives on the horizon and shift from a more individualistic patient care approach to a more public health interconnected model (90). In other words, the definition of what it means to be a "good doctor" has changed (91).
Commitment, leadership, and collaboration among mental health consumers as well as clinicians are necessary to improve quality at a clinical level and are equally critical for creating system change. Ongoing participation of such individuals with intimate knowledge of the challenges of care of patients with mental illnesses is essential to assure that these perspectives are incorporated by policymakers and administrators in ongoing system redesign and progressive quality improvement at multiple levels. Of course, approaches applied in general health will need to be tailored to reflect the unique aspects of psychiatric care. Nonetheless, implementation of the aims, rules, and strategies for redesign laid out by the IOM in Crossing the Quality Chasm, could transform the structure, processes, and outcomes of daily practice and improve the lives of individuals with mental disorders.
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To enable you to continue using the digital download service and to allow for continued customer support, certain account information has or will be transferred to AtGames. Your payment information has not been nor will be transferred. AtGames has agreed to maintain the existing GameFly privacy policies with respect to your user information. You may opt out of receiving future communications by clicking here.
UPDATE: The wait is almost over! AtGames is extremely proud to announce that Direct2Drive.com is returning on November 7, 2014. That's right, the original digital download site is back, and in a big way.
As our name changes from GameFly Digital to Direct2Drive, we're taking the opportunity to reimagine how you, the gamers, buy games digitally to create a dramatically improved service that delivers bigger, better exclusive offers and options for the most popular hit games, catalogue games and retro titles you love.
You will get your first taste of the new Direct2Drive.com on November 7 when we launch the all-new site. More exciting new features and experiences will then come online over the following months.
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If you're new to Direct2Drive, we're excited to welcome you to our community at an incredible time. Come check out what gamers have known for years… the incredible service, deep library, and vibrant community of gamers here is second-to-none. So jump into the driver's seat and game on!


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The Resource Center has all the info you'll need From content to user feedback, the resource center has the information you need for every level of the entrepreneurial process.
Healthcare business plans and business models are among the topics for discussion at the Kauffman Life Science Ventures Summit in June. Read more about this opportunity for life science entrepreneurs.
Early-stage life science entrepreneurs are being sought to take part in the Kauffman Life Science Ventures Summit in June. Read more about the industry experts participating and the topics they will address.
Two entrepreneurs will be recognized by the National Postdoctoral Association and the Ewing Marion Kauffman Foundation at the NPA's annual meeting tomorrow in San Francisco. Read more about the accomplishments of this year's 2012 Ewing Marion Kauffman Foundation Outstanding Postdoctoral Entrepreneur and 2012 Ewing Marion Kauffman Foundation Emerging Postdoctoral Entrepreneur.
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High blood
sugar, also called hyperglycemia, occurs when the sugar (glucose) level in the
blood rises above normal. For a person who has
diabetes, high blood sugar may be caused by missed
diabetes medicine or insulin injection, eating too much, skipping physical
activity, or illness or stress. The rapid growth during the teen years can also
make it harder to keep your child's blood sugar levels within a target
Unlike low
blood sugar, high blood sugar usually develops slowly over a period of hours or
days. But it can also develop quickly (in just a few hours) if you eat a large
meal or miss an insulin dose. Blood sugar levels just above the target range may
make a person feel tired and thirsty. If your child's blood sugar level stays
higher than normal, his or her body will adjust to that level. Over time, high
blood sugar damages the eyes, heart, kidneys, blood vessels, and nerves. If
your child's blood sugar continues to rise, his or her kidneys will increase
the amount of urine produced and your child can become
. If your
child becomes severely dehydrated, he or she can go into a coma and possibly
Unless you or your child fails to notice the symptoms, you
usually have time to treat high blood sugar so that it doesn't become an
emergency situation. Three steps can help you prevent high blood sugar
The best ways
to prevent a high blood sugar (hyperglycemia) emergency are to check blood
sugar levels often, be prepared for emergencies, treat high blood sugar
promptly, treat infections right away, and make sure your child gets plenty of
sugar-free liquids.
Untreated infections, such
as urinary tract infections and skin infections, can increase your child's risk
of a high blood sugar emergency.
The best way to
prevent high blood sugar emergencies is to treat high blood sugar as soon as
your child has symptoms or when his or her blood sugar is significantly above
the target range (200 mg/dL or higher).
If your child's blood
sugar levels are above his or her target range, offer extra liquids to replace the
fluids lost through the kidneys. Water and sugar-free drinks are best. Avoid
caffeinated drinks, regular soda pop, fruit juice, and other liquids that
contain a lot of sugar.
Last Revised:
August 15, 2013
Healthwise Staff
Medical Review:
John Pope, MD - Pediatrics
Stephen LaFranchi, MD - Pediatrics, Pediatric Endocrinology
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Herrera dealing post-injury blues
Anthony Herrera is trying to stay positive while waiting for surgery on his knee. The intense guard…
Teddy Bridgewater is trying to get the ball out of his hands and trust himself more, but the rookie has struggled against some of the top defenses in the league.Read More
Mike Zimmer believes both John Sullivan and Vladimir Ducasse should be able to play Sunday after leaving the loss against Buffalo with injuries.Read More
The prosecution's request to remove judge Kelly Case from Adrian Peterson's trial has been denied.Read More
The Thursday night showdown between the Broncos and Chargers at Mile High Stadium (sponsorship withstanding) could see passing yardage a half mile long. Peyton Manning and Philip Rivers are at the top…Read More
Every week, Fantasy Football Expert Rob Warner recommends a handful of players who should ride the pine. It may be because of a bad matchup, lost playing time, a nagging injury or an overwhelming…Read More
Anthony Herrera is trying to stay positive while waiting for surgery on his knee. The intense guard…


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