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Answering Clinical Questions Improves Patient Safety and Saves Money
- Pearl Cobb
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1 Answering Clinical Questions Improves Patient Safety and Saves Money The Hospital Clinical Knowledge Systems and Health Outcomes Study Peter A.L. Bonis, M.D. Executive summary: Improved care results in cost savings Several tools are currently being deployed in provider environments to improve quality and efficiency of care. Chief among these are electronic medical records (EMR), computerized physician order entry (CPOE), E-prescribing, and medication bar-coding systems. UpToDate Hospitals with access to UpToDate performed significantly better on patient safety, complications, and length of stay resulting in a strong return on investment. However, it is imperative that quality improvement initiatives also include a clinical knowledge system. Physicians generate one question for every two or three patient encounters and two-thirds of those questions go unanswered. If physicians had access to the appropriate clinical information system, and could answer clinical questions as they arise, some 40 percent of management decisions would be changed, improving patient care. Regularly updated electronic clinical knowledge systems have decreased barriers to answering these questions. However, there has previously been little evidence as to whether they have an impact on health outcomes. The Hospital Clinical Knowledge Systems and Health Outcomes Study was designed to evaluate whether a leading clinical knowledge system (UpToDate ) was associated with improvement in patient safety and efficiency in hospitalized patients, and to estimate the financial impact associated with its implementation. The study demonstrated a strong association between hospital quality and efficiency and use of UpToDate. Hospitals with access to UpToDate (n=424) performed significantly better on risk adjusted measures of patient safety (p=0.0163) and complications (p=0.0012) and had significantly shorter length of stay (by an average days per discharge, 95% confidence interval to days, p<0.0001) compared with hospitals without access. These associations persisted after adjusting for hospital characteristics known to be associated with the outcomes including geographic location, teaching status, and discharge volume. 1.
2 The study also confirmed a strong correlation between how much UpToDate was used at each hospital reflecting a dose-response effect. For example, a doubling of usage from 26,000 to 52,000 topic reviews annually in a hospital with 20,000 annual admissions could save an additional 520 hospital days each year. Metrics used in the 100 Top Hospitals differentiate hospitals on a variety of performance dimensions such as quality and efficiency. They have been used in many previous studies evaluating healthcare quality UpToDate provided Solucient with a list of hospitals that had online access to UpToDate from 2000 through 2005 as well as usage data detailing how much UpToDate was used at each hospital. Solucient compared outcomes in Medicare recipients who were treated at hospitals with online access to UpToDate to those in acute care hospitals included in the Solucient 100 Top Hospitals database. For more specific information on the chart above, see page 3. Research study supports the value of UpToDate Background Clinical knowledge systems help providers answer clinical questions. A large body of evidence has demonstrated that most clinical questions are not pursued even though the answers to the questions would have a favorable impact on management decisions Physicians generate about one question for every two to three patient encounters and two-thirds of those questions go unanswered. If answered, approximately 40 percent of management decisions would be changed. 11 The ability to answer clinical questions quickly has the potential to improve patient safety and hospital efficiency. The outcomes evaluated were riskadjusted for mortality, complications, the Agency of Healthcare Research and Quality Patient Safety Indicators, and hospital length of stay. These outcomes were chosen because they reflected the types of benefits that might be expected from a knowledge system that has been designed to answer clinical questions. Details on the study methods and statistical analyses are provided in Appendix 2. The Hospital Clinical Knowledge Systems and Health Outcomes Study was designed to assess whether the use of a leading clinical knowledge system, UpToDate, (see Appendix 1) was associated with quality of patient care and the economic implications of decreased length of stay and complications, and increased patient safety. 26 Methods Solucient (now a subsidiary of Thomson Healthcare) is a well recognized leader in measuring hospital performance. Each year it reports on the top performing hospitals in the United States (the Solucient Top 100 report, now the Thomson Top 100 report) based upon analysis of a database that contains information regarding inpatient Medicare admissions from 3,091 short-term general, non-federal hospitals in the United States (i.e. approximately 75 percent of the 4,200 acute, non-federal hospitals in the United States). 2.
3 Results Hospitals with access to UpToDate (n=424) performed significantly better than other hospitals in the Solucient database (n=3,091) on risk-adjusted measures of patient safety (p=0.0163) and complications (p=0.0012), and had significantly shorter length of stay (by an average days per discharge, 95% confidence interval to days, p<0.0001). These associations persisted after adjusting for hospital characteristics known to be associated with the primary outcomes including geographic location, teaching status, and discharge volume. The study demonstrated a strong linear association between hospital efficiency and safety, suggesting that UpToDate represents an important component of hospital quality. UpToDate allows providers to answer questions quickly, leading to changes in decision-making that can improve management and efficiency. 11,17,36 In addition, UpToDate is an important factor in medical knowledge acquisition among medical residents. 37 These effects, along with time savings and early adoption of efficient diagnostic and management strategies, may explain the observed benefits on patient safety measures and length of stay. Financial implications of improved efficiency and patient safety In addition, all of these associations correlated significantly with how much UpToDate was used (reflected in hits per week [HPW], the average number of topic reviews viewed each week) supporting a dose-response relationship. The graphs depict the relationship between hospital discharge volume, the amount that UpToDate was used, and the observed benefits on complications and length of stay. The cut points on HPW reflect the quartiles of the data. The improved efficiency and patient safety benefits associated with use of UpToDate would be expected to have substantial economic benefits which were estimated by an analysis performed by UpToDate. The frequency and costs associated with adverse events are somewhat more difficult to estimate. The Solucient data, which are based on medical claims, likely underestimate the frequency of adverse events since claims-based data are known to be insensitive to adverse events. 38 The cost of an adverse event was estimated to be $30,936 based on a study of preventable medical injuries in 28 hospitals in the United States adjusted to 2006 dollars. 39 Notably, substantial additional financial benefits would be expected for payers and from a reduction in costs to society, factors that were not included in the models. 3.
4 The financial impact of UpToDate is directly associated with the amount that UpToDate is used at each hospital. Use grows spontaneously year after year (both in the number of users and the amount of use for each user) at hospitals that subscribe. Thus, the economic benefits described above would grow proportionally to the rate of adoption and the amount that UpToDate is used. Efforts to stimulate use of UpToDate could further increase the benefits. As the data suggest, these systems can improve care and hospital efficiency producing a large return on investment comparable to if not exceeding the expected return on investment for implementation of CPOE systems. Thus, they should be considered complementary and an essential component of efforts to improve hospital efficiency and safety. Relationship between use of UpToDate, complications avoided and hospital days saved each year for a hospital with 20,000 annual discharges. The graph on the left shows that the number of complications that can be prevented increases with greater use of UpToDate. The complications evaluated considered the underlying severity of illness. They included conditions that should not occur and thus represent substandard care, and complications that occurred with a frequency more than expected. The complication methodology has been used in many studies evaluating patient safety. The graph on the right shows that the expected number of hospital days that can be saved increases with greater use of UpToDate. The estimates were based upon the regression model and considered case mix and hospital characteristics known to be associated with hospital length of stay. (See Appendix 2). Whether the observed associations with hospital quality and efficiency are applicable to all electronic knowledge resources is unclear. It is likely that the benefits from an electronic clinical knowledge resource would be related to the degree to which it is adopted and used. Spontaneous usage levels for UpToDate increase year after year as a result of increased use among providers and an increasing number of users. The return on investment compares favorably with other technological innovations aimed at improving the quality, safety, and efficiency of care. Relatively few studies have directly evaluated the return on investment for information technology initiatives. 40,41 A landmark study involving six Massachusetts community hospitals estimated that implementation of a CPOE system could save each hospital $2.7 million annually. 42 The one-time average total cost of a CPOE system was estimated to be $2.1 million with an annual incremental operating cost of $435,000. Most of the savings were anticipated to result from avoidance of preventable adverse drug events, which were estimated to occur in 10 percent of hospitalized patients. The economic case for CPOE systems is strong based upon these data but the magnitude of expected benefits is less than those associated with the implementation of clinical knowledge systems. The chart depicts the median topics viewed each week at 114 hospitals with 18,000 to 25,000 admissions each year. Usage shown is for the year and is stratified according to how many continuous years each hospital had subscribed. Use increased significantly (p<.0001). Clinical knowledge systems can also be implemented far more easily than decision support tools embedded within CPOE or EMR systems. The challenges involved in successful implementation of EMR and CPOE systems with acceptable decision support are well-recognized. 43,44 By contrast, implementation of clinical knowledge systems can be accomplished easily and with enthusiastic acceptance by providers. 4.
5 The acceptance of UpToDate among providers has translated into widespread adoption. Over 88% of academic medical centers in the United States subscribe to UpToDate and nearly 320,000 healthcare providers use it worldwide. About 98 percent of hospitals that subscribe to UpToDate continue to renew their subscription year after year. UpToDate users at these hospitals depend on it for their practices. Hospitals that subscribe to UpToDate frequently report that providing access is important for recruiting and retaining their physicians. Studies of users in community hospitals have demonstrated that use is not confined to doctors. UpToDate is also used extensively by nurses, nurse practitioners, physician assistants, and pharmacists. This permits UpToDate to become the standard of care, thereby helping to ensure consistent care that is well-integrated across all caregivers. This degree of use means that UpToDate impacts more than 90 million patient visits a year in more than 140 countries. Use has an impact on learning The widespread adoption and use of UpToDate has had an impact on learning among providers and trainees. A study performed by the Mayo Clinic, for example, examined the impact of learning habits (use of UpToDate and conference attendance) on medical knowledge acquisition as measured by the Internal Medicine In-training Examination (IM-ITE). 37 The IM-ITE assesses medical knowledge acquisition during residency; scores correlate with subsequent performance on the American Board of Internal Medicine Certification Examination. Use of UpToDate was an independent predictor of performance. Remarkably, use for 20 minutes a day was associated with a comparable increase in IM-ITE scores as an entire year of residency. The most frequently used methods to retrieve clinical information were Medline (73%) and UpToDate (70%) in a study of residents from the University of Colorado Health Sciences Center. From Schilling, L. Acad Med 2005; 80:51. Methods to increase use Increased benefits from clinical knowledge support systems can be realized by increasing their usage. For example, a doubling of UpToDate usage from 500 to 1000 topic reviews per week in a hospital with 20,000 annual discharges could result in more than 520 hospital days saved each year (and more than $800,000 in annual savings). Increasing use can be accomplished by: Increasing awareness and training Reducing the click distance to the resource by integrating it into the EMR system Rewarding providers for use by granting continuing medical education credits Conclusions and recommendations Many factors are involved in hospital quality and efficiency. The value of clinical knowledge systems such as UpToDate as part of efforts to improve care has not been fully recognized. The Hospital Clinical Knowledge Systems and Health Outcomes Study demonstrated that use of an electronic clinical knowledge system was associated with hospital quality and efficiency. Such systems can improve care and efficiency and are well-accepted by providers. The benefits on patient safety and efficiency also translate into a large return on investment, and require minimal resources to be implemented. That return on investment can be continually improved by efforts to increase usage. The march toward broad implementation of electronic medical record, CPOE, E-prescribing, and medication bar-coding systems is continuing. The costs and complexity involved in implementing such systems have overshadowed the comparatively easily acquired benefits of implementing clinical knowledge support systems. Such systems can be implemented rapidly leading to almost immediate improvements in patient care. In addition, these systems are important for education of trainees and continuing medical education of providers. 5.
6 Appendix 1: Description of UpToDate UpToDate is an evidence-based, peer reviewed information resource available via the Web, desktop, and PDA. UpToDate is designed to answer clinical questions quickly and provide synthesized recommendations for treatment. Over 90 million patient-related problems are researched each year with UpToDate. The UpToDate community includes our faculty of more than 3,800 leading physicians, peer reviewers, and editors and nearly 320,000 users. Our faculty writes topic reviews that include a synthesis of the literature, the latest evidence, and specific recommendations for patient care. Our users provide feedback to the editorial group. This community s combined efforts result in the most trusted, unbiased medical information available. UpToDate is available through institutional or individual subscriptions. Providers at hospitals that subscribe to UpToDate can access it through an Internet connection at any terminal within the facility. UpToDate content UpToDate includes more than 7,400 clinical topics, each an average of 10 pages of text, figures, references, and abstracts, as well as drug and drug interactions programs, guidelines, patient handouts, and clinical calculators. Access to the content of UpToDate is through a search screen with a search box. UpToDate uses a proprietary search engine. The search engine is not static but undergoing continual adjustments to provide the best search results given the content offering. The search engine can handle multiple concepts from a natural language question like: Treatment of hypertension in a pregnancy. The search concepts here are: treatment, hypertension, and pregnancy. During the search, the entire database gets reorganized in order of relevancy. Authors All topics in UpToDate are written by the listed authors in conjunction with a deputy editor. Authors are identified as experts by the Editors-in-Chief, our editorial staff, and participating societies. Exceptions are guidelines from major societies, which are added to UpToDate in their original form. All material is originally prepared by the contributing author(s) whose name(s) and affiliation(s) appear in the upper left corner of each topic. This material is reviewed extensively by our physician editors and peer reviewers for accuracy and completeness of the literature search, and for consistency with all aspects of the editorial policy. Physician editors suggest changes to ensure that the topics summarize the relevant evidence, and that the recommendations are consistent with the evidence, with our understanding of patients values and preferences, and with UpToDate s editorial policy. Some of the content may be taken from other topics in UpToDate. In such cases, the text is hyperlinked to the topic from which it originated. Evidence UpToDate follows a hierarchy of evidence consistent with most evidence-based resources. At the top of the hierarchy are randomized trials of high methodological quality, followed by randomized trials with methodological limitations, observational studies, and unsystematic clinical observations. Inferences are stronger when the evidence is summarized in systematic reviews of the literature that present all relevant data. Each topic has an author who is an expert in the area discussed, and at least two separate physician reviewers. This group works together to perform a comprehensive review of the literature and carefully select studies for presentation based upon the quality of the study, the hierarchy of evidence discussed above, and clinical relevance. 6.
7 When current, high-quality systematic reviews are available, UpToDate topics and recommendations rely heavily on these reviews. When such reviews are unavailable, UpToDate summarizes the key studies bearing on the clinical issues at hand. Systematic reviews and the design of primary studies (randomized trial, observational studies) are often identified explicitly in the text with the relevant data. However, in cases where either the type of study or the data are not stated explicitly, users can click on the reference and bring up the Medline abstract to obtain this information. Evidence is derived from a number of resources, including but not limited to: Hand-searching of over 400 peer reviewed journals Electronic searching of databases including MEDLINE, The Cochrane Database, Clinical Evidence, and ACP Journal Club Guidelines that adhere to principles of evidence evaluation described above Published information regarding clinical trials such as reports from the Food and Drug Administration, as well as other sources of information produced by federal agencies such as the Centers for Disease Control and Prevention and the National Institutes of Health Proceedings of major national meetings The clinical experience and observations of our authors, editors, and peer reviewers Recommendations UpToDate strives to provide a Summary and Recommendations section (see figure below) where appropriate. Structured questions UpToDate s process of arriving at recommendations involves constructing a structured clinical question. That structure includes carefully defining the patient population of interest, the alternative management strategies, and the outcomes of importance to patients. Values and preferences A fundamental principle of evidencebased medicine, as described by Dr. Gordon Guyatt from McMaster University, is that Evidence alone is never sufficient to make a clinical decision. Decision makers must always trade the benefits and risks, inconvenience, and costs associated with alternative management strategies, and in doing so consider the patient s values. 45 This principle has led some evidencebased resources to avoid making specific recommendations for patient care, since the recommendation needs to account for all of the factors cited. UpToDate has taken a different approach. It is the policy of UpToDate to make specific recommendations for patient care whenever possible. Recommendations in UpToDate are based upon a synthesis of evidence including that from clinical trials and clinical experience; whenever possible, the evidentiary basis for recommendations is stated explicitly. When there is no published systematic evidence available (eg, prednisone dosing regimen in pulmonary sarcoidosis), recommendations are based upon the unsystematic clinical observations of our experts and reviewers, and on pathophysiologic rationale. 7.
8 UpToDate recommendations identify situations in which different decisions might be appropriate for patients with different values and preferences. Furthermore, UpToDate recognizes that recommendations will not apply to every patient, and counts on clinicians to evaluate the recommendations in light of the individual circumstances of their patient. Nevertheless, UpToDate feels that giving clinicians access to recommendations based on a sophisticated understanding of the clinical issues, the best evidence, and a consideration of patient values and preferences, allows them to make informed decisions with and for their patients. Grading UpToDate began grading recommendations for treatment and screening in This is a continuing process and not all such recommendations have yet been graded. Graded recommendations appear in the Summary and Recommendations sections at the end of topics. UpToDate uses the UTD-GRADE format, a modification of the GRADE system. 46,47 Grades have two components, a number (1 or 2) reflecting the strength of the recommendation and a letter (A, B, or C) reflecting the quality of the evidence supporting that recommendation. A Grade 1 recommendation is a strong recommendation to do (or not do) something, where the benefits clearly outweigh the risks (or vice versa) for most, if not all patients. A Grade 2 recommendation is a weaker recommendation, where the risks and benefits are more closely balanced or are more uncertain. The majority of recommendations will be Grade 2 recommendations. UpToDate uses wording that reflects the strength of the recommendation: strong (Grade 1) recommendations are recommended and weak (Grade 2) recommendations are suggested. Grade A evidence means high-quality evidence that comes from consistent results from well-performed randomized controlled trials, or overwhelming evidence of some other sort (such as well-executed observational studies with very strong effects). Grade B evidence means moderate-quality evidence from randomized trials that suffer from serious flaws in conduct, inconsistency, indirectness, imprecise estimates, reporting bias, or some combination of these limitations, or from other study designs with special strength. Grade C evidence means low-quality evidence from observational evidence, or from controlled trials with several very serious limitations. 8.
9 Moving from evidence to recommendations The following table presents the criteria that UpToDate authors and editors consider when weighing the advantages and disadvantages of treatments to decide on a recommendation, and grade the strength of that recommendation. Each topic has a date indicating the most recent time the topic has been reviewed and/or modified. On average, approximately 40 percent of the topics are updated during each four-month cycle. Peer review The Deputy Editor for a specialty, as well as the Editor-in-Chief and/ or Section Editors assigned to a topic, review the entire UpToDate content, including all new topics, updates, and recommendations. In addition, each UpToDate specialty has assembled a group of peer reviewers, often in conjunction with a sponsoring specialty society, that is responsible for reviewing selected topics in each specialty. Finally, any comments from users of UpToDate are formally addressed with changes made as necessary. Updating UpToDate performs a continuous comprehensive review of resources previously outlined to keep the program updated. All of the topics in UpToDate are revised whenever important new information is published, not by any specific time schedule. Updates are integrated carefully, with specific statements as to how the new findings should be applied clinically. Policy review UpToDate s policies and procedures are continuously reviewed in consultation with our Evidence- Based Medicine Advisory Group. Members of this group include Dr. Gordon Guyatt and Dr. Roman Jaeschke from McMaster University, Dr. Holger Schünemann from the Italian National Cancer Institute in Rome/McMaster University, and Dr. Yngve Falck-Ytter from Case Western Reserve University. 9.
10 Appendix 2: Hospital clinical knowledge systems and health outcomes study methods 26 Patient safety indicators The patient safety indicator (PSI) scores represent a set of measures on potential complications and adverse events on hospitalized patients. They were developed with a comprehensive literature synthesis, analysis of ICD-9 codes, and review by expert clinicians and implementation of risk adjustment and empirical studies. 48 The Agency for Healthcare Research and Quality (AHRQ) provides free, publicly available tools necessary to determine PSI scores and they are a widely used measure of patient safety. The AHRQ Patient Safety Indicators are used in at least 9 states for public reporting on hospital performance. The rationale is that hospitals that show good performance on these measures are likely to be providing good quality of care. There are 23 AHRQ PSIs that are relevant for provider-level (hospital-level) analysis. Seven, which are birth-related, are not relevant to a Medicare population and were thus excluded. Five require Cause of Injury or E-codes, which are not coded consistently across acute-care hospitals in the United States, and were therefore not included in the study. Complications Solucient has constructed a database containing normative, case-level data on a national level; it contains more than 21 million annual patient discharge levels. The case-level data include age, sex, race, payer, length of stay, clinical grouping (Diagnosis Related Groups or Refined Diagnosis Related Groups), comorbid conditions, and hospital identification information. The database permits analysis of hospital-level data for two general types of complications: 1) Conditions of concern in which there are outcomes that should not occur and thus represent substandard care (e.g. air embolism); 2) Expected complications (e.g. venous thrombosis) that (when occurring in higher than expected frequencies) may indicate opportunities for improving patient safety. Complication rates can be compared across hospitals after adjusting for differences in the severity of illness, geographic location, hospital size and teaching status, and community setting (urban versus rural). Thus, facilities are compared to other facilities with similar characteristics. The complications methodology has been extensively validated and used in many studies evaluating patient safety Mortality Risk-adjusted mortality is determined based upon normative comparisons using patient-level data to control for case mix and severity of illness. 52,53 Thus, patients are compared to other patients with similar characteristics and co-morbid conditions. The risk-adjusted mortality index has been extensively validated. 52,53 Length of stay Determination of average length of stay was based upon severity-adjusted diagnostic related groups (DRGs). 54,55 Severity-adjusted DRGs are intended to distinguish discharges that are clinically similar and require comparable resources (e.g. diagnostic, therapeutic, and nursing services). Severity of illness is based upon the patient s medical condition or evidence of physiologic decompensation. The DRG system is used to determine reimbursement by the Centers for Medicare and Medicaid Services and most private insurers. Eligibility Hospitals included in the Solucient database were required to have a Centers for Medicare and Medicaid Services (CMS) Medicare Provider Analysis and Review (MEDPAR) dataset for 2003 to 2004, CMS standard analytic files outpatient dataset for 2002 and 2003, and a CMS cost report for Hospitals were excluded from the Solucient database if a current Medicare cost report was unavailable, if they were specialty hospitals (e.g. children s, women s, psychiatric, substance abuse, rehabilitation, cardiac, orthopedic, long-term acute care), had fewer than 25 acute care beds, 500 total facility admissions, or 100 Medicare patient discharges in fiscal year 2004, or had Medicare average lengths of stay longer than 30 days. All UpToDate hospitals fulfilling these criteria were included in the analysis. Weighting strategy Hospitals that subscribed to UpToDate were compared to the Solucient database on bed size, teaching status, and geographic region. These are variables known to be associated with the primary outcome measures. Two weighting strategies were used to allow the model coefficients to be applicable to a national distribution of acute-care hospitals. Because all the outcome variables were based on dischargelevel observations, weighting for hospital volume was done to account for differences across hospital inpatient volume. 10.
11 Weighting by hospital class was done to derive model coefficients that would better reflect the national distribution of hospitals on bed size category, teaching status, and region. Thus, the analysis was performed without weighting, by weighting for discharge volume only, and by weighting for discharge volume and hospital class. Hospital class was categorized as small community (bed size 25-99), medium community (bed size ), or large community (bed size >250). Teaching hospitals were classified as standard teaching (bed size >250 and resident-to-bed ratio of >0.03 or total residency programs >3), or major teaching (bed size >400 and residents-to-beds ratio >0.25 and >10 residency programs, or resident-to-bed ratio >0.60 if fewer residency programs). Statistical analysis Hospital-specific performance on mortality, complications, and patient safety were represented by a z-score for each measure, while severity-adjusted length of stay (LOS) was based upon the Yale Refined Diagnosis-Related Group methodology. 28,56 Severity-adjusted LOS was represented in the models in units of days. Hospital-level, risk-adjusted mortality, complications, and PSI were based on two years of data (2003 and 2004) to increase the precision of hospital-level measures through larger sample sizes; LOS was based on 2004 data only. Data regarding the average hits per week were also matched to the Solucient database to determine whether associations with the primary outcomes correlated with the amount that UpToDate was used at each facility. Thus, UpToDate status was evaluated in two ways: 1) as a binary variable indicating whether a given hospital was using UpToDate and 2) as a continuous variable representing HPW. Hospitals that were not UpToDate users were assigned a zero HPW. The relationship between the primary outcome measures and HPW was presented graphically by converting changes in z-scores associated with UpToDate HPW to risk-adjusted rates. The PSI composite measure was created by calculating the average of the normalized z-scores for 11 individual AHRQ PSI indicators that were appropriate for a Medicare population aged 65 years and older, and did not depend on E-codes. As noted above, use of cause of injury codes, or E-codes, varies extensively from hospital to hospital, thus PSI measures that used E-codes were omitted. The measure-specific z-scores were calculated by subtracting the expected number from the observed number and dividing by the standard error. 57,58 The mortality, complications, and PSI z-scores, as well as the severity-adjusted LOS, were used as outcome variables in the analyses. Separate linear regression models were developed for each combination of outcome and weighting strategy. All models included adjustment variables described above to control for hospital bed size category, teaching status, and geographic region (i.e. Northeast, Midwest, South, and West). The primary predictor variables of interest were: 1) the UpToDate status of the hospital and, 2) in separate models, the average number of topic reviews per week (hits per week, or HPW). HPW refers to the average number of topic reviews that were viewed at each institution each week. All comparisons were between UpToDate hospitals versus all nonuptodate hospitals in the Solucient database. 11.
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text:
South Korean President Kim Dae-jung is expected to conduct a sweeping cabinet reshuffle this week, after all of his ministers submitted their resignations. The mass resignation followed a Parliamentary vote for the dismissal of the president's key North Korean policy adviser. The vote in the assembly has seriously jeopardized Mr. Kim's personal efforts to reconcile the two Koreas before the end of his presidential term.
South Korea's Unification Minister, Lim Dong-won, tendered his resignation Tuesday with the rest of the cabinet.
Monday's vote in the assembly to dismiss Mr. Lim passed overwhelmingly triggering concerns that President Kim Dae-jung's so-called "sunshine" policy to open up North Korea was finished. "Lim Dong-won is the headmaster of the sunshine policy. He has made a great contribution to engaging the North," said South Korean political analyst Ok Nim-chung.
In addition to overseeing all aspects of North-South relations, the minister played a pivotal role in arranging last year's landmark summit in Pyongyang. The meeting was the first North South summit since the Korean War ended in an armed truce and left the two sides technically at war for more than 50 years. The hugely successful summit also earned President Kim a Nobel Peace Prize.
But in January, North Korea, unhappy with the perception that the Bush administration's was taking a harder stance against Pyongyang, froze all contacts with the South. Eager to resume reconciliation talks, Mr. Lim's ministry last month allowed a group of South Korean activists to attend joint Liberation Day celebrations in North Korea.
During the trip, however, some of the delegates allegedly participated in events that glorified the North Korean government. On Monday, outraged conservative opposition members in the South Korean National Assembly introduced the no-confidence motion to hold Mr. Lim personally accountable for the scandal.
Political professor Chun Hong-chan in Pusan says since January, a collective anger has replaced the optimism that flowed in South Korea after the summit. "I don't think the opposition party opposes the sunshine policy itself but many people think that we've had enough of it," he says. "The sunshine policy includes the hypothesis that if we give this much, then we will receive in kind. But we haven't received that kind of reward from the North."
Despite the anger and the demise of his unification minister, President Kim is expected to pursue his life-long dream of reconciling the divided Koreas before his term in office ends next year. But the task will be far from easy.
After the ruling party's coalition partner supported the no-confidence vote in Parliament, Mr. Kim declared that the partnership was over. Political observer Lee Sook-jong says that means Mr. Kim will no longer have a way to politically outmaneuver conservatives in the assembly. "The ruling party is not the majority party," she says. "So, if he's losing this coalition partner, it will be very difficult for President Kim to run policy and pass important laws."
Mr. Chun in Pusan agrees. He says the president's biggest challenge will not be in engaging Pyongyang further, but in keeping his opponents from killing his initiatives. "The president will go on with the sunshine policy. But the problem is some policies may need approval of the assembly. That kind of sunshine policy will have difficulty," Mr. Chun says.
Analysts say how President Kim fares in his remaining months in office could depend largely on North Korea. If Pyongyang decides to fully cooperate with Seoul on various issues, the gesture could generate popular support for the sunshine policy and help avoid a lame-duck presidency. But analysts say if there is to be better cooperation between the two sides in the future, the timing of it must not appear to be aimed at helping Mr. Kim's political career.
There is already strong suspicion brewing in South Korea about North Korea's sudden call to renew contacts. Pyongyang made the unexpected offer Sunday on the eve of Mr. Lim's no-confidence vote. Angry opposition leaders urged the government to disregard the offer saying it was a North Korean attempt to save the minister and to manipulate South Korean politics.

subset: commoncrawl


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Science Changing the "Facts of Life"
Though sexual reproduction lies at the core of life science, technology is progressing in a way that could change the way we think about reproductive issues:
- In 2004, scientists at the University of Pennsylvania grew mouse "spermatagonial stem cells," or stem cells that can become sperm cells. Other scientists are working to create human sperm and egg cells from stem cells... effectively removing sex from the reproductive process.
- A St. Louis surgeon has successfully performed an ovarian transplant on a woman from ovarian tissue donated by the woman's twin sister. The woman, whose cancer treatment as a teen left her sterile, then became pregnant and delivered a healthy baby. The ability to remove and replace ovaries offers women a number of reproductive benefits. Women undergoing cancer treatment could have their ovaries removed for the duration of their therapy, then have them restored. It could also serve as a form of "extreme birth control," in which a woman could have her ovaries removed, preserved, and then restored when she is ready to start a family.
- Scientists have been able to perform in vitro fertilization on mice using microscopic channels on a silicon surface -- literally a "baby on a chip."
While these advances offer new options for treating infertility, they also raise important ethical questions. "Designer" sperm and eggs, for instance, can be altered genetically, with those changes retained by future generations. On the upside, scientists could make such changes to prevent genetic birth defects and diseases. But it also raises the possibility of eugenics, allowing manipulation of both appearance and emotions.
Sources: Wired, KurzweilAI.net


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The children of Ahwatukee Foothills Montessori School have been bringing in their change for their love light banks in each classroom. The children raised more than $600 and Mrs. Meaghan McClung matched it. The school used this money to buy new toys for children whose families need help for the holidays.
The toys were on display in the school lobby.


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By Eric Killelea
Ranger-Review Staff Writer
Dawson County High School senior Emily Kuehn finished an outstanding cross country season placing fourth in the Class A state tournament last Saturday in Helena.
In email, head coach Tom Temple wrote that Kuehn is now considered a three-time all-state cross country athlete.
He added: "A truly elite status."
In Temple's words, Kuehn ran among 132 girls at the Bill Roberts Golf Course, which "doesn't have big hills like Sidney or Lewistown, but it has a lot of medium sized hills and side hills that are kind of relentless," he wrote. "So, it makes for a real challenging course to get into any kind of rhythm for the runners. Plus, it was windy and chilly so you will notice that across the board most runners ran anywhere from 30 seconds to over a minute slower than their season's best."
Overall, Hardin won the tournament, defeating Corvallis, Polson, Whitefish and Beaverhead County. The Lady Red Devils finished last out of 18 teams.
Click here to read more....


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Barbecue: America's National Folk Food
John T. Edge is the Director of the Southern Foodways Alliance and a James Beard Award-winning writer. He says we're living in a Golden Age of barbecue and he talks about barbecue's troubled racial history.
What makes "journalists" say such things?
"Rib tickling"?
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The interview
(First, I'M not certain it was in this segment or in segment 3 that this occurred )The interviewer uses the term "African American" (which I fully endorse as respectful and appropriate), but then refers to the interviewee as a "white guy". While this may be accurate, I was struck by how disrespectful it sounded in this context and wondered if this is an intentional choice of words or have we fallen to disrespect the Euro-American descendants out of cultural collective guilt? The term "white man" might have even conveyed a little more respect.
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I very much enjoyed the
I very much enjoyed the author's discussion of the history of barbeque, and I thought he provided a thorough and very respectful dissertation on the very difficult history that current barbeque is built upon. He showed tremendous respect for those African-American pitmasters who were craftsman of their trade and who grew to be "Masters". The interviewer, on the other hand, was continually attempting to "race bait" him into the typical "white guilt" discussion, and to his credit the author did not bite. He continued his very interesting, and again respectful, factual, and facinating discussion. That did not prevent the interviewer from continuing her race-baiting style. While I completely enjoyed the interview, she made me cringe.
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Nok Air gives you the most convenient way to book and manage your trip directly from your mobile. With mobile Check-in you can get your boarding pass in less than two minutes and use your phone as a boarding pass to reach the gate.
Mobile Check-in service is available from 24 hours up to 45 minutes prior to the scheduled departure time. Nok Air application is available for iPhone, iPad and Android. You also can connect to our mobile website (m.nokair.com) to Check-in from any other compatible mobile devices.


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Chocolate Peanut Butter Ice Cream
Kraft has introduced, here in Canada, a chocolate peanut butter. I knew I had to try it in an ice cream, and came up with this yummy dessert. But it's...
salt, +flour, +peanut butter, +eggs, +cream, +sugar, +vanilla extract, +heavy cream, +whole milk
www.recipezaar.com - Similiar recipes
Chewy Chocolate Peanut Butter Chip Cookies
"Chocolate cookies with peanut butter chips instead of chocolate chips."
salt, +baking soda, +butter, +cocoa powder, +eggs, +flour, +peanut butter chip, +vanilla extract, +sugar
Chocolate Peanut Butter Double Chip Cookies
I have made these twice in one week and plan on making them again soon, they are amazing!...a chocolate cookie packed with chocolate and peanut butter...
salt, +baking soda, +butter, +eggs, +egg yolks, +flour, +brown sugar, +peanut butter, +semisweet chocolate chips, +cocoa powder, +vanilla extract, +sugar
www.recipezaar.com - Similiar recipes
Peanut Butter and Chocolate Peanut Butter Cup Cookies
"I thought this up totally by scratch! If you like peanut butter cups, you'll like this cookie."
salt, +baking soda, +brown sugar, +butter, +eggs, +flour, +peanut butter chip, +peanut butter, +semisweet chocolate chips, +vanilla extract, +sugar
Double Chocolate Peanut Butter Thumbprint Cookies
"These peanut butter-filled chocolate thumbprint cookies are a must with a tall glass of ice-cold milk."
salt, +cocoa powder, +baking powder, +butter, +peanut butter, +eggs, +flour, +sugar, +vanilla extract
Candi's Chocolate Peanut Butter Chip Cookies
"These cookies are very soft. You can also use chocolate chips instead of the peanut butter chips."
salt, +applesauce, +baking soda, +brown sugar, +butter, +cocoa powder, +eggs, +flour, +peanut butter chip, +vanilla extract, +sugar
Chocolate Peanut Butter Cookies
"An all-time favorite flavor combination; chocolate and peanut butter morsels combine in a melt-in-your-mouth cookie treat."
salt, +cocoa powder, +baking soda, +brown sugar, +butter, +eggs, +flour, +milk chocolate, +sugar, +vanilla extract
Chocolate Peanut Butter Swirl Fudge
"An easy chocolate fudge is swirled with peanut butter fudge to make this beautiful and delicious candy. Great for gift giving or party trays."
Chocolate/Peanut Butter Drop Cookies
" Delicious chocolate and peanut butter cookies!"
salt, +brown sugar, +butter, +eggs, +flour, +peanut butter, +shortening, +vanilla extract, +sugar
Chocolate Peanut Butter Pie VI
"Sweet, chewy chunks of peanut butter lie like buried treasures under a layer of chocolate custard. You can top this pie with meringue to make it extra...
salt, +butter, +cocoa powder, +powdered sugar, +cornstarch, +egg yolks, +milk, +peanut butter, +sugar
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Flesh and Blood, with words by the British playwright and poet Howard Barker, is about the parting of a soldier from his mother. It begins with the soldier expressing his dread and anxiety and wish for love and concealment, but as the scene develops this is revealed to be part of a ritual in which the soldier eventually insists that his mother send him to his death because she created him and therefore only she can dispose of him.
The conclusion is that she does then send him away, knowing he will never return, or only as a body. It is therefore shown that it is the mother (rather than, conventionally, the soldier) who makes the supreme sacrifice of their flesh and blood.
The music for the mother is at first lyrical and expressive, and that for her son more rhythmic and driven. As the piece develops, the two types of music gradually swap over.
David Sawer
Please note that this text is not to be used as a programme note.
The world première of Flesh and Blood will be broadcast live on BBC Radio 3.
Friday 15 Feb, 7.30pm London time. Listen here.
View the full vocal score
Flesh and Blood
for mezzo-soprano, baritone and orchestra | 30'
3 3 3 3 - 5 3 3 1 - timp(2), perc(4), hp(2), cel, str
15/2/2013, Barbican, London; Christine Rice, ms, Marcus Farnsworth, bar; BBC Symphony Orchestra, cond. Ilan Volkov


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Second Annual 'Avery Give Back to Schools' Promotion Expands
Tuesday, June 21, 2011
Press release from the issuing company
PASADENA, Calif., – The 'Avery Give Back to Schools(TM)' promotion launched today, marking the second year the global office supply company has implemented the initiative. The biggest difference this year--Avery is expanding the promotion to award 30 schools with much-needed educational resources and offering cash benefits through Avery's partnership in Box Tops for Education(R). Avery manufactures a large selection of school supplies such as binders, dividers, Sticky Notes, NoteTabs(TM), highlighters and glue sticks that will prove to be extremely valuable for schools across the country.
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It's been so long since I've posted. Sorry. We've been on a severe budget crunch. Greek austerity like. We paid a steep price moving to Cedar Rapids. It's going to hurt financially for probably five years, but still, totally worth it.
So a rare dinner out while the kiddo is at gymnastics. Took the opportunity to try a new to us Mexican restaurant, El Paraiso Bar and Grill. And it was on our way to Aldi. When we arrived we were a little confused because even though there were quite a few cars in the parking lot, the neon beer lights were all off and the place looked closed. The big doors in front of us that looked like an entrance from the parking had a big sign that said Employee Entrance. We hesitated but then got off our lazy asses and walked to the side of the building. That's where the front door was and yes they were open.
First impression was the place was HUGE. Most of the seating is in booths which is no bueno for us.When we asked for a table we were seated on the edge of a back section far away from the rest of the customers. This would prove problematic.
The menu was small but more like what we were used to seeing in Georgia but not like our previous excursions in Cedar Rapids to Los Compadres or Cancun Mexican Grill. There were a few new things to me though.Siete Mares, a seafood soup I have not seen before on a menu. Nor have I seen a ham and cheese quesadilla before, Quesadilla Sincronisadas. And there were no nacho plates listed on the menu which was a bummer for the wife.
The chips and salsa were meh. I would rate the salsa as weak, almost no spice. The wife ordered the Quesadilla El Paraiso which was a large quesadilla filled with chicken and chorizo with a fancy side of sour cream, lettuce and pico de gallo which looked like a mini taco salad. She raved about the quesadilla and was only able to eat half. She was excited about having it for lunch the next day with a side of their refried beans which she said were very good.
I ordered the Burrito Campechano, filled with steak and chorizo, and one beef hard shell taco. I'm still searching for that magical taco like Mi Ranchito had on Westnedge in Kalamazoo. This wasn't it. The taco also serves as my side since I don't eat the beans or rice. The burrito was quite salty, not inedible but still heavy. I thought maybe it was the chorizo but the wife didn't notice it in her quesadilla. Probably just a heavy hand in the kitchen.
Unfortunately service was very inadequate though would not deter me from coming back again. I watched and the main section had at least four servers including ours. I think the problem was a function of being a Sunday, under staffing, and being seated in an out of sight section. It was a shame our server didn't come to our table more often because I liked her, I mean REALLY liked her.


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Biopharma major Biocon Ltd said on Thursday its profits increased 13% to Rs 103 crore in the third quarter compared to the same period a year ago.
The company's revenue rose 10% to Rs 828 crore in the October-December quarter, helped by an increase in business growth from its contract research arm Syngene International. Syngene posted a 31.25% increase in net profit to Rs 58.8 crore for the December quarter.
"Excluding profit contribution from Syngene, Biocon's net profit this quarter has increased by 28% y-o-y despite a 45% jump in R&D spends and a significant increase in tax. This reflects a marked improvement in the quality of our earnings led by better realisations from biosimilars and immunosuppressants in emerging markets," Biocon chairperson and managing director Kiran Mazumdar-Shaw said in a statement.
"Syngene, our research services company, has delivered yet another strong quarter both in terms of revenues and profits," she said.
The company spent Rs 68 crore on research and development as the prospects for biosimilars and new drug development improved. It also earned licensing income of Rs 32 crore from monetising its biosimilars portfolio in emerging markets.
Bangalore-based Biocon had earned a profit of Rs 91 crore and revenue of Rs 761 crore in the October-December quarter in 2014.
Biocon said it had received positive clinical data from key studies for Insulin Tregopil in the US.
"Biocon's four most advanced biosimilar and generic insulin programmes, Insulin Glargine, Trastuzumab, Pegfilgrastim and Adalimumab, continue to cross critical clinical milestones and are on track for regulatory filings in US & Europe in CY2016," the company's chairperson said.
Biocon shares traded almost flat at Rs 483.80 on the Bombay Stock Exchange on Friday.


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Hi everyone,
I'm Liz. I'm in my thrid year of studying illustration at The University of Lincoln, currently having a great time and vigorously trying to prepare myself for the big scary real word.Wish me Luck!
Please feel free to leave lovely comments or constructive criticism. It makes me feel nice and helps me grow.
If you like my work or just want to say hello, please contact me:


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Chesterfield are yet to bring anyone in during the January transfer window.
But Spireites fans have been voting on the Derbyshire Times website, for the area of the squad they believe Danny Wilson should strengthen.
Almost half of the fans who responded suggested that the midfield is where reinforcements are needed.
And 38 per cent would like to see the defence shored up with a new signing or two.
The attack needs bolstered, according to 13 per cent.
Just one per cent of Spireites fans polled believe goalkeeping is an area to be looked at.


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Get A Free Synora Beauty Product Samples Set!
Enjoy FREE samples of skincare, makeup, cosmetics and other beauty products from Synora Beauty! With today's freebie, you can enjoy free samples from their skin care system, lipstick, eyeshadows, or other items from their amazing line of beauty products!
To get the freebie please click on this link:
Get A Free Synora Beauty Product Samples Set!
The linked site is not operated or owned by FreebieSelect!


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Directions: Cook ground beef and onion, drain. Mix oregano, tomato soup, garlic salt and chili powder. Add to ground beef, let cool. When cool add grated cheese, mix well. Spread on slices of sandwich bread and place on a well-buttered baking sheet. Bake in a 400°F oven until cheese is melted and bubbly.
Notes: This recipe was served at my children's school. They liked it so well that they insisted I get the recipe.


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MACKINAW CITY — The Mackinac Bridge is closed to all vehicles except passenger cars, passenger vans and empty pick-up trucks because of wind, according to the bridge conditions page on mackinacbridge.org.
The bridge conditions report states that winds are blowing across the bridge surface in excess of 50 miles per hour.
As a result, motorists are instructed to reduce their speed to 20 miles per hour as they approach the bridge and motorists should be prepared to stop, according to the bridge conditions report. And bridge personnel are positioned at both ends to provide further instructions to motorists.
The bridge will be re-opened to all vehicles when conditions improve, according to the website. Motorists can also tune to AM radio 530 or 1610 for updates.
Photo courtesy of Shutterstock.com


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More than ever, brands need to create authentic and meaningful relationships with consumers who are well-connected and can greatly influence others' purchase decisions. At Linhart PR, we're committed to deeply understanding your brand, including business goals, points of differentiation, target audiences and trends that are (or will be) shaping your industry and consumer perceptions. From there, our team partners with you to develop and execute the most effective, creative ways to reach and engage your consumers, whether online, offline or through traditional and emerging media. Our consumer marketing team delivers proven results with product and service launches, events and other experiential campaigns, cause marketing efforts, and media and influencer relations.
Contact Kelly Janhunen, to learn how we can help your brand build relationships with current and potential consumers.
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© Copyright 2018
Suleman Shittu & Co.
All Rights Reserved
Our Client Service:
At the present time, Suleman Shittu & Co. has offices in Lagos and Dopemu- Agege with branch offices in Kano and Port Harcourt and a liaison office in Abuja. However, as new markets for our services develop, so will our network of offices in more States. Over the next few years, we expect our practice to expand considerably to all the nooks and corners of Nigeria. We also have a liaison office in The Gambia, West Coast of Africa.
Our organization is essentially client oriented and seeks to combine on-the-spot service by executives familiar with the clients' individual problems with the professional and technical expertise of a coordinated crop of accountants and tax practitioners nation-wide.
We believe it provides an appropriate balance of control and flexibility to allow the firm to achieve it basic goals and to maintain the momentum of its development.
The Practice:
The Practice Group operates through the following firms:
Our Staff
As with any service organisation, the strength of the firm may be assessed by the quality of the staff it employs. Suleman Shittu & Co. devotes considerable resources to developing and maintaining the quality of staff all at levels.
The process starts with the recruitment of carefully selected candidates either at student level or to a more limited extent from amongst recently qualified accountants. New staff members attend courses at the beginning of their career or shortly thereafter to introduce them to our approach to work and to inculcate in them the standard we apply. Thereafter, practical experience is supplemented by a programme of continuing education up to and including partner level.
Senior members of staff including the partners strictly attend Mandatory Continuing Professional Education Programme organised by the Institute of Chartered Accountants of Nigeria and Mandatory Professional Training Programmes organised by the Chartered Institute of Taxation of Nigeria.
Our staffs are dedicated to being foremost in servicing our clients and our profession. Ultimately, the reputation and success of our firm depends upon the cumulative knowledge, experience, judgement and imagination of those who work for us. Our staff is indeed our greatest strength.