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Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Countries
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1 Selecting Indicators for the Quality of Diabetes Care at the Health Systems Level in OECD Countries Sheldon Greenfield, Antonio Nicolucci and Soeren Mattke 15 OECD HEALTH TECHNICAL PAPERS
2 Unclassified DELSA/ELSA/WD/HTP(2004)15 DELSA/ELSA/WD/HTP(2004)15 Unclassified Organisation de Coopération et de Développement Economiques Organisation for Economic Co-operation and Development 28-Oct-2004 English - Or. English DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS COMMITTEE OECD HEALTH TECHNICAL PAPERS NO. 15 SELECTING INDICATORS FOR THE QUALITY OF DIABETES CARE AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES SHELDON GREENFIELD, ANTONIO NICOLUCCI AND SOEREN MATTKE English - Or. English JT Document complet disponible sur OLIS dans son format d'origine Complete document available on OLIS in its original format
3 DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS OECD HEALTH TECHNICAL PAPERS This series is designed to make available to a wider readership methodological studies and statistical analysis presenting and interpreting new data sources, and empirical results and developments in methodology on measuring and assessing health care and health expenditure. The papers are generally available only in their original language English or French with a summary in the other. Comment on the series is welcome, and should be sent to the Directorate for Employment, Labour and Social Affairs, 2, rue André-Pascal, PARIS CEDEX 16, France. The opinions expressed and arguments employed here are the responsibility of the author(s) and do not necessarily reflect those of the OECD Applications for permission to reproduce or translate all or part of this material should be made to: Head of Publications Service OECD 2, rue André-Pascal Paris, CEDEX 16 France Copyright OECD 2004 Health Technical Papers are available at: 2
4 ACKNOWLEDGEMENTS The co-authors of this report were Sheldon Greenfield, University of California at Irvine, US, Antonio Niccolucci, Consorzio Mario Negri Sud Center for Biomedical and Pharmacological Research, Italy, and Soeren Mattke, OECD Secretariat. The authors would like to thank Peter Hussey for his contribution to the indicator selection process, Elizabeth Cote and Leighna Kim for providing research support and Victoria Braithwaite and Orla Kilcullen for their help in preparing this manuscript. The comments of the members of OECD Expert Group on the Health Care Indicators Project and the Ad Hoc Group on the OECD Health Project on an earlier version of this manuscript are greatly appreciated. The authors would also like to thank John Martin, Martine Durand, Peter Scherer and Jeremy Hurst for review and comments. This work was supported in part by the Commonwealth Fund of New York. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its director, officers or staff. 3
5 SUMMARY 1. This report presents the recommendations of an international expert group on indicators for diabetes care. Based on a review of existing indicators and an assessment of gaps left open by existing indicators, the experts set out to select indicators to cover clinical processes of diabetes care as well as proximal and distal outcomes of care. The review led to a recommendation of nine indicators as follows: Processes of diabetes care Proximal outcomes Distal outcomes Area Indicator Name Annual HbA1c testing Annual LDL cholesterol testing Annual screening for nephropathy Annual eye exam HbA1c control LDL cholesterol control Lower Extremity Amputation Rates Kidney Disease in Persons with Diabetes Cardiovascular mortality in patients with diabetes 4
6 RESUME 2. Ce rapport présente les recommandations d un groupe d experts internationaux sur les indicateurs relatifs au diabète. Les experts se sont basés sur un examen des indicateurs existants et ont répertorié les carences d informations des indicateurs existants pour sélectionner des indicateurs devant couvrir des processus cliniques pour le diabète ainsi que des résultats de soins proximaux et distaux. L examen a conduit à une recommandation des neuf indicateurs suivants : Domaine Soins du diabète Résultats proximaux Résultats distaux Nom de l indicateur Dosage annuel de l HbA1c Dosage annuel du cholestérol ADL Dépistage annuel pour néphropathie Examen annuel des yeux Contrôle de l HbA1c Contrôle du cholestérol LDL (cholestérol basse densité) Taux d amputations des extrémités inférieures Maladie des reins chez des patients diabétiques Mortalité cardiovasculaire chez les patients diabétiques 5
7 TABLE OF CONTENTS ACKNOWLEDGEMENTS... 3 SUMMARY... 4 RESUME... 5 Background... 7 SELECTION OF QUALITY INDICATORS FOR DIABETES CARE... 8 ESTABLISHED MEASURES... 9 NEW MEASURES PROPOSED FOR USE IN HEALTH SYSTEMS COMPARISONS Lower Extremity Amputation Rates Kidney Disease in Persons with Diabetes Cardiovascular mortality in patients with diabetes REFERENCES Tables Table 1: Summary table of newly-proposed measures Boxes Box 1. The OECD Quality Indicator Project... 7 Box 2. Selection Criteria for Quality Indicators
8 Background 3. This paper presents proposals for indicators of quality of care in the area of diabetes care. This is one of five areas which have been identified by the OECD as having priority for the development of quality indicators (see Box 1) An Expert Group of academic experts from the participating countries was tasked with identifying a shortlist of potential indicators in close collaboration with the Secretariat. Given resource constraints, this work was limited to reviewing existing indicators in Member countries rather than developing new indicators. This Technical Paper summarizes the indicator recommendations of the Expert Group and incorporates comments from Member countries on an earlier report of the Group. The first section portrays a set of nine indicators for which widespread consensus has emerged and recommends to consider six of them for health systems comparisons. The third section discusses three additional indicators that are not yet well established, but could provide valuable insight into the performance of health care systems. Box 1. The OECD Quality Indicator Project The technical quality of medical care, long regarded as a professional responsibility rather than a policy issue, now rivals cost and access as the foremost concern of health policymakers. A growing body of evidence suggests that the daily practice of care does not correspond to the standards that the medical profession itself puts forward. In addition, improving quality of care presents itself as an avenue to restraining the growth of medical expenditures by reducing costly complications and unnecessary procedures. In other words, better organisation and management of medical care would allow countries to spend their health care dollars more wisely. To improve care for their citizens and to realise these potential efficiency gains, policymakers are looking for methods to measure and benchmark the performance of their health care systems as a precondition for evidence-based health policy reforms. As published international health data sets such as OECD Health Data currently lack comparable measures for the technical quality of national health systems, there is, so far, little possibility of such international benchmarking. To fill this gap, the OECD Health Care Quality Indicators Project (HCQI) has brought together 21 countries, 1 the World Health Organization (WHO), the European Commission (EC), the World Bank, and leading research organisations, such as the International Society for Quality in Health Care (ISQua) and the European Society for Quality in Healthcare (ESQH). An expert group representing these countries and organizations has identified five priority areas for initial development of indicators: cardiac care, diabetes mellitus, mental health, patient safety, and prevention/health promotion together with primary care. 1. The participating countries are Austria, Australia, Canada, Denmark, Finland, France, Germany, Iceland, Ireland, Italy, Japan, Mexico, The Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom and the United States. 7
9 SELECTION OF QUALITY INDICATORS FOR DIABETES CARE 4. A great deal of progress has been made in the development, specification, and field-testing of measures for diabetes in the United States. Parallel efforts in the form of large national and international studies have been carried out in Italy by Nicolucci and colleagues (Pellegrini et al., 2003) and by the CODE-2 investigation group across eight European countries (Jonsson, 2002). While the origin of these indicators has been provider-level comparison, they can be aggregated to the regional and national levels and be used for health system comparisons Thus, diabetes care can be characterised as a field in which there is widespread consensus on good practice patterns and international convergence on measures for processes and outcomes of care. This paper will present two categories of measures that could be used for international comparisons. The first category describes and recommends a set of now widely used provider-level measures that can also be used for benchmarking of healthcare systems by aggregating to the national level. It is argued that this set represents a comprehensive set of scientifically sound and relevant measures, which reflect an international consensus standard. The second category discusses new measures, such as incidence of kidney disease and diabetes-related amputations. Because of attribution problems, those measures are currently not used in provider comparison, but they could reveal valuable insight into the differential performance of health systems. Box 2. Selection Criteria for Quality Indicators Following the recommendations for indicator evaluation developed by the US Institutes of Medicine, the Expert Group and all expert panels agreed on the following three selection criteria for indicators (Hurtado, Swift, and Corrigan, 2001). First, it had to capture an important performance aspect. Second, it had to be scientifically sound. And third, it had to be potentially feasible. The importance of an indicator can be further broken down into three dimensions: Impact on health. What is the impact on health associated with this problem? Does the measure address areas in which there is a clear gap between the actual and potential levels of health? Policy importance. Are policymakers and consumers concerned about this area? Susceptibility to being influenced by the health care system. Can the health care system meaningfully address this aspect or problem? Does the health care system have an impact on the indicator independent of confounders like patient risk? Will changes in the indicator give information about the likely success or failure of policy changes? 2. The concepts embedded in those indicators are also increasingly being used for policy purposes, such as the definition of the National Standards in the National Health Service in England and the criteria for Disease Management Programs in Germany. 8
10 The scientific soundness of each indicator can also be broken down into two dimensions: Face validity. Does the measure make sense logically and clinically? The face validity of each indicator in this report is based on the basic clinical rationale for the indicator, and on past usage of the indicator in national or other quality reporting activities. Content validity. Does the measure capture meaningful aspects of the quality of care? The feasibility of an indicator reflects the following two dimensions: Data availability. Are comparable data to construct an indicator available on the international level? Reporting Burden. Does the value of the information contained in an indicator outweigh the cost of data collection and reporting? As the experts were not able to make a definite statement about data availability for an indicator in all OECD countries, feasibility was given less weight in the decision process. The experts were asked to express their opinion as to whether it was likely, possible or unlikely to find comparable data on the international level for each indicator. If data availability was regarded as unlikely, an indicator was dropped. ESTABLISHED MEASURES 6. As mentioned above, much of the work on standardised measures for the quality in this area originated in the US: There, the development of measures began with the Diabetes Quality Improvement Program (Fleming et al., 2001), a physician-driven quality improvement program, which has evolved into National Diabetes Quality Improvement Alliance (the Alliance), a voluntary collaboration that now comprises all of the organisations 3 in the US that are concerned about the care of diabetes patients (NDQIA, accessed 2003). This collaboration has converged on a core list of measures that address the most important aspects of good diabetes care. A comprehensive discussion of the importance and scientific soundness of those indicators can be found in a paper by Fleming et al. (2001), and in materials produced by the Alliance (NDQIA, accessed 2003). The recently revised list of nine consensus measures, which have also gained widespread acceptance internationally, contains six indicators for care processes and three for outcomes of care. 4 Process Measures: Percentage of patients with one or more HbA1c tests annually; Percentage of patients with at least one LDL cholesterol test annually; Percentage of patients with at least one test for microalbuminuria during the measurement year; or who had evidence of medical attention for existing nephropathy; Percentage of patients who received a dilated eye exam or evaluation of retinal photography by an ophthalmologist or optometrist during the current year or during the prior year if the patient is at low risk for retinopathy; 3. These organizations include: Agency for Healthcare Research and Quality; American Academy of Family Physicians; American Association of Clinical Endocrinologists; American College of Physicians; American Diabetes Association; American Medical Association; Centers for Disease Control and Prevention; Centers for Medicare and Medicaid Services; Joint Commission on Accreditation of Health Care Organizations; National Committee for Quality Assurance; National Institute of Diabetes and Digestive and Kidney Diseases; The Endocrine Society; us Department of Veteran Affairs. 4. Recent research also suggests that combining the measures into a single aggregate measure is possible, which would facilitate the communication and interpretation of performance data (Kaplan, 2003). 9
11 Percentage of patients receiving at least one foot exam annually; Percentage of patients whose smoking status was ascertained and documented annually. Outcome Measures: 5 Percentage of patients with most recent HbA1c level >9.0% (poor control); Percentage of patient with most recent LDL<130 mg/dl; Percentage of patients with most recent blood pressure <140/90 mmhg. 7. All measures use the number of clinically diagnosed diabetics as their denominator, i.e. they reflect quality of care contingent upon the patient having been identified as diabetic. 6 For the outcome measures, it is commonly stipulated that the patients who were not tested have failed the standard to avoid creating incentives for undertesting challenging cases. 8. While the importance and scientific soundness of those nine measures goes uncontested and recent studies by Jencks et al. (2003) and McGlynn et al. (2003) indicate that these measures could be used for health system comparisons, there are some challenges to their feasibility for international comparisons. The first four process measures (HbA1c tests, LDL tests, microalbuminuria tests, and eye exams) stand the best chance of being implementable, as they refer to distinct clinical services and the delivery of those services is usually well documented in administrative records, such as billing data. Recent research by Kaplan and colleagues developed an aggregate measure of the processes obtainable from administrative data that has good measurement properties and performs as well as when those measures are obtained from the medical record (Kaplan, 2003). Those four measures can thus be recommended for use without reservations. 9. Reliably measuring the remaining two process measures on the international level may be challenging, however. A foot exam is not a well-defined clinical test and may not be billed as an individual service in many countries, hampering the ability to extract the necessary information from administrative data. Documentation of smoking status is also not done in administrative data. Thus, both measures are likely to require dedicated data collection, such as medical record review, and substantial efforts would be needed to ascertain that data could be collected in a comparable fashion across countries. A more widespread use of Electronic Medical Records, which can be expected in many OECD countries, may improve the situation in the long run. 10. As to the outcome measures, while administrative records document reliably whether a test has been conducted, they do not record the test result. It is therefore not possible to construct the measures for HbA1c and LDL control form such data sources. However, electronic laboratory data, which are becoming more common, and national reporting requirements could provide the necessary information. For example, the CODE-2 European research project collected data on blood glucose and lipid control (Jonsson, 2002). 5. The concept behind these measures is adequate control of the variables. It has been operationalized as percentage of patients meeting a standard. For international comparisons, an alternative conceptualisation as national average rate is conceivable. 6. Obviously, it would be desirable to combine these measures with information about how well a health system identifies the affected population. Such concerns bout underidentification are commonly voiced when health systems, but are particularly salient in conditions with a long preclinical phase such as diabetes. However, assessing the identification would be very demanding, as it would require testing representative samples of the population for the presence of given disease with standard criteria and determining which percentage of the diagnosed had already been correctly identified as having the disease. 10
12 Routine data showing performance levels and change in performance for the US are provided by NCQA, a US organisation for the accreditation of health plans and providers (NCQA, accessed 2003). Thus, there is hope that comparable data would become available for OECD countries. 11. Measuring and reporting blood pressure control in a comparable fashion would be more challenging. The protocols for measuring and reporting of blood pressure would have to be standardized across countries and data collection would require dedicated reporting or Electronic Medical Records, whose implementation lags substantially the implementation of electronic laboratory data systems. In addition, data from the CODE-2 project and the US suggest that blood pressure control may be subject to ceiling effects and therefore not be useful to discriminate sufficiently the performance of health systems. Further research would thus be necessary prior to implementation of this indicator. 12. To summarize, a robust and comprehensive set of indicators for the quality of diabetes care has emerged on the international level that could be used to benchmark health systems. Some operational issues need to be resolved prior to implementation, such as the availability of comparable data for some indicators, and international consensus will have to be found on the periodicity of the process indicators and the threshold levels of the outcome indicators. NEW MEASURES PROPOSED FOR USE IN HEALTH SYSTEMS COMPARISONS 13. It should be emphasised that the recommended set of measures covers mainly proximal concepts, i.e. quality characteristics under the immediate control of providers of medical care For policy purposes, those measures should be combined with indicators that reflect more distal concepts, i.e. the long-term outcomes for those chronically ill patients. While such indicators could never be used to compare individual providers, because they represent the end product of numerous little steps that cannot be attributed to a single provider, they are very useful for overall health system comparisons. 7 Several such measures are currently discussed in the literature for possible use at the health system level, such as rates of lower extremity amputations and the incidence of kidney disease. In addition, a novel outcomes measure, cardiovascular disease mortality in patients of certain ages with diabetes, could be considered. Table 1: Summary table of newly-proposed measures Indicator Name Numerator Denominator Lower Extremity Amputation Rates Patients with major (above or below knee) amputations in a given year. All patients with diagnosed with diabetes. Kidney Disease in Persons with Diabetes Patient with End Stage Renal Disease (ESRD). All patients with diagnosed with diabetes. Cardiovascular mortality in patients with diabetes Number of cardiovascular deaths in a given year All patients with diagnosed with diabetes. 7. A similar reasoning underlies the now commonly reported cancer survival rates. They are the product of the performance of various aspects of the health care system, such as screening, initial diagnosis, initial treatment and aftercare, and thus reflect overall system performance. 11
13 Lower Extremity Amputation Rates Numerator: All patients with major (above or below knee) amputations in a given year. Denominator: All patients diagnosed with diabetes. Importance of the indicator 14. Two of the main complications of longstanding inadequate glycemic control or poor diabetes management are peripheral vascular disease, the chronic deprivation of blood supply of the legs due to arteriolosclerosis, and peripheral neuropathy, damage to the peripheral nervous system. The combination of those two complications put diabetics at great risk for lower extremity lesions: The insensate foot makes it more likely that minor trauma occurs and goes unnoticed, the inadequate blood supply results in impaired healing of the trauma. Thus, osteomyelitis (severe infections of the bone) and gangrene (infection-induced tissue necrosis) may result. Foot ulcers and infections can be prevented by careful self foot care behavior, and proper fitting footwear and early treatment of foot lesions can prevent osteomyelitis and gangrene. Amputations also have a large impact on health, particularly on quality of life, and result in substantial follow-on cost in the form of rehabilitation, prostheses and disability. Scientific soundness of the indicator 15. Although it is widely believed that careful monitoring and intensive treatment of both neuropathic and arterial disease of the extremities can prevent amputations, there are only a few randomised trials to support the conventional wisdom, once it has developed. However, the occurrence of neuropathy and vascular disease is also already suggestive of poor diabetes management. And because of the widely shared belief in the preventability of amputations, and because the data can be collected reliably from administrative data, as is done currently in the US by the CDC (NCQA, accessed 2003), amputations have been proposed as regional, state or national quality measures. 16. This measure is at the moment far from being uncontroversial for several reasons: 1) An amputation is not easily attributable to a provider or a set of providers because the prevention and treatment needed to avert the amputation may have to be performed many years before the amputation itself. This argument would not hold for its use in national comparisons where attributability to given providers is less important, but it does reflect the tension between measures of a nation's population health that are clearly in the public health domain, those that are in the provider quality domain, and those that share both domains. 2) Minor amputations of the toes and feet may be done to prevent major amputations, and could conceivably be the result of improved system and patient surveillance that leads to earlier detection and treatment of foot lesions. Consequently, there are no universally applied criteria for appropriateness. Since major amputations result in large decreases in quality of life (Peters et al., 2001), they may be considered to be a failure of care even, if necessary when performed. Thus, major amputations may be more likely to be linked to antecedent poor quality of care. Rankings of units vary when minor versus major amputations are reported (Tseng et al., in preparation). It should also be noted that major amputations may have low frequencies (5-10 /thousand patients with diabetes or fewer), and statistical comparisons at those levels may not be possible at the provider level, a problem that is resolved with the large sample sizes of health system comparisons. 12
14 3) Inadequate self-examination and care of the feet may play a large role in the development of the pathology leading to a major amputation. So the question arises whether and to what degree a health care system can be held accountable for the behaviour of patients. 4) The measure may be distorted by demographic characteristics. In the U.S, minority populations have had the highest rates of amputations and it is thought that socioeconomic status is a major factor leading to amputations. Thus, differences in level and distribution of wealth may be reflected in the measure together with differences in quality of care. 17. Because of the importance of this complications and plausibility of the concept behind the indicators, this measure has great potential. But it needs to be further studied before adopting it for international comparisons. If implemented, the measure should be confined to major amputations, for the reasons mentioned above. Operational Issues 18. As this indicator is typically derived from hospital discharge information, the ability to construct it reliably for international comparisons depends on the comparability of coding and reporting practices across countries. Amputation rates or the numerator should be ascertainable in a reliable fashion in administrative data, as is done currently in the US by the Centers for Disease Control and Prevention, 8 because such major procedures usually influence hospital payments and are thus reliably reported. But it may be difficult to reliably identify the diabetic population or the denominator, because diabetes may only be recorded as comorbid condition rather than the primary reason for admission and coding of such secondary diagnoses may vary across countries. Kidney Disease in Persons with Diabetes Numerator: Patients with End Stage Renal Disease (ESRD). Denominator: All patients diagnosed with diabetes. Importance of the indicator 19. Diabetes is the single most frequent cause of ESRD in industrialised countries. Its treatment through chronic dialysis and kidney transplantation has tremendous implications for quality of life and functional status of patients as well as for health care spending. Scientific soundness of the indicator 20. Research on the prevention and retardation of kidney disease in patients with diabetes has consistently shown that it is possible to prevent or retard kidney disease through blood sugar control, blood pressure control, and certain specific medications such as ACE inhibitors, and angiotension receptor blockers, alone and in various combinations. Thus, the incidence of kidney disease in patients with diabetes would seem to be a good measure of the quality of care for patients with this condition, lending the measure face validity. Operational Issues 8. NCQA, Available at: Accessed August
15 21. While rates of dialysis initiation and of renal transplantation are readily available in Europe and the US, this information only approximates the true incidence and prevalence of ESRD, because the definition of ESRD and the criteria for dialysis initiation might differ across countries. Ascertainment of the cases could be achieved more precisely by standardized lab tests, such as blood creatinine levels. A creatinine level of 3.0 mg/dl has been a traditional definition of kidney failure, but there has been recent interest in lowering this level in order to initiate treatment at an earlier stage. An even better reflection of the incidence of renal disease could be derived from estimates of the Glomerular Filtration Rate (GFR) (O Sullivan et al., 2002) rather than creatinine by alone. However, consensus would have to be reached on the threshold level, and creatinine and other variables would have to be universally required and recorded to estimate GFR. In addition, diabetes is not the only cause of kidney disease among patients with diabetes, and one would have to account for differential rates for those diseases across countries. Cardiovascular mortality in patients with diabetes Importance of the indicator 22. Macrovascular complications represent the leading cause of morbidity, mortality, and resource consumption in diabetes and their burden is expected to grow in the next years due to the increasing incidence of the disease worldwide. For example, individuals with type 2 diabetes have a two- to fourfold increased risk of cardiovascular disease (CVD) compared with non-diabetic subjects and CVD mortality rates are times higher than in the general population (Haffner, 2000). The increase in the incidence of coronary events is greater for more severe clinical outcomes, such as myocardial infarction and sudden death, than for less serious outcomes, such as angina pectoris (Haffner, 2000). Furthermore, the case fatality rate after a myocardial infarction among subjects with diabetes is higher than that for patients without diabetes; after a first cardiac event, 50% of patients with diabetes die within one year, and half of those who die do so before they reach the hospital (sudden deaths) (Miettinen et al., 1998). 23. Diabetes is responsible for premature CVD deaths; the adjusted relative hazard of CVD mortality is in fact 5 times higher in the age range and years for diabetic individuals as compared to non-diabetic ones (Saydah et al., 2002; Roper et al., 2002). Median life expectancy is estimated to be 8 years lower for diabetic adults aged years (Gu et al., 1998). Recently, a decline in heart disease mortality in the general US population has been documented, mainly attributable to reduction in cardiovascular risk factors and improvement in treatment of heart disease. Nevertheless, such a positive trend was not documented for diabetic patients, thus suggesting that these changes may have been less effective for persons with diabetes, particularly women (Gu et al., 1999). More aggressive interventions targeted at CVD risk factors have thus been advocated to try to reduce this excess premature mortality. Scientific soundness of the indicator 24. Monitoring CVD mortality, particularly among in the age band years, could thus represent an important indicator of the overall care delivered to diabetic patients, to be used for international comparisons. In fact, using intermediate outcome measures only (i.e. blood pressure and cholesterol levels) cannot fully replace the monitoring of the longer-term outcomes they are designed to predict. It is always possible that positive results in the short run fail to be sustained in the long run, even in the presence of scientifically tested indicators that had predicted otherwise (Safran and Vinicor, 1999). Operational Issues 25. While conceptually appealing, the implementation of this indicator would be challenging. Mortality data, as the numerator for the indicator, are readily available in almost all countries, and causes of death are usually reported using internationally standardised coding systems, such as the ICD-9 or ICD- 14
16 10 systems. However, identifying the diabetic population as the denominator for the indicator is difficult. For example, it will depend on national reporting requirements and conventions whether and to what degree underlying diseases that led to the actual cause of death are recorded on death certificates. Alternatively, diabetic patients could be identified from drug prescription databases and mortality data (with specific cause of death) then linked using unique patient identifiers. This method has already been successfully applied (Koskinen et al., 1998), but privacy concerns and operational complexity may stand in the way of widespread adoption. Another data source could be national disease registries, which are now commonly available for cancer diagnoses, that prospectively track all patients or representative samples of patients with chronic diseases. 26. To summarize, all three discussed new outcome measures have great potential to contribute to policymakers and researchers understanding of differences in quality of care between health systems, in particular because they represent the long-term outcomes of diabetes care. They would help to gain insight into whether and to what degree differences in the processes and intermediate outcomes that are captured by the established measures translate into better outcomes for patients. However, these measures are not yet universally accepted so that further research remains necessary before they could be recommended for benchmarking the performance of health care systems. A particular challenge will be to assure that the necessary data can be collected in a reliable and comparable fashion across OECD countries. 15
17 REFERENCES CENTER FOR DISEASE CONTROL AND PREVENTION (2003), Lower extremity amputations episodes among persons with diabetes-new Mexico, 2000 Morbidity and Mortality Weekly Report, January 31, 2003, Vol. 52(04), pp FLEMING, B.B., GREENFIELD, S., ENGELGAU, M.M., et al. (2001), The Diabetes Quality Improvement Project: moving science into health policy to gain an edge on the diabetes epidemic Diabetes Care, Vol. 24(10), pp GU, K., COWIE, C.C., and HARRIS, M.I. (1999), Diabetes and decline in heart disease mortality in us adults JAMA, Vol. 281(14), pp GU, K., COWIE, C.C., and HARRIS, M.I. (1998), Mortality in adults with and without diabetes in a national cohort of the US population, Diabetes Care, Vol. 21(7), pp HAFFNER, S.M. (2000), Coronary heart disease in patients with diabetes N Engl J Med, Vol. 342(14), pp HURTADO, M.P., SWIFT, E.K., and CORRIGAN, J.M (eds.) (2001). Envisioning the National Health Care Quality Report. The US Institute of Medicine. Washington: National Academy Press. JENCKS, S.F., HUFF, E.D., and CUERDON, T. (2003), Change in the quality of care delivered to Medicare beneficiaries, to JAMA, Vol. 289(3), pp JONSSON, B. (2002), Revealing the cost of Type II diabetes in Europe Diabetologia Vol. 45(7), pp.s5-12. KAPLAN, S.H. (2003), Final report. Developing summary scores for assessment of diabetes quality at the individual doctor level Robert Wood Johnson Foundation. KOSKINEN, S.V., REUNANEN, A.R., MARTELIN, T.P., and VALKONEN, T. (1998), Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus Am J Public Health, Vol. 88(5), pp MCGLYNN, E.A., ASCH, S.M., ADAMS, J., et al. (2003), The quality of health care delivered to adults in the United States N Engl J Med, Vol. 348(26), pp MIETTINEN, H., LEHTO, S., SALOMAA, V., et al. (1998), Impact of diabetes on mortality after the first myocardial infarction The FINMONICA Myocardial Infarction Register Study Group. Diabetes Care, Vol. 21(1), pp NATIONAL COMMITTEE FOR QUALITY ASSURANCE (2003). Available at: Accessed August
18 NATIONAL DIABETES QUALITY IMPROVEMENTALLIANCE (2003), Measures and supporting document. Available at: Accessed August O'SULLIVAN, A.J., LAWSON, J.A., CHAN, M., and KELLY, J.J. (2002), Body composition and energy metabolism in chronic renal insufficiency Am J Kidney Dis, Vol. 39(2), pp PELLEGRINI, F., BELFIGLIO, M., DE BERARDIS, G., et al. (2003), Role of organisational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group--quality of care and outcomes in type 2 diabetes Arch Intern Med, Vol. 163(4), pp PETERS, E.J., CHILDS, M.R., WUNDERLICH, R.P. et al. (2001) Functional status of persons with diabetes-related lower-extremity amputations Diabetes Care, Vol. 24(10), pp ROPER, N.A., BILOUS R.W., KELLY, W.F., et al. (2002), Cause-specific mortality in a population with diabetes: South Tees Diabetes Mortality Study Diabetes Care, Vol. 25(1): SAFRAN, M.A. and VINICOR, F. (1999), The war against diabetes. How will we know if we are winning? Diabetes Care, Vol. 22(3), pp SAYDAH, S.H., EBERHARDT, M.S., LORIA C.M., and BRANCATI, F.L. (2002), Age and the burden of death attributable to diabetes in the United States Am J Epidemiol, Vol. 156(8), pp TSENG, C.L., HELMER, D., RAJAN, M., et al. Differential ranking of veterans health administration networks using major, minor and total amputations In Preparation. 17
19 Available OECD Health Technical Papers No. 1. No. 2. No. 3. No. 4. No. 5. No. 6. No. 7. No. 8. No. 9. No. 10. No. 11. No. 12. No. 13. No. 14. No. 15. No. 16. No. 17. No. 18. SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, AUSTRALIA Lindy Ingham, Rebecca Bennetts and Tony Hynes SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, CANADA Gilles Fortin SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, DENMARK Iben Kamp Nielsen SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, GERMANY Natalie Zifonun SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, HUNGARY Maria Manno and Mihalyne Hajdu SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, JAPAN Hiroyuki Sakamaki, Sumie Ikezaki, Manabu Yamazaki and Koki Hayamizu SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, KOREA Hyoung-Sun Jeong SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, MEXICO María-Fernanda Merino-Juárez, Maluin-Gabriela Alarcón-Gómez and Rafael Lozano-Ascencio SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, THE NETHERLANDS Cor van Mosseveld SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, POLAND Dorota Kawiorska SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, SPAIN, Jorge Relaño Toledano and María Luisa García Calatayud SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, SWITZERLAND Raymond Rossel and Yves-Alain Gerber SHA-BASED HEALTH ACCOUNTS IN THIRTEEN OECD COUNTRIES: COUNTRY STUDIES, TURKEY Mehtap Kartal, Huseyin Ozbay and Halil Erkan Eristi SELECTING INDICATORS FOR THE QUALITY OF CARDIAC CARE AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES Laura Lambie, Soeren Mattke and the Members of the OECD Cardiac Care Panel SELECTING INDICATORS FOR THE QUALITY OF DIABETES CARE AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES Sheldon Greenfield, Antonio Nicolucci and Soeren Mattke SELECTING INDICATORS FOR THE QUALITY OF HEALTH PROMOTION, PREVENTION AND PRIMARY CARE AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES Martin Marshall, Sheila Leatherman, Soeren Mattke and the Members of the OECD Health Promotion, Prevention and Primary Care Panel SELECTING INDICATORS FOR THE QUALITY OF MENTAL HEALTH CARE AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES Richard Hermann, Soeren Mattke and the Members of the OECDMental Health Care Panel SELECTING INDICATORS FOR PATIENT SAFETY AT THE HEALTH SYSTEMS LEVEL IN OECD COUNTRIES John Millar, Soeren Mattke and the Members of the OECD Patient Safety Panel 18
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text: The new 2006 3-Series BMW has been redesigned for greater power, performance, luxury and safety. The 215-horsepower 325i and the 255-horsepower 330i are longer, and wider than before, giving them better weight distribution for improved handling. The two available lighter weight 3.0L, 24-valve inline six-cylinder engines, offer more horsepower with better fuel efficiency. The 3-Series is available as a sedan, sedan wagon, coupe or convertible. The addition of two six-speed transmission options -- a manual or optional Steptronic automatic -- allows for smoother acceleration. The Steptronic transmission enables the driver to select a drive, sport or manual driving mode for more involved driving. "It also has a new aluminum suspension," said Chris Egan, sales manager for Basney BMW in South Bend. "The ride and handling are even better than they were before." And models are also available with all-wheel drive. The larger body allows for more rear passenger room and an expanded luggage compartment, complete with a hidden compartment that formerly housed a spare tire. Run-flat tires come standard on all models. This feature allows a tire that has lost pressure to be driven up to 150 miles at reduced speeds. "There's no need for a spare tire, anymore," said Egan. "No calling for roadside assistance." Known for its superior braking system, the 3-Series has gotten even better with the inclusion of a more advanced Dynamic Stability Control system. It also has brake drying for wet brakes and Start-off Assistant to keep the car from rolling backwards on hills. And with traction control and anti-lock brakes, the car is built to stay on the road. The interior of the new 3-Series is more comfortable and equipped with more standard equipment such as auxiliary audio inputs and electronic oil monitors. It also comes standard with six interior airbags as well as a new curtain-type head protection system. Partnered with a more rigid body frame and the optional Active Steering system that navigates for tighter response, the 3-Series BMW is safer than ever. "The safety features are part of what has put this car on the Car and Driver's top ten list for 15 years," said Egan. "No other car has been able to do that. And we recently learned that the BMW 3-Series was voted the 2006 World Car of the Year." That honor is determined by an independent panel of automotive journalists who judge the world market contenders on style, performance, handling, comfort and utility as well as value and safety. "The 3-Series has been our best seller -- our bread and butter," said Egan. "It's a great car." The 3-Series is backed with BMW's 4 years/50,000 mile full maintenance warranty. Located at 52203 Indiana 933 North in South Bend, the Basney BMW showroom is open Mondays and Thursdays from 8:30 a.m. to 8 p.m., Tuesdays, Wednesdays and Fridays from 8:30 a.m. to 6 p.m. and Saturdays from 8:30 a.m. to 4 p.m. Automart F I N E L I N E S Seven decades of Morgan Cars Keeping things the same has actually helped the Morgan company move forward. The pop-up notice at www.morgan-motor.co.uk/ proudly announces that the Morgan 4/4 has been in production for (are you ready for this?) 70 years. "This is the longest continuous run of any production car in the world and is obviously cause for celebration." What kind of celebration? "We will be producing a limited run of anniversary models, with two cars built to celebrate each year of manufacture." For most companies, that wouldn't amount to much. For Morgan, it's a whopping 142 cars that will even be "styled" to represent the decade (20 from each) they represent. So much history, so little space and so much . . . time. That is to say that with a 12-month waiting list for cars, Morgans are built in a time-honored manner: never, ever rushed. The "Works," as the Malvern, England, plant is called, assembles just 500 Morgans a year (11 or so a week) and treats mass production as something not only to be avoided, but, it seems, loathed. However, lurking behind the ancient brick walls of the Works, the pungent aroma -- and irony -- of progress is in the air. Additions have been made to accommodate the Aero 8, the first radially new Morgan since the introduction of a four-wheeled roadster in 1936. It's powered by BMW's 286-horsepower 4.4-liter DOHC V8 that turns this slick-looking 2,200-pound sports car into a rip-snorting rocket ship. Even though it's all new, the Aero 8 could never be a real Morgan without being fitted with the company's signature waterfall grille, a patented shape first used in 1954. It also features a wooden frame, made from ash, just as every car since founder H.F.S. (Henry) Morgan began building them in 1910. Morgan, then 29, with help from his father and other family members, exhibited his first three-wheeled cycle car at the London Motor Show. The engine was positioned forward of the front wheels, directly in front of the radiator, which kept the car stable. A single rear wheel provided the traction. As improbable as it sounds today, these early Morgans were successfully campaigned in a variety of racing events, including hill climbs, cross-country trials and road courses. In subsequent years, Morgans became ever more popular with the British public as well as in other European countries. Not only were they cheap to own and operate (they were actually classed as motorcycles), but their light weight and powerful twin-cylinder engines gave them a distinct advantage in competition. The company continued to manufacture three-wheelers using a variety of motors right up until 1950, 14 years after producing its first vehicle that could actually be classed as a true car. The Morgan 4/4 was so named because of its four-cylinder Coventry Climax powerplant and because the car had four wheels, noteworthy when you're used to making three-wheeled vehicles. Although the car's rudimentary suspension gave it a spine-numbing ride, its low center of gravity and favorable power-to-weight ratio made it fun to drive. Following World War II, Morgan was able to quickly return to making cars (instead of anti-aircraft-gun parts and airplane undercarriages), developing a viable worldwide export market in the process. By this time, the 4/4 was available in both two- and four-seat models and with more power from its borrowed Standard and Vanguard engines. The 4/4 morphed into the four-inch-longer Plus Four in 1950, which became a major export, with close to 60 percent of total production (a mere 3,854 units) shipped to North America. The Plus 8 arrived in 1968, which was powered by the Buick-based (but Rover-built) 3.5-liter V8. While change might be the only thing we can count on, it's keeping things the same that has kept Morgan cars popular to this day, even if you have to wait 12 months for your very own.

subset: commoncrawl


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A May downpour last season wiped out what would have been the first career grand slam for Mitch Moreland.
No rain showers were in sight Wednesday night when he did it again, but this one might also be wiped from many fans' minds because of another fierce storm.
Hurricane Beltre.
Adrian Beltre homered in his first three at-bats, including two in one inning, and Moreland matched his career-high with five RBIs as the Rangers roughed up Tommy Hunter and the Baltimore Orioles en route to a 12-3 victory.
Beltre, who also drove in five runs, grounded out in the sixth and bounced into a double play in the eighth as he vied for a four-homer game. But he gladly settled for the first regular-season three-homer game of his career.
"Any time, any day," said Beltre, who became the ninth third baseman in major league history with 10 20-homer seasons. "It was a lot of fun. Finally, I got a good game offensively. I've been kind of struggling for a couple weeks. Today was a good day. I hit the ball hard in the air."
Moreland's grand slam and the second and third Beltre homers came in a nine-run fourth inning. The only other Rangers player to hit two homers in the same inning is Carl Everett, who pulled off the feat on July 26, 2002 against Oakland.
Josh Hamilton, who became the 16th player in major league history to hit four homers in a game May 8 at Baltimore, was on base for two of the Beltre homers and was pulling for a fourth.
"I told him to do it so we could get a figurine of us," Hamilton said. "It's exciting to be on base to see it first-hand. It's a neat experience."
Beltre, who had a three-homer game last year in Game 4 of the American League Division Series at Tampa Bay, said he wasn't aware that he had hit two homers in the fourth until a teammate reminded him of it.
If he thought it was a long inning, imagine how Hunter felt.
Hunter, a 2007 Rangers draft choice who was traded away last year in the Koji Uehara deal, surrendered eight of the runs in the fourth and nine overall. He faced eight batters in the fourth and failed to record an out.
"That's the way it goes sometimes," Moreland said. "Tommy's a competitor, and he's going to throw you strikes. You've got to go up there and battle."
Moreland remembers the day he lost his grand slam. He hit it off Gio Gonzalez on May 11, 2011, as the Rangers stormed to a 7-0 lead before rain soaked Rangers Ballpark. The sun was out within 20 minutes of the game being called.
His teammates remembered, too.
"That was the first thing everybody said to me when I got in the dugout," Moreland said. "They thought rain was coming."
The Rangers' onslaught, which included three more hits from David Murphy, came on the five-year anniversary of the biggest game by an offense in major league history. The Rangers beat Baltimore 30-3 in 2007 in the first game of a doubleheader at Camden Yards.
"I wouldn't have known that today was the day we put up those 30 runs if I hadn't been reminded," manager Ron Washington said. "It was just another day, and Baltimore was on the schedule."
Derek Holland (8-6) benefited from the tremendous run support, allowing three runs in seven innings as the Rangers maintained a five-game lead over Oakland in the AL West.


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MILLBURN, N.J. - At halftime of Friday night's boys basketball game, Caldwell and Millburn found themselves in an extremely slow moving game, tied at 12. But in the third quarter, Millburn's Brian Barkley and Aiden Favia caught fire and sparked a 17-7 third period run, and held on in the fourth for a 41-32 win, their first victory of the season.
Favia knocked down three of his four three pointers in the third, while Barkley scored all 15 of his points in the second half, leading all scorers.
"We came in at halftime and we were missing a bunch of shots, and coach told us that we had to start hitting our shots, and that we were definitely going to win this game, and that's what we did," Barkley said.
Barkley opened up the third quarter knocking down three consecutive baseline jumpers, helping to build a four point lead, and sparking what turned into a 12-2 run. Favia came alive during that stretch, as did the home Millburn crowd, as he drained three triples in less than four minutes, completely seizing the momentum for the Millers.
"He was vocal on the court, which helped, he was yelling after that shot, and everyone was definitely pumped up," Barkley said. "We took a lead and just never looked back from that point on."
Millburn went into the fourth quarter with a 10-point lead and extended to 13, following a Barkley jump shot, putting them up 34-21. But the Chiefs, who could not find the basket at all it seemed, made a late 9-2 run, closing within six with under three minutes left to play. However, a bank shot in the paint from Josh Landau seemed to halt Caldwell's momentum. Millburn scored five of the game's final seven points to stave off Caldwell.
"I want to give a lot of credit to Caldwell, they played very hard, they're a very physical team, they make you earn everything you get," Millburn head coach Rodger Blind said.
Favia opened up the game's scoring, knocking down an early three pointer in the first quarter. However, it would be Millburn's only field goal of the period, as they went one-for-eight in the period and turned the ball over three times. Luckily for the Millers, Caldwell wasn't shooting the ball very well either. The Chiefs made just 3-of-11 in the opening period, carry an 8-6 lead into the second.
It was more of the same for both teams in the second frame, with them combining to score 10 points in the quarter. They made a combined five-of-17 shots in the second period, which is under 30 percent.
"To only get 12 points in a half, means you're not playing really great offense, or at least shooting the ball," Blind said. "But I thought we did some good adjustments at halftime, and then in the second half, Aiden Favia and Brian Barkley really started shooting the ball. That was the difference."
Landau also played well for the Millers on Friday, chipping in eight points, as the team's third highest scorer. Billy Pierce scored 12 to lead Caldwell, while Jack Kinney chipped in eight. Millburn is 1-2 after claiming its first win of the season, and will face Chatham on Wednesday. Caldwell remained winless at 0-3, and will play in the West Essex Holiday Tournament, beginning Thursday.


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Instagram does not have ownership of any of the members' photos because they're private and should only be viewed by people you know unless they pay you for using your photos on ads, etc. We have the right to receive something out of it. Plus they should not have even done that policy in the first place without us approving that term first.
Instagram does not have the right to claim ownership of their member's photos. The fact is Instagram is just a site that hosts pictures, and should not own their user's pictures. The pictures belong to those who took them, and unless they are compensated in someway or release the rights to them they are still the user's property.
Instagram is free to join, and there is no contract to sign that states that photos on the site will become the property of Instagram. To take someone's photos and use them without permission is wrong, and Instagram should resolve this quickly. Also, if the company wants to use a photo that belongs to a user, some form of compensation should be offered.
Instagram is a free service for those who join. Saying they have the right to claim ownership to members' photos is like saying Facebook and Twitter would have the same. Instagram is not a freelance writing site where its members are contributing something to them and receiving something in return.
If I post something on a public forum, everyone reads it, as this is now. In the case of a photo I took, that Instagram may profit from in some way, I believe they should offer that member a small compensation for that photo, much like micro tasking sites offer for small jobs done.


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April 19th, 2018Start the clock! In a little over three months, it's time for my favorite party in the pines, the 23rd annua more...
April 5th, 2016 | Sarah Mason, HarvestMoon
Toronzo Cannon was born not all that long ago (1968), but he's already earned his place in the Chicago Blues scene. He has battled his way to the top of the ultra-competitive Windy City blues scene, played multiple tours of Europe, and delivered roof-raising performances around the country. He received his unofficial launch from local hero to national star in 2015 at the world-renowned Chicago Blues Festival, and today, is revered as one of Chicago's most popular and innovative bluesmen.
And Cannon has worked hard for it. He soaked up plenty of blues growing up in Chicago's tough South Side. But it wasn't until he bought his first guitar at age 22 that he quickly found his true calling. He became absorbed in the sounds, styles and licks of Buddy Guy, Albert Collins, Hound Dog Taylor, B.B. King, Albert King, Freddie King, Al Green, Jimi Hendrix, J.B. Hutto, Lil' Ed and many others. But Cannon's raw, singing guitar is his own. Even his album debut with Alligator Records, The Chicago Way, features Cannon's originals and his blistering guitar and soul-baring vocals. Chicago-born blues guitarist/vocalist/songwriter Toronzo Cannon is the real deal, and a passionate bluesman to boot.
And the kicker to all of this? Cannon drives a Chicago Transit Authority bus during the day and performs at night, on weekends and during vacation breaks. He arranges his schedule to gig out of town as much as possible.
Man, are we lucky he's making the trek west. We can't wait to hear this electrifying bluesman and his true Chicago Blues on California's Bluesapalooza stage.
Be the first to hear what's happening with the Mammoth Festival of Beers & Bluesaplooza
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Most cruises to South America are on traditional, ocean-going cruise ships, but expedition-style cruises of the Galapagos Islands are also offered. Traditional cruises of South America are available from September through May and vary greatly in length. Ports of call vary depending on your itinerary, but your cruise may include stops in picturesque ports in countries like Argentina, Brazil, Chile and Peru. Galapagos cruises are ten to 13 nights in length and are offered year-round.
Some cruise lines offer cruise tours, a combination of a South America cruise and a land tour that might include Rio de Janeiro, Machu Picchu or Iguazu Falls.
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The Feetures Men's No Show Tab Elite Light Cushion Socks are the perfect socks that will be the difference for all your running experiences. The iWick fibers wick moisture to keep your feet cool and dry. The Sock-Lock technology provides targeted compression where you need it the most. The Light Cushion is great for those who prefer cushioned comfort with a lot of bulk.
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Halle Berry is ready to take flight once again!
Director Bryan Singer has revealed the first look of the Oscar winner reprising her mutant Storm/Ororo Munroe role in the upcoming "X-Men: Days of Future Past."
"Storm watch," he Tweeted on Monday, posting a photo of the actress in her caped black leather "X-Men" costume.
PHOTOS: Sexy Superheroes
The director also gave fans a glimpse of Shawn Ashmore (who plays Bobby Drake/Iceman) in costume last week.
Last month, Halle talked to Access Hollywood about playing the weather-controlling mutant once again.
"I am [excited], yeah," she said, when asked if she's looking forward to donning her superhero duds again. "I love Storm. That's one of my favorite characters that I've played. And people love that character as well."
Halle will appear with a long roster of stars returning to the "X-Men" franchise for "Days of Future Past" (due to hit theaters on July 18, 2014), including Hugh Jackman, Anna Paquin, Ellen Page, Patrick Stewart, Sir Ian McKellen, James McAvoy, Jennifer Lawrence and more.
Copyright © 2018 by NBC Universal, Inc. All Rights Reserved.
This material may not be republished, broadcast, rewritten or redistributed.


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Corb7 Blog
Offshore Banking Defined
Posted On November 15, 2010Offshore Private Banks Broadly defined, Private International Banks (PIB's), Offshore Banks or Captive Banks are simply banking entities established outside of the United States or the country in which the owner resides. These entities are only responsible for meeting the standards established by the jurisdiction which licensed and regulates the bank. They are not subject […]... Read more
Is the United States Anti-business???
Posted On October 13, 2010There are rumblings and they are getting louder. The United States is quickly becoming known internationally as an anti-business State. A recent article which ran in Forbes entitled "Obama's Problem with Business" tagged "Barack Obama as the most anti-business president in a generation, perhaps in American history." Let's keep in mind that this is not […]... Read more
Privacy; a Necessity not a Luxury
Posted On September 11, 2010The year was 1917 and the location was Latvia. A poor and mostly agrarian country in Northern Europe's Baltic region bordered to the north by Estonia and to the south by Lithuania. My grandparents were children at the time. As the saying goes, "timing is everything," and theirs could not have been much worse. The […]... Read more
Despite the Weak Dollar, Foreign Buyers aren't Rushing In
Posted On August 12, 2008An interesting article from the Wall Street Journal 8/12/08: American sellers are desperate to sell their homes to foreigners, who these days are more likely to have ready cash than their countrymen. And with falling home prices and a weak dollar, a place in the United States is more affordable for a wider variety of […]... Read more


text: Thimphu is the capital and largest city of Bhutan. The city became the capital of Bhutan in 1961. Thimphu, as the political and economic center of Bhutan, has a dominant agricultural and livestock base, which contributes to 45% of the country's GNP. Tourism, though a contributor to the economy, is strictly regulated, maintaining a balance between the traditional and development and modernization. Thimphu contains most of the important political buildings in Bhutan, including the National Assembly of the newly formed parliamentary democracy and Dechencholing Palace, the official residence of the King, located to the north of the city.Read More


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The developer Zootfly recently announced on their web site that it has acquired the Mr. T Graphic Novel license from Mohawk Media and will be developing a series of games featuring everyone's favorite member of the A team. From what we've gathered on the company's home page the game will fall into the action-adventure genre with a sprinkling of platforming, puzzles, and punching people in the face.
In the first installment of this series of games Mr. T will take on a mechanized Nazi army in a variety of locals including South American rain forests. If that plot seems a bit outlandish, boy are you in for a surprise. Along with other characters from the graphic novel, Mr. T is joined by game designer Will Wright, who in this alternate universe is a geneticist being forced to work on an evil plot. According to the announcement, Mr. Wright eventually joins up with Mr. T to take on the Nazi war machine.
This news and more in the Daily Fix.
- Capcom '09 Line-Up
So far the game has been announced for PS3, 360, Wii, and PC. We'll let you know the instant we get more information on this game. If you're interested in the source material for this game you can head on over to Mohawk Media and download the entire first chapter of the graphic novel for free. Enjoy!


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What makes a great art journal blog? Clear photos, progression through the design and most of all, an inspiring attitude. It doesn't matter if you produce perfect art or if you only use two pencils and some string. It's about the passion.
Without further ado, in no particular order...
Artisty Crafty by Marta Lapkowska
Marta combines beautiful materials with a clear understanding for composition in all her projects; I absolutely love her use of 3D elements in her pieces. As her art journals are made from old hardback books, her work has an extra dimension that is often missing from plain page journals. I now really want to use a book as a journal but would feel a bit silly running four at once! I love how bold she is with colour use as well.
Notes on Paper by Julie Kirk
Whilst Julie from Notes on Paper is strictly an art journalist, but rather a paper crafter for all occasions, her tutorial on how to compose an art journal page from the very start is one of the first ones that I saw that got me working on my own journal. In contrast to Marta and the others in this list, she use a lined notebook as part of a 'Learn Something New Everyday' Journal - which gives a fantastic effect of relieving the pressure of a plain page in a sketchbook. And the tips she provides are really great for the novice journaller; it can be really easy to get bogged down feeling that you need to have lots of different expenive materials to create something special.
Pink Suede Shoe
I think the most inspiring thing I find about Pinksuedeshoe.com is that her style is so simple, and yet so beautiful and effective. Her journal pages are uncomplicated and just a true reflection of her thoughts and desires at that moment - isn't that really what we all aim for in a journal? Plus her sewing items are absolutely gorgeous too.
Words of Me Project
Words of Me never fails to produce a beautiful page, which always has a deep meaning and highly creative depth to it. She manages to combine colours and elements in a manor of which I can just dream - it's stunning. Her tag line for her blog is 'I hope I've inspired you to tell your story'; which she truly has for me. Reading through her blog gives me a lot of things to think about that are not limited to the wonderful art journalling pages she posts. We could all use a little bit of her positivity I think!
Anna manages to do what I so wish I could - she creates not only a useful diary page, but also one that is absolutely beautifully busy and creative. Her diaries are the ones that I could see being passed down from mother to child to grandchild and each generation getting as much joy and energy out of as the last. Her art journal pages and scrapbook pages are no exception either.
So go ahead and check them all out! Who's your favourite art journal blogger? What inspires you to create? And do you have a blog yourself? I'm always looking for more to follow :) I'll do a post with my favourite pages soon for you all to see inside my journal!


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Oh sweet, sweet cafe au lait dahlia. I know we all go gaga over peonies and garden roses but give me a big, beautiful, peachy dahlia any day of the week and I am a happy, happy girl. That's why this San Luis Obispo wedding has quickly made it's way into my list of favorites. Besides the beautiful arrangements by April Flowers, it boasts beautiful photographs by the extraordinary Jen Rodriguez Photography and perfectly planned details by Events Redefined. Make sure you spend some time in the full gallery to see them all!
Click here to see the entire gallery of images!
From Jen Rodriguez Photography...Jen and Joey with the help of the talented ladies of Events Redefined created a gorgeous event at a charming fruit ranch tucked in the hills just outside of San Luis Obispo. The Ranch is gorgeous on its own but with the added beauty of the flowers designed by April Flowers it was magical. The overall design seemed to have a collected feel with old books, containers, a mix of florals and soft and sweet neutral tones.
Jen and Joey opted to do a first look to allow more time with family and friends during cocktail hour. We did the first look at the bottom of the steps leading down to the ceremony site. It was the perfect location to see each other for the first time. They had a beautiful ceremony and Jen was walked down the aisle by her uncle while she held onto her bouquet that was wrapped in her dad's handkerchief to keep him close to her. After the ceremony they partied into the evening and said an early goodbye to guests. After the wedding we were able to venture to the nearby Avila Beach for some amazing sunset shots at both the cliffs overlooking the beach and down on the beach itself.
Wedding Photography: Jen Rodriguez Photography / Venue: See Canyon Fruit Ranch / Wedding Planning + Coordination: Niki + Jonnell of Events Redefined / Floral Design: April Flowers / Wedding Cake: The Cakery / Caterer: Phoenix Fine Catering / DJ: AMS Entertainment / Make-up + Hair: Asha of The Queens Bees / Bride's Dress: J.Crew / Bridesmaid Dresses: J.Crew / Grooms + Groomsmen Suits: JoS. A Bank / Flower Girl Dresses: Nordstrom