text:
Value-based healthcare analysis of joint replacement surgery for patients with primary hip osteoarthritis
Lucinda Gabriel1,
Joseph Casey1,
Matt Gee2,
Claire Palmer3,
Joydeep Sinha2,
John Moxham1,
Toby James Colegate-Stone1,2
1 King's Health Partners, London, UK
2 Department of Orthopaedic Surgery, King's College Hospital NHS Foundation Trust, London, UK
3 King's College Hospital NHS Foundation Trust, London, UK
Correspondence to Toby James Colegate-Stone; tobycolegatestone{at}yahoo.com
Background A quarter of the population present at least once a year with a musculoskeletal disorder. Primary hip osteoarthritis is a high-volume condition with significant clinical need and population-level costs. There remains much variation in patient outcomes and care delivery costs for this condition.
Aims The study aimed to gauge if pathway redesign based on the principles of value-based healthcare (VBHC) could increase value. The aim was to calculate the value of treatment for primary hip osteoarthritis through measuring outcomes that matter to patients, as well as the costs of delivering them. Additionally it aimed to compare two care pathways to identify which elements may better promote the delivery of high-value clinical care.
Methods Two care models were evaluated: the first being a traditional model with multiple entry points and without pathway standardisation, and the second an intentionally designed standardised multidisciplinary pathway. Mandated National Health Service patient-reported outcomes were assessed but were restructured into a patient-centred format to assess the impact on pain, function and psychological outcomes. Patient-level pathway economic evaluation was performed. Using these data, outcomes were mapped against cost to calculate value.
Results There were no significant differences in clinical outcomes between the two models. The intentionally designed model delivered better value care, having lower pathway costs. This model produced a small but inconsistent positive financial margin.
Conclusions Intentionally designed, integrated elective services offer an opportunity to develop and evaluate VBHC models. Analysis of two care pathways from a VBHC perspective demonstrated that an intentionally designed pathway had higher value. The higher value pathway maximised the benefits of having physiotherapists and orthopaedic surgeons working side by side. Developing and measuring patient-orientated outcomes and performing accurate economic evaluation are the key to understanding and achieving better value care.
quality measurement
Given the current resource limitations, delivering high-quality care to all patients who require it remains a significant challenge. The scale of this challenge is well documented1 and arises from population growth, an ageing demographic and the consequential rise in the number of patients who suffer multiple comorbidities.2–5 Research leads to perpetual improvements in medical therapies and technologies that increase the range of conditions and patients we are able to treat. These welcome new care options can have the effect of driving up costs and patient expectations, confounding the inequality seen in healthcare outcomes as well as access.1 Care delivery is rarely standardised and financial constraints result in some treatment modalities being distributed unevenly across a population. Even at a local level, there is considerable variation in attained outcomes for the same conditions at variable costs between providers.1 4 6–9 These issues are unlikely to be solved by existing paradigms which offer only limited short-term solutions.
In the UK approximately 18 million people have a musculoskeletal (MSK) condition, and the annual National Health Service (NHS) budget for MSK-related conditions is approximately £10 billion.10–12 MSK conditions are the greatest cause of sick leave and related loss of productivity to the economy at an estimated annual cost of £18 billion.12–14 A quarter of the population require clinical review for an MSK condition at least once a year, and more than 25% of all surgical procedures undertaken by the NHS are for MSK conditions.5 15 16 The demands that MSK disorders place on healthcare are increasing at every point of clinical contact and have a relentless upward trajectory.5 17 Patients who are 45–65 years old are now the most common age group to present with MSK conditions. This growing subgroup contributes significantly to the already overburdened health service.1 10 Osteoarthritis forms the bulk of the MSK clinical workload. In the UK alone over 210 000 hip and knee replacements were undertaken in the last year according to the National Joint Registry.18 This number however is dwarfed by those seen in the USA, where over 1.2 million hip and knee arthroplasty procedures are performed annually.19 The cost of joint replacement itself is over £1 billion per annum in the UK, while in the USA it is over $20 billion per annum.13 19 The escalating cost of healthcare needs to be addressed as an urgent priority.
The value-based healthcare (VBHC) agenda sets out to reorientate our healthcare delivery system.1 6–8 Value in healthcare is defined as outcomes that matter to patients and carers relative to the costs of delivering those outcomes and is measured over the complete care pathway. The VBHC approach describes a stepwise process to deliver this model of care. The first step is to segment the patient population being treated. A segment is a group of patients with similar or related medical conditions and healthcare needs. The optimal definition for population segmentation requires the criteria of population homogeneity, distinctiveness and completeness to be met.20 Care along the entire pathway is best delivered by a specialised and organised multidisciplinary team (MDT) of clinicians, termed an integrated practice unit (IPU).1 Care is colocated in dedicated facilities to which there is a single point of access with a single physician team leader or clinical care manager (or both) overseeing each patient's care process. The team measures outcomes, costs and processes for each patient across the full cycle of care, using a common measurement platform. There is joint accountability for outcomes and costs. This aligns with what clinicians want to deliver, what patients would like to receive and what commissioners would wish to pay for. VBHC models have been delivered in the UK.21
The aim of this study was to assess the management of a defined MSK segment. Primary routine hip osteoarthritis was selected as it is a common and high-volume condition that lends itself to the VBHC toolkit. The study aimed to ascertain if pathway value calculation is achievable through measuring outcomes that matter to patients and the costs of delivering those outcomes. Second, we wished to compare two pathways of care for the same condition in order to identify which elements may better promote the delivery of high-value clinical care.
Cohort
A retrospective assessment of 50 patients with primary hip osteoarthritis who underwent a surgical care pathway was performed. Hip osteoarthritis is a prevalent condition, but its genesis can be from a variety of aetiologies, including congenital conditions, trauma, systemic progressive medical diseases, as well as the most common causation of routine degenerative change. Comparing patients who have different arthritic aetiologies makes comparative evaluation difficult as the population then may lack significant shared and similar characteristics. Correct segmentation of condition is vital to remove bias. As such the segment was judiciously defined in order to only evaluate patients with a similar condition. Inclusion criteria were patients who had routine primary hip osteoarthritis and who subsequently underwent routine primary total hip replacement (THR) surgery at a single site. Surgery was performed by a teaching hospital consultant. Patients were excluded if they had a complex hip history, including paediatric hip disorder, hip dysplasia, hip trauma, trauma as a surgical indication, a history of regional infection, any intraoperative periprosthetic fracture, if they required revision surgery or had a complex medical history with an ASA classification of 4 or more (as per the American Society of Anesthesiologists (ASA) system).22
Pathway mapping
The patients were subdivided into two subsegments corresponding to the pathway that the patient's care followed. Patients in model 1 were managed within a traditional evolved care pathway. Model 1 patients were referred directly to an orthopaedic hip consultant surgeon at a clinic located within a teaching hospital (see figure 1). Referrals into this pathway were from multiple sources and occurred at multiple points along the pathway.
Model 1 (traditional evolved care pathway) and model 2 (intentionally designed multidisciplinary team pathway). GP appt, general practitioner appointment; MSK, musculoskeletal; ortho, orthopaedic; physio, physiotherapy.
Patients in model 2 were managed within an intentionally designed MDT IPU (figure 1). The IPU in model 2 was a specialist integrated MSK unit. This comprised orthopaedic nursing staff, a service management team, physiotherapists, extended scope triaging physiotherapists (ESPs) and subspecialist consultant orthopaedic surgeons. Patients referred into model 2 followed a linear pathway. All referrals were received and triaged by the ESP. They reviewed the patient, requested initial investigations and initiated therapy as appropriate. If the patient required onward orthopaedic surgical review, this then occurred. The ESPs were physically sited adjacent to the orthopaedic surgeons, and this close proximity facilitated swift MDT review in cases where an ESP was unsure about how to proceed.
The treating orthopaedic surgeons in model 2 also saw patients in model 1 as they worked cross-site. The model 2 clinic was located at a satellite centre in the community. All patients underwent surgery at the same orthopaedic elective centre, receiving preoperative work-up subsequent to referral by the same teams, surgery from the same surgeons and the same postoperative physiotherapy regimens. As such the main difference between the two models was the preoperative pathway, specifically how the patients entered the care pathway, their triage and the type of clinician (ESP or orthopaedic surgeon) conducting the initial work-up. Surgery and postoperative care were uniform for all patients, although delays in postoperative physiotherapy occurred disproportionately in model 1.
The patients were allocated into pathways dependent on their local geography; those living local to the satellite centre in model 2 were treated by the model 2 pathway and similarly for those patients under model 1 pathway. Only those with full data sets over the 2-year period of the study could be reviewed.
Clinical outcomes were measured using the standard patient-reported outcome measures (PROMs) as set by NHS England for the assessment of care for hip arthritis following THR.23 These mandated outcome scores comprise the Oxford Hip Score (OHS), the five-level EuroQol-5D (EQ-5D-5L) and EuroQol-Visual Analogue Scale (EQ-VAS).24 25 Outcome assessment was performed preoperatively and at 6 months postoperatively as per national guidance.
To translate the data into a more patient-centred format, a matrix formula was applied. The different scales used with each scoring tool were all converted into a scale of 0–100, where 0 represents the worst outcome possible and 100 is representative of the best outcome achievable. The three outcomes tools used comprised a total of 20 questions (see online supplementary appendix 1). These questions formed the basis of the tier 2 outcomes relating to utility of care.1 6 7 They were grouped into questions relating to three domains: pain, function and psychological and secondary health markers. These domains were linearly scaled within each category to a score where 0 represented the worst outcome and 100 the best possible outcome. The scores for each of the three domains could then be summed to form an aggregate score out of 300. The percentage change in patients' preoperative and postoperative outcomes was then compared across each separate domain as well as the summed score percentage change. This provided a score for the numerator of the value equation.
Supplementary file 1
This approach to outcome scoring was novel and only used data already existing and mandated by NHS systems. No additional questions were asked to patients to those already routinely collected. The aim of this approach was to enable a different perspective of clinical outcomes to be assessed. Improving outcomes relating to pain, function and psychological well-being is pragmatic and of clear need from the patient's perspective and forms the basis of clinical decision making when planning treatment.
In order to establish baseline costs, each care pathway was mapped in detail (figure 1). Each part of the pathway was then allocated a cost. An economic assessment at the individual patient level was then performed. The total cost per patient was established using the Patient Level Information Costing System (PLICS) methodology.26 These patient-level cost data were verified and cross-checked for accuracy using the electronic patient record.
Income was calculated using the parameters set by NHS England. This is done according to the condition and treatment-specific code set by the Office of Population Censuses and Surveys (OPCS) Classification of Surgical Operations and Procedures and corresponding Health Resource Group (HRG) tariff.27–30 The OPCS similarly does not unbundle elements that are coded and paid for separately (eg, consultant or anaesthetist cost). An estimation of per-patient reimbursement allowed the margin to be calculated. Margin was considered to be reimbursement minus costs. A margin figure could then be provided at a patient level and was used as an adjunct to cost as the denominator to the value equation. The economic evaluation started at point of referral from general practitioner to the provider and included the postoperative care period (outpatient and physiotherapy reviews). The cost of the primary care in the community prior to the initial referral was excluded as secondary care costing systems lack access to such data.
Value calculation
The individual patient-level outcome scores together with costs enabled both an individual and cohort model assessment of value. Percentage change in meaningful outcome could be plotted against cost. These data points formed the numerators and denominators of the value equation, respectively. Data sets were aggregated for all patients in each model. This enabled a meaningful comparison between the two models and a methodology for calculating value.
Pathway populations
Each model care pathway comprised 25 patients who complied with the described inclusion and exclusion demands. There was no significant difference on t-testing between groups with regard to age, sex or the number of comorbidities of the subgroups (table 1). The two model care pathways are described in figure 1.
Age, sex and ASA score
There was 100% survival in both cohorts. There was no significant difference in PROMs as assessed by either the traditional or reformatted outcome assessment techniques (figure 2). Patients in both models demonstrated improvements in EQ-5D-5L, EQ-VAS and OHS in excess of the national expected average. Similarly, when outcomes for both models were analysed from the described patient-centred prism, improvements were noted with regard to pain, function and psychological markers. At an individual patient level, however, variation was noted in outcomes, with not all patients uniformly seeing improvement in all domains (figure 3A).
(A) Outcomes (EQ-5D-5L, EQ-VAS, Oxford Hip Score): traditional approach. (B) Outcomes (pain, function, psychological): reformatted patient-centred approach. EQ-5D-5L, five-level EuroQol-5D; EQ-VAS, EuroQol-Visual Analogue Scale.
(A,B) Change in response to PROM questions before and after surgery. EQ-5D, EuroQol-5D; EQ-VAS, EuroQol-Visual Analogue Scale; OHS, Oxford Hip Score; PROM, patient-reported outcomes measure.
The data required multiple quality reviews to ensure only related costs had been included (figure 4). Despite this costing outliers were uncovered, including those whose total cost was less than the prosthesis alone. Given that this was implausible, such information was removed from the final analysis. Model 2 generated lower costs compared with model 1 (table 2). Model 2 had a leaner pathway and produced a small but inconsistent positive margin; however, this was not statistically significantly on t-testing (p>0.05).
Reimbursement, cost and margin
Pathway total cost to provider, total income to provider (ie, tariff) and margin by patient.
Both models delivered good clinical outcomes. However, model 2 delivered better value given that the associated costs were lower (figure 5). This is likely due to the more standardised nature of the IPU model characterised by a single point of entry. A single point of entry hastens the patient's journey and the patient can proceed to surgery faster. This potentially reduces the ill effects of a protracted wait, meaning that they are more likely to be in a better physical condition when they do have surgery. This can undoubtedly influence length of stay and is likely to have a positive effect on their postoperative recovery. The initial triage and management by physiotherapists and ESPs is also less costly than having a surgeon perform this role. Pathway process mapping facilitates a multidisciplinary approach and allows each member of the MDT to optimally perform their role in the delivery of care. The standardised IPU in model 2 facilitated better communication and teamwork between ESPs and orthopaedic surgeons. This expedited the diagnostic, clinical decision making and treatment processes.
Value calculator. EQ-5D, EuroQol-5D; EQ-VAS, EuroQol-Visual Analogue Scale.
Primary routine hip osteoarthritis is a rational starting point in the development and implementation of a standardised VBHC clinical care model and value assessment framework. The condition is high volume, important for patients, can be discretely segmented and offers the potential for a standardised linear pathway that can be delivered efficiently through an intentionally designed IPU. Outcome assessment for this pathway is already recommended with well-established and universally documented outcome tools. Cost analysis of a linear standardised pathway is more predictable independent of economic evaluation methodology. This study has demonstrated that a well-designed, standardised, multidisciplinary approach (as evident in model 2) generated equivalent clinical outcomes to the traditional care model. The multidisciplinary approach provides patients with good care in a standardised and timely manner. This designed approach offers lower costs and subsequently better margin generation. This is important as generation of a positive margin remains important to support long-term service viability and stability.
Both models delivered similar improvements in clinical outcomes. This was true when measured using the existing validated and universally collected PROMs (EQ-5D-5L, EQ-VAS and OHS), as well as when scores were rearranged into the three patient-centred outcome domains (pain, function and an assessment of psychological and secondary health markers). Providing patients with a holistic and meaningful decision-making tool for their treatment options is part of good clinical practice,31 and studies have shown quality decision aids do affect the proportion of patients going forward with joint replacement surgery.32 Variance in our PROM data sets was noted, emphasising the point that the care that is delivered does not always result in positive outcomes. Harm is a potential outcome of any intervention.33 34 Arguably what is more important than the absolute values is the percentage change that can be expected for an individual regarding outcomes that resonate with their expectations.
Hierarchies of outcomes regarding survival, degree of recovery, its process, health sustainability and disease recurrence are separate phases of care which broadly correspond to each other in a time-dependent manner1 (online supplementary appendix 2). The VBHC agenda assesses relevant patient-related outcomes at each level of the hierarchy. This was done using the standard data set mandated by NHS England.23 While these validated, widely accepted and easy-to-record outcome measures have formed the standard for outcome reporting for THR in the NHS, they are not easily interpretable for the patient. The VBHC agenda asserts that outcomes should have meaning to patients and carers and be measured over the whole pathway of care. This requires the data to be reformatted into a patient-centred prism to facilitate meaningful interpretation. The methodology used in this study is novel in that respect, and while intuitively sensible requires further evaluation. It is important to consider the inadvertent and potential unknown impacts of combining independent validated measures into compound scores. Consequences of such an approach include issues relating to question weighting, rescaling and reliability of the subsequent outcome measure, and how this affects value measurement.35 36 Further work is being conducted to review how patients perceive the validity of the reformatted outcome scores in terms of how they weight the importance of the outcomes measured and what other outcomes they view as significant. However the questions asked in this study are universally accepted ones, and the data are easily returned to traditional formats. Such novel approaches are gaining increased but judicious support.37
Importantly, the measures assessed are universally requested for collection by the NHS. The collection of these PROMs forms part of the tariff generation of hip replacement in the form of best practice tariff. Consequently, the methodology used to evaluate outcomes in a patient-centred manner did not introduce any new elements and could be easily applied by any trust undertaking such data collection.
Inaccurate costing analysis frustrates clinicians and non-clinicians alike and can impede the delivery of stable and solvent clinical services. Accurate economic clinical costing is a patient-centred issue. Assessment of cost can be achieved in many ways. The VBHC agenda suggests time-driven activity-based costing (TDABC) as the methodology to most accurately measure pathway cost.8 Currently the NHS does not routinely use TDABC as its economic evaluation process but rather uses PLICS.26 38 PLICS was promoted by the Department of Health as a patient-based bottom-up costing approach. It replaced previous top-down models that often employed service-level aggregates. PLICS uses elements of an activity-based costing modelling and apportions direct and indirect individual patient-level costs by the actual resources used. However, PLICS models continue to use cost pool allocation techniques when estimating different materiality by quality scores. Pooled costs are not patient-specific and can inadvertently become a significant driver to the cost matrix.26 38 The TDABC model also incorporates activity-based costing but using a time-driven approach.8 TDABC suggests measurement of two main factors: first, the cost per minute of each process within the pathway, and the second the specific time devoted to the activities themselves. The cost of a fixed event is the product of the cost of the activity per minute and the number of minutes it occurs for. The total pathway cost is the sum of each fixed point on the pathway. To that end accurate pathway mapping is an essential prerequisite for TDABC. In this study, model 2 had been designed to deliver maximum clinical benefit while using each clinician (ESP or orthopaedic surgeon) at the top of their respective licence. This proved more cost-effective while having no detriment to clinical outcomes. Despite this, when worked out in terms of margin generation, both pathways failed to consistently deliver a significant positive margin (figure 4). Model 2 on average generated a modest margin of 0.6% but it lacked consistency. This relates to the compensation structure. Income for elective work can be calculated using HRG tariff reimbursement rates. To add to this financial complexity, income is frequently provided on the basis of a block contract. This is where the trust providing care is not paid on a per-episode basis but rather given a block of funds to manage all the conditions and patients for a service line. Such block contracting can divorce interest between service delivery and clinical outcomes. Similarly, fee-for-service business models can do the same while incentivising income-generating interventional procedures. Incorporating outcomes into a bundled business model approach is a way to reprioritise the delivery of quality clinical outcomes while improving care standardisation and promoting the design of effective clinical pathways.39 In comparison with other analyses, the reported costs in this study are comparable with those recorded both nationally and internationally.40–42 Going forward HRG rates have been recently reduced for those with comorbidities by 13.25%.43 Given that the majority of patients with hip osteoarthritis have many comorbidities, the burden on the system is even greater.
Value calculator
Understanding how different pathways compare is useful when needing to objectively assess and agree on how we can best deliver healthcare while aligning all the involved stakeholders. The value calculator in this study describes a methodology to achieve this. The calculator pictorially and objectively describes value and compares pathways that manage the same condition. Crucially the outcomes assessed are ones that are important to the patient and are pertinent at an individual level as they measure change instead of absolute values. Positive change is what patients and clinicians wish to achieve, and by mapping this against pathway costs it provides evidence as to why continuing to fund such care is important. This is of relevance currently given the focus that is on elective care. Conditions such as hip osteoarthritis and THRs feature widely on national lists of 'procedures of limited clinical value'.44 Such lists are concerning when, as demonstrated by this study, quality care can have such a positive impact on a patient's pain, function and psychological well-being. Previous high-quality clinical studies have suggested THR for the management of hip osteoarthritis may be the 'operation of the century'.45 Objective value calculation is important to verify such claims and highlights the need to fund pathways and treatments that offer such high value. If there is an opportunity to support more effective and efficient pathways for the same condition, the value calculator can again help mitigate against the subjectivity of individual preferences. It helps to provide a rationale for objective pathway redesign and care standardisation with patient-centred outcomes at the fore.
Value calculation can be performed but it remains challenging for organisations. It requires considerable resource and access to NHS PROMs and costing information. Despite being a high-volume pathway, the small sample size here reflects these critical issues. Data capture, even for this small cohort, was time-consuming and subject to innumerable barriers. Having initially attained the primary data set, considerable effort was needed to make constructive use of it. The reasons for these difficulties were multifactorial. In the midst of front-line clinical care, data collection may be perceived as an adjunct to duty and is not always perceived to be mandatory. No doubt quality suffers accordingly. If data capture, and specifically outcomes collection, becomes more relevant to financial remuneration, it may improve and allow outcomes to be better understood.
The value calculator methodology described also requires good clinical leadership and relies heavily on secure relationships between clinicians and those responsible for managing costing information systems. The absence of such a collaborative relationship makes meaningful clinical and economic evaluation very difficult.46 47 Reimbursement contracts that include outcomes will stimulate the VBHC approach and promote bundled pathways that deliver it.48 49 Accurate economic evaluation forms the denominator to the value equation and considering the merits of TDABC against PLICS is important going forward.38 40 50 This study found the PLICS data to be challenging, and a significant amount of work was required to verify its individual components. PLICS incorporates elements of pooled costing mechanisms which inadvertently can distort the calculation (eg, management and overhead costs). This study was conducted in a tertiary-level teaching hospital that is also a major trauma centre. Overhead costs are significant and PLICS accounting can skew data because of aggregation and pooling.
We accept that this study has several flaws. These include the accuracy of the costing data given the limitations of the PLICS methods, a relatively small patient population and the limited follow-up period. Although the methodology is broadly generalisable, the cost and the value of reimbursement will vary over time and cannot be compared directly. A separate potential flaw to the study is its dependence on the VBHC framework as described by Porter and Teisberg7 in order to generate its methodology. While such frameworks may not be directly applicable to all conditions and segments, routine orthopaedics conditions such as hip osteoarthritis do offer an opportunity to assess this technique at the coalface of clinical work and assess potential clinical and patient-centred benefits.
There is also a need to validate the method used to rearrange hip PROMs into a patient-centred outcomes set. The number of questions that comprise the domain for psychological and secondary health markers is limited, and future revisions require this to be expanded and supplemented.
This study has however shown that a standardised MDT pathway can offer high-value care. Intentionally designed, linear elective services offer the opportunity to develop and evaluate VBHC care models. Thought needs to be given to condition segmentation before commencing. The multidisciplinary approach described allowed staff to engage at their highest level of licence, and in doing so facilitated patients maximising the individual outcomes they attained. Implementing a VBHC approach will change the way healthcare is incentivised, and ultimately has the potential to reinvent the funding structure while delivering sustainable, equitable and effective healthcare services.
We acknowledge and give thanks to all in the trust (both clinicians and non-clinicians) who have helped to deliver this study.
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. Assessing hospital cost of joint arthroplasty. Joints 2015;3:186–90.doi:10.11138/jts/2015.3.4.186
DiGioia AM ,
Greenhouse PK ,
Giarrusso ML , et al
. Determining the True Cost to Deliver Total Hip and Knee Arthroplasty Over the Full Cycle of Care: Preparing for Bundling and Reference-Based Pricing. J Arthroplasty 2016;31:1–6.doi:10.1016/j.arth.2015.07.013
BOA statement. National Tariff for Trauma and Orthopaedics 2017-19 presents major risk to patients. 2018 https://www.boa.ac.uk/wp-content/uploads/2016/12/National-Tariff-01-12-16.pdf (accessed August 2018).
Royal College of Surgeons Briefing. Procedures of Limited Clinical Value Royal College of Surgeons Briefing. 2018 https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/rcs-briefing-procedures-of-a-limited-clinical-value-jan-11.pdf (accessed August 2018).
Learmonth ID ,
Young C ,
Rorabeck C
. The operation of the century: total hip replacement. The Lancet 2007;370:1508–19.doi:10.1016/S0140-6736(07)60457-7
Nilsson K ,
Bååthe F ,
Andersson A , et al
. Experiences from implementing value-based healthcare at a Swedish University Hospital - a longitudinal interview study. BMC Health Serv Res 2017;28:169.
Erichsen Andersson A , et al
. The need to succeed – learning experiences resulting from the implementation of value-based healthcare. Leadersh Health Serv 2018;31:2–16.doi:10.1108/LHS-08-2016-0039
Piccinin MA ,
Sayeed Z ,
Kozlowski R , et al
. Bundle Payment for Musculoskeletal Care: Current Evidence (Part 2). Orthop Clin North Am 2018;49:147–56.doi:10.1016/j.ocl.2017.11.003
Rana AJ ,
Bozic KJ
. Bundled Payments in Orthopaedics. Clinical Orthopaedics and Related Research® 2015;473:422–5.doi:10.1007/s11999-014-3520-2
Sabharwal S ,
. Time-driven activity based costing of total knee replacement surgery at a London teaching hospital. Knee 2015;22:640–5.doi:10.1016/j.knee.2015.07.006
Contributors LG: conducted analytical and research work for the study and developed the script for submission. JC: conducted analytical and research work for the study and developed the script for submission. CP: helped to collect the data for the study. MG: performed clinical work examined in the study and helped to develop the models of care. JS: contributed to the development of the models of care and study design. JM: helped to plan and oversee the study. TJC-S: helped design, plan and action the study, and oversaw the study, data collection analysis, reporting and study write-up.
Data sharing statement No additional data are available.


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Eye For Film >> Movies >> Summer Of Soul (...Or, When The Revolution Could Not Be Televised) (2021) Film Review
Summer Of Soul (...Or, When The Revolution Could Not Be Televised)
Reviewed by: Amber Wilkinson
"There's a difference between talking about something you remember and talking about something you have just watched – something to think about when you watch yet another documentary about another old white guy who has already had 15 films made about him" | Photo: Mass Distraction Media
In the US, February is designated Black History Month and there were a number of films at Sundance this year acting as a illustration of why this sort of additional focus remains so vital. Watching documentaries like this debut from Ahmir "Questlove" Thompson, My Name Is Pauli Murray and Ailey is a reminder of how many vital stories about African-American pioneers and communities have been, if not completely erased, then most certainly left out in the cold by historical chroniclers.
This joyous celebration of the 1969 Harlem Cultural Festival – which an initial intertitle notes happened in the same year as Woodstock – not only features some electrifying performances but also takes a whistle-stop tour through some of the key politics, news stories and cultural developments of the era. British viewers who remember the TV show The Rock 'n' Roll Years, will find a similar, though ultimately more complex, structure at play, as the music of the era is dovetailed with archival news footage and interviews with some of those who were there.
The end result is a triumph of editing from Joshua L Peterson (What Happened, Miss Simone?) and archival research, which brings the vibrancy of this six-week free concert series that drew a crowd of 300,000 to the fore, while also leaving room to ask questions about how this footage came to languish in a basement for 50 years and the, more general, importance of seeing a history you remember immortalised on screen.
Thompson - who took home both the US Doc Grandy Jury Prize and Audience Award at Sundance - is certainly on to a winner in terms of content, with performances including The 5th Dimension's Aquarius/Let The Sun Shine In, Nina Simone's Young Gifted And Black, along with gospel from Mahalia Jackson, and Stevie Wonder, who sings and puts in some serious beats on a drumkit. The music is, as you would expect, incredible, but there's also a quirkiness to all this live performance – from Wonder being followed around the stage by someone holding an umbrella over him to the Pips putting on the smooth moves as the then up-and-coming Gladys Knight belts out I Heard It Through The Grapevine. This is coupled with a 'going to church' element of some of what was presented, not only through Gospel music but speeches from the likes of the Reverend Jesse Jackson recalling the assassination of Martin Luther King – moments that have a spiritual purity and resonance that put me in mind of Aretha Franklin in last year's Amazing Grace, another film that waited far too long to see the light of day.
Thompson's idea of playing back the footage to some of the stars and audience as a way of beginning a conversation about the event has a striking immediacy. There's a difference between talking about something you remember and talking about something you have just watched on screen – something to think about when you see yet another documentary about another old white guy who has already had 15 films made about him.
The recollections of people like The 5th Dimension's Marilyn McCoo and Billy Davis Jr, along with audience members including Musa Jackson and Dorinda Drake, open the door for Thompson to spin out into broader considerations of everything from the rise in the popularity of dashiki fashion to the ramifications of the deaths of JFK and King the year before to the Black Panthers and civil rights movements of the time. Some of the contributors touch on prejudice, such as McCoo's dissection of the ridiculous suggestion that 5th Dimension had "a white sound" but there's also a wealth of anecdote here, such as the lost wallet that led to her band's recording of Aquarius and reminiscences about the event's organiser Tony Lawrence, whose larger than life personality and boss-level hustling brought it to life. If there's one thing you want from this film, it's more - more of the performances, more of intricacies of the politics and cultural shifts of the time - but Thompson crams every second of this two-hour film with information.
The theme of this year's Black History month is The Black Family: Representation, Identity and Diversity - it may be long overdue but it's here in all its glory, don't miss it.
Reviewed on: 04 Feb 2021
During the same summer as Woodstock, over 300,000 people attended the Harlem Cultural Festival, celebrating African American music and culture, and promoting Black pride and unity. The footage from the festival sat in a basement, unseen for over 50 years, keeping this incredible event in America's history lost – until now.
Director: Questlove
Starring: Stevie Wonder, B.B. King, Nina Simone, Moms Mabley, Mavis Staples, Abbey Lincoln, Mahalia Jackson, Jesse Jackson, David Ruffin, Sly and Stone the Family, Cal Tjader, Max Roach, Brothers The Chambers, Gladys Knight & The Pips, Hugh Masekela
Doc/Fest 2021
DOC NYC 2021
If you like this, try:

redpajama_set_name: RedPajamaCommonCrawl


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Kansas Law BlogLegal updates, news, and commentary from the attorneys of Baker Sterchi Cowden & Rice LLC
Utilizing the Kansas Uniform Interstate Depositions and Discovery Act
November 27, 2013 | Angela Higgins
Kansas has joined a majority of states in passing the Uniform Interstate Depositions and Discovery Act ("UIDDA"), which is codified at K.S.A. 60-228a. The UIDDA replaces the arcane practices of commissions and letters rogatory with a more straightforward approach to obtaining discovery from third parties in states outside the jurisdiction of the court where your case is pending.
The procedure is simple, though Kansas courts are relatively unfamiliar with the statute, which was enacted in 2010. To obtain a Kansas subpoena for materials to be used in another jurisdiction, a litigant must first obtain a properly-issued subpoena from the home court. Once that subpoena is issued, the foreign subpoena, a proposed Kansas subpoena, and a docketing fee for a new civil case should be transmitted to the clerk of court in the county in which the subpoena recipient is located. The cover letter to the clerk should specifically cite K.S.A. 60-228a, and it is probably best practice to set forth the pertinent text from the statute:
(c) Issuance of subpoena.
(1) To request issuance of a subpoena under this section, a party must submit a foreign subpoena to a clerk of court in the county in which discovery is sought to be conducted in this state and pay the docket fee as required by K.S.A. 60-2001, and amendments thereto. A request for the issuance of a subpoena in this state under this act does not constitute an appearance in the courts of this state.
(2) When a party submits a foreign subpoena to a clerk of court in this state, the clerk, in accordance with that court's procedure, must:
(A) Promptly issue a subpoena for service on the person to which the foreign subpoena is directed; and
(B) assign the subpoena a case file number and enter it on the docket as a civil action pursuant to K.S.A. 60-2601, and amendments thereto.
(3) A subpoena under subsection (c)(2) must:
(A) Incorporate the terms used in the foreign subpoena; and
(B) contain or be accompanied by the names, addresses and telephone numbers of all counsel of record in the proceeding to which the subpoena relates and of any party not represented by counsel.
Service of the subpoena must be proper under the Kansas statutes.
Kansas permits the issuance of records subpoenas, but most counties' subpoena forms require the option for the subpoena recipient to appear in person. K.S.A. 60-245, which pertains generally to subpoenas, is modeled upon Fed. R. Civ. P. 45, and contains virtually identical provisions and limitations.
Attorneys: Angela Higgins
About Kansas Law Blog
The BSCR Kansas Law Blog examines significant developments, trends and changes in Kansas law on a broad range of topics that are of interest to Kansas practitioners and to businesses evaluating risks under Kansas law or managing litigation subject to Kansas law. Learn more about the editor, Bryan Mouber.
The Kansas Law Blog is made available by Baker Sterchi Cowden & Rice LLC for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. Your use of this blog site alone creates no attorney client relationship between you and the firm.
Do not include confidential information in comments or other feedback or messages related to the Kansas Law Blog, as these are neither confidential nor secure methods of communicating with attorneys. The Kansas Law Blog should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.


DenizBank was founded in 1938 as a state-owned bank in order to provide funding for the developing Turkish maritime sector. In October 2006 DenizBank was acquired by Dexia, a Belgian financial group. Since 8 September 2012 DenizBank operates under the umbrella of Sberbank (Russia). DenizBank provides a range of products and services in retail and corporate banking for local and international clients.
DENİZBANK A.Ş. is the 9th largest bank in Turkey in terms of total assets. In 2017 its total assets were 121,05 bln TRL, providing the bank with the market share of 3.91%. In 2017 the bank's net income was 1 879,79 mln TRL.
DENİZBANK A.Ş. is rated by Fitch, Moody's. Long-term credit rating assigned to the bank by Fitch is BB+ (speculative). Long-term credit rating assigned to the bank by Moody's is Ba3 (non-investment grade speculative).
DENİZBANK A.Ş. participates in deposit guarantee scheme of Turkey. This scheme covers accounts up to 100,000 TRL per bank per depositor.


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Parliament backs new laws to crack down on letterbox companies
S&D - Socialists & Democrats in the European Parliament
Press release on socialistsanddemocrats.eu
The European Parliament today backed new rules governing how companies can move between EU member states. The right wing ECR Group had attempted to block the proposals that will help crack down on companies artificially moving their headquarters to other member states to avoid taxes or social legislation.
S&D MEP and author of the report Evelyn Regner said:
"We are pleased that the Parliament has overwhelmingly backed our position, butare disappointed by the attempt of right-wing groups to block these proposals.These new rules will create a clear procedure to follow for genuine businesses to set up offices in other member states, while cracking down on companies doing it for artificial reasons such as evading tax, social contributionsor avoiding national labour laws. We have been pressuring the European Commission to crack down on this type of abusive behaviour for years and finally they presented draft proposals to do this earlier this year.
"The European Parliament has greatly strengthened the proposals to ensure that workers are fully informed and consulted throughout the process whenever a company wants to move offices to another member state. If a company is attempting to merge or relocate then workers must be fully involved and have their participation rights protected.
"Company mobility should be about genuine economic activity, not just searching for the laxest labour protections or lowest tax rates. We can't allow a race to the bottom, with member states competing to offer the lowest standards possible. Authorities need to be able to check, if a company is relocating for genuine reasons or simply creating an artificial arrangement to avoid theirobligations and responsibilities. If they are engaged in an artificial arrangement then the company should not receive the necessary certificate it needs to finalise the cross-border operation.
"These proposals are important to help rebuild citizens' trust in the Single Market. Now, we ,must convince the Council to protect workers' rights on the highest possible level and find a solutionto show that it brings genuine economic benefit and crackdown on companies abusing it to avoid their taxes and their responsibilities."


"The internet? Cars work in the real world!" Why sign up to auto body programs online?
If you are thinking about working in the automotive industry, looking into the availability of auto body programs online is a good initial step, albeit one that it can be easy to discount, given the physical nature of working with cars. It is also worth considering this kind of approach if you have a reasonable amount of knowledge but no previous employment in that field- getting some official certification attached to your name goes a long way to reassuring potential customers that you know what you are doing. In a crowded marketplace, anything that can differentiate you from the cowboys is well worth thinking about.
The good thing about training in the auto body field is that there is a huge amount of choice. Apart from the fact that there is so much that goes into working with cars (do you want to be an engine mechanic, a bodywork specialist, an interiors technician specialising in on-board electronics, a spray painter, a wheels and tires specialist?), there is a crowded training marketplace. Simply typing the words auto body programs online into a search engine brings up all kinds of options, from full-time apprenticeships for the young, through part-time evening classes at community colleges, or distance-learning schemes run by various online bodies. There are a myriad of articles around that give practical advice, to varying degrees of detail. You will also find countless forums of people eagerly discussing the modifications on their particular makes of car. Some of this will be worthless, though even if you are serious about being a professional, it is worth dipping into these informal sources from time to time. The usual caveats apply about thinking for yourself of course, but it is counter-productive to overlook or simply write off any source of information from the outset. If you are looking to become a professional in this field, however, then doing a course is probably essential- you will need to have a good general framework of knowledge about all aspects of auto body work- the basics of shop work, information about tools and materials, metalworking and welding, and body painting, to name but a few. With the basic knowledge in place, you can then add to your expertise or specialise at your leisure.
If you are 16, or 18, and looking to learn a trade, then a college is probably the right way forward for you. Auto body repair is an inherently hands-on subject, and there is no way that you can learn how to fix a dent on a car's bodywork, or to mask a panel for re-spraying, whilst sat at a computer desk. There are disadvantages, however, in signing up to something full-time if you need to keep working, and cannot work around someone else's schedule, or perhaps have problems with location. This is when auto body programs online can be more useful. Of course, always ask what you are getting from the course, and if possible get testimonials from people who have gone through it.


Edit 515 Limited - Who are we?
Having all enjoyed successful careers in diverse senior management roles (international finance, commercial banking, academia, engineering, logistics, intelligence services, manpower-planning and management consultancy), the original founders and Directors are still very much involved with the company.
Edit 515 Limited's principle aim was (and still is) the design and use of bespoke business simulations. With forty five years continuous experience and an estimated 200,000 participants later (and increasing to more than half a a million if the Global Management Challenge GMC) is included), we are confident that our experience in designing realistic, robust and relevant simulations is second to none.
Because we are small, we are flexible and can tailor our service to client needs. We are also inventive and can usually provide a solution to the most extraordinary requests.
Our preferred approach is to invite enquiries from potential clients, discuss their objectives, resources and constraints (if any), make helpful suggestions, decide on an access method and issue a priced proposal. If the proposal is accepted, we then work closely on the detail with the client's training staff before the event takes place.


The Scottish countryside is beautiful. Regardless of the season, it can be a magical place for a romantic getaway. Especially when you are staying somewhere special.
With that in mind, today's Big Deal whisks you off to the elegant and historic Friars Carse Hotel near Dumfries for a cosy and classy overnight stay in beautiful surroundings. It has inspired poetry in the past. No pressure to write a sonnet; just enjoy your stay.
With purchases valid until the end of May, it's the ideal chance to book that break for the Borders.
With its origins in a 13th-century friary, Friars Carse was the home of the Riddell family who regularly hosted a lively local bard called Burns, despite his penchant for rowdy behaviour. The house was remodelled in Victorian times and became a hotel in 1938. It's an imposing and classically-elegant building, set in a woodland estate close to the river Nith, ideal for a romantic break.
Under two hours from Glasgow or Edinburgh, Friars Carse combines historic character and atmosphere with all the contemporary comforts of a country house hotel.
Available Sunday to Thursday, the Big Deal is for a couple to enjoy an overnight stay in a standard double or twin room at Friars Carse. As well as a full Scottish breakfast, guests will also enjoy a two course dinner from the main restaurant menu.
Friars Carse's 21 ensuite bedrooms are individually styled and many have views over the surrounding fields, gardens or down to the river. This is a historic building so rooms vary in size and layout, giving each a unique character. All guest rooms have WiFi.
We don't recommend you emulate Burns' notorious drinking contest in the dining room at Friars Carse, but the Whistle Restaurant is nevertheless the perfect location for a memorable evening.
The offer includes a two course dinner chosen from a menu that uses fresh, locally-sourced produce. Expect seasonal Scottish fare with a nod to the hotel's rich heritage.
If you want to pursue the Burns theme, there are plenty of local associations with the poet in the vicinity, including a Burns Trail, an easy walk taking in the Hermitage, within the hotel grounds, and nearby Ellisland Farm where he wrote works including Tam o'Shanter and Auld Lang Syne.
Swapping stanzas for salmon, anglers may want to take advantage of the Friars Carse lengthy fishing beat on the Nith, accessed by paths direct from the hotel, with numerous spots to go after salmon and trout.
A short break in Dumfriesshire is a treat any time of the year, but winter and early spring show the Scottish countryside at its finest.
Today's Big Deal stay at Friars Carse would be the perfect way to treat a loved one, offering a romantic atmosphere and some great local cuisine.
Valid from 21.11.18 until 30.05.19.
The Big Deal is for an overnight stay for 2 people in a standard double or twin room with full Scottish breakfast and 2 course set dinner each from main restaurant menu.
Dinner is served 6.30-8.30pm; menu is subject to change.
Once reservation has been made, bookings are non-transferable and non-refundable.
Multiple purchases permitted and may be used for consecutive nights. Must be purchased and booked separately.
Children welcome. Ages 0-11 stay free, pay for meals as taken. Ages 12 and over classed as adults.
Pets welcome at £15 per night. Max 1 per room.


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West Palm Beach to Twin Falls distance (PBI to TWF)
Distance between West Palm Beach, FL (PBI) and Twin Falls, ID (TWF)
Flight distance from West Palm Beach to Twin Falls (Palm Beach International Airport – Magic Valley Regional Airport) is 2221 miles / 3574 kilometers / 1930 nautical miles. Estimated flight time is 4 hours 42 minutes.
Driving distance from West Palm Beach (PBI) to Twin Falls (TWF) is 2656 miles / 4275 kilometers and travel time by car is about 44 hours 16 minutes.
West Palm Beach - Twin Falls
Map of flight path and driving directions from West Palm Beach to Twin Falls.
Shortest flight path between Palm Beach International Airport (PBI) and Magic Valley Regional Airport (TWF).
How far is Twin Falls from West Palm Beach?
There are several ways to calculate distances between West Palm Beach and Twin Falls. Here are two common methods:
Magic Valley Regional Airport
City: Twin Falls, ID
IATA Code: TWF
ICAO Code: KTWF
Coordinates: 42°28′54″N, 114°29′16″W
The time difference between West Palm Beach and Twin Falls is 2 hours. Twin Falls is 2 hours behind West Palm Beach.
West Palm Beach (PBI) → Twin Falls (TWF).
West Palm Beach to Hailey distance (PBI to SUN)
West Palm Beach to Pocatello distance (PBI to PIH)
West Palm Beach to Boise distance (PBI to BOI)
West Palm Beach to Elko distance (PBI to EKO)
West Palm Beach to Idaho Falls distance (PBI to IDA)
West Palm Beach to Jackson distance (PBI to JAC)
West Palm Beach to Butte distance (PBI to BTM)


Watch How- To Videos. Schedule Service. Log Into FordPass. Jul 05 subscribe to the Windows Mobile Newsletter — your source for information on Microsoft ActiveSync , more from Windows Mobile: • Sign up , tricks, cool downloads , new Windows Mobile devices, tips , · Stay up- to- date with information on the latest Microsoft ActiveSync upgrades, special offers, other mobile software upgrades, setup help more.
Set the Auto Sync feature for every 15 minutes or manually sync on your own. Each Note Card type is designed to complement the type of note you' re taking.
Learn all about your Ford vehicle on the Official Ford Owner Site! Pocketbook is a free budget planner that makes managing personal finance ridiculously panionLink will synchronize your PC data to your Phone and Tablet.
It synchronizes data with handheld devices and desktop computers. Different types of notes should be treated differently.
Find SYNC & Support Advice. ActiveSync is a mobile data synchronization app developed by Microsoft, originally released in 1996. Stay up- to- date with information on the latest Microsoft ActiveSync upgrades setup help , other mobile software upgrades, tips , new Windows Mobile devices, subscribe to the Windows Mobile Newsletter — your source for information on Microsoft ActiveSync , cool downloads , tricks, special offers, more from Windows Mobile: • Sign up the latest versions of our products!
The processor mother board of a Ford Sync system is similar to a slow but steady laptop computer. To install any one of the programs, you should have the program distribution package on your local storage device.
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With its excellent sound quality, the Welch Allyn Elite helps you to hear more of the sounds you need to hear and less of what you don't. Using its two-position frequency selection switch, you can listen to either high or low frequencies to easily pick up low diastolic murmurs or high-pitched pulmonary sounds. In addition, accessories can be purchased that electronically capture, record and distribute body sounds or allow multiple users to co-listen, making the scope perfect for teaching or consult situations.
Two-position filter switch lets you listen to high or low frequencies.
Adjustable binaurals and eartips ensure all-day comfort.
Long-life lithium ion battery lasts up to 140 hours.
Optional Distributor allows others to hear simultaneously.
Optional Analyzer stores and analyzes the sounds you hear right on your PC.
Click the button below to add the Welch Allyn Elite Electronic Stethoscope to your wish list.


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Caesarsallad är en sallad från 1920-talet som är vanlig i det amerikanska köket. Originalreceptet innehöll romansallat, vitlöksdoftande olivolja, worcestershiresås, citronjuice, vitlöksdoftande krutonger, parmesan och ägg.

Rätten skapades av Caesar Cardini, som till ena hälften var italienare och andra hälften mexikan. Efter första världskriget flyttade han med sin bror från Milano i Italien till San Diego i USA, men drev en restaurang i Tijuana i Mexiko för att locka över amerikaner som tröttnat på alkoholförbudet.

Enligt en legend, berättad av hans dotter Rosa, skall han ha skapat rätten på USA:s nationaldag den 4 juli 1924. Maten höll på att ta slut i köket, så han fick hitta på ett nytt recept utifrån vad han hade kvar, och introducerade den nya salladen under en föreställning framför de väntande restauranggästerna.

Många tillägg till originalreceptet förekommer. Några exempel är sardeller, kyckling, bacon, senap, grädde och majonnäs.

Referenser

Externa länkar

Sallader
Maträtter uppkallade efter personer
Amerikanska maträtter
Mexikanska maträtter

redpajama_set_name: RedPajamaWikipedia


text:
Kinetic parameters for phenacetin O-deethylation by recombinant CYP1As and CYP2As
Data are mean ± S.D. of three independent experiments.
Vmax/Km
μM pmol/min/pmol P450 nl/min/pmol P450
CYP1A1 56.2 ± 2.3 1.5 ± 0.1 26.8 ± 2.7
CYP2A6 N.A. N.A. N.A.
CYP2A13
21.8 ± 2.4a,b
2.9 ± 0.3a,b
133.2 ± 17.6a,c
N.A., not applicable.
↵ a P < 0.005 compared with CYP1A1.
↵ b P < 0.05 and c P < 0.005 compared with CYP1A2.


At this this time of year - most of us have our 'winter coats on' and the sun is just coming out... that's right - time to get out of hibernation and time to get in shape!! Sounds like a faff right?! So, we thought instead of the usual obvious 'eat less, exercise more' we're going to give you the little tips that we love to help get you beach body ready - some of which may surprise you!
Dry brushing, hot water and lemon first thing (even better is some apple cider vinegar in here) and as much as you can - just say no to caffeine and alcohol. Your body will thank you!
You ever find that no matter what you do you can't shift that stubborn weight?! Yup - watch your hormones - it's still not widely appreciated but modern life plays havoc with hormones that cause our bodies to go in to storage mode - not enough sleep is terrible for this (also caffeine and alcohol) causing levels of cortisol and leptin to get out of whack - 8hrs a night is great for putting that right.
Whilst we are not suggesting you load up on fries, bread, pasta and pizza, having some low GI (that's glycocemic index - a low level means it releases sugar slowly in to your body) food in your evening meal has actually shown to promote sleep and regulate your hormones - hooray! Our favourite low GI foods are a slice of whole meal bread, quinoa or some sweet potato. Plus starchy veg like peas, beans etc. Nice and filling.
This will fill you up and get your metabolism cracking. Our favourites are: Greek yogurt, oat bran with a handful of berries and walnuts (top tip cinnamon here is tasty and helps regulate blood sugar), porridge ideally with some fresh berries and cinnamon (avoid syrups and dried fruit - sugar spike) and of course scrambled eggs or an omelette.
At bb robinson we are big advocates of preparing food for the week ahead in advance. See below for one of our yummy easy to make recipes to make in bulk and freeze to enjoy through the week. Good preparation means you know what you're eating and can make with nice organic ingredients - wonderful for hormones too!
Super easy to do and tastes great - just involves a bit of chopping. Also - you can pick and choose which veggies to use to suit you - throw ' em all in and enjoy!
Step 1: heat a large pan of boiling water with some organic vegetable stock - add to this: (chopped) courgettes, broccoli, cauliflower and aubergine. Heat until softened.
Step 3: get a nice big oven tray and in goes your softened veg and your onion and mushrooms. Add to this: couple of tins of finely chopped tomatoes (quantity depends on how tomatoey you like it), fresh garlic, sundried tomato paste, lentils (cooked), cayenne pepper and chilli flakes plus Worcester sauce (to your taste preference of course) and salt and pepper. Mix it all thoroughly.
Step 4: Wack in the oven for 45 mins to 1hr (180 degrees C) and to garnish some grated cheese and fresh coriander. Scrummy !!!
Finally - we are not saints and life is short so if you do want to have drinks or treats - don't beat yourself up just be smart with your portions and choices 1) dark chocolate not milk (darker the better) 2) have Greek yogurt and berries rather than a sugary treat 3) a spirit and soda with tonnes of fresh lime vs calorific wine.


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The Korte Company
Building Safely
Key Employees
Korte in the Community
Ralph Korte Legacy
Where We've Built
Centers of Worship
Municipal / Government
Renovations and Additions
Diversified Operations
EM 385 Training
Historic Building Restoration
Why Korte
The Korte Company earns NAIOP awards
The Korte Company earned three well-deserved Spotlight Awards from the National Association of Industrial and Office Properties' Southern Nevada Chapter.
Awards won included General Contracting Firm of the Year, and another for Mixed-Use Development.
These awards add to a pretty long list of honors we've earned. Want to see the rest?
Find the other NAIOP 2019 Spotlight Award winners here.
General Contracting Firm of the Year
For the second time in four years, The Korte Company was named General Contracting Firm of the Year for the NAIOP Southern Nevada Chapter. We previously earned the award in 2016.
"It certainly is an honor to win this award again," said Greg Korte, President of our Las Vegas Division. "It's humbling to be selected among that group (of other contractors)."
The other contenders for the award included some of the biggest contractors in Las Vegas, including some national firms.
Korte said that being a repeat winner of the award is "proof of our good reputation in town of treating clients, subcontractors and community members the way you want to be treated."
In our Korte in the Community page, see the ways we strive to be "a force for good in Las Vegas."
El Benjamin earns NAIOP Mixed-Use honors
The Korte Company has been involved in the resurgence of Downtown Las Vegas for years. One of our latest projects completed is another example of how, project by project, vibrancy is returning to the city's core.
El Benjamin sits at the corner of 6th Street and Bonneville Avenue. The 24,000-square-foot mixed-use development features 12 luxury townhouses on the second and third floors with a boutique restaurant and offices on the ground floor.
The project showcases the mid-century design aesthetic common among structures in the area.
We're accustomed to working in this neighborhood. El Benjamin is located a half-mile southwest of the Fremont & 9th Apartment Complex and just two blocks from the Robert T. Eglet Advocacy Center—both recent projects we've completed.
Curious about how El Benjamin got its name?
It honors French-born U.S. Army officer Benjamin Bonneville, a 19th century explorer of the American west. Incidentally, Bonneville, who died in 1878, is buried in the famed Bellefontaine Cemetery in St. Louis, Missouri, a few miles from our company headquarters.
Get build-smart guidance from our experienced Design-Build team.
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Get the Ebook that Helps Businesses Break DOWN the Barriers and Break THROUGH to the Next Level of Success!
Includes proven strategies that teach businesses how to build a top-down approach that fosters engagement at all levels and creates an environment that JUMPSTARTS morale and SKYROCKETS innovation.
As you expand beyond merely surviving and begin to thrive in the marketplace, the problems you face, and ultimately must solve to be successful in the marketplace grow in complexity.
When you were getting started, keeping a finger on the pulse of your business was easy. But your company is a living, breathing thing and as things have grown, the challenge of knowing exactly what's going on inside it has grown as well.
You need data to stay in touch with your business at all levels. Data can not only validate your concerns, it can uncover the problems you didn't even realize you had that are holding your business back.
The problem is, getting the data your company needs to be successful has become nearly impossible. Gone are the days when an annual survey were enough to keep your business a step ahead of the competition. The marketplace evolves way too fast and unless you have a way to get engage your workforce, you're going to be left behind.
Studies have shown that 63% of employees across the United States are disengaged, costing employers 34% of their entire labor budget. Worse yet, when your workforce is disengaged, turnover skyrockets, morale plummets, and operational costs go up considerably.
So how can you develop a culture that is happy and engaged? We set out to solve that exact problem in our ebook.
Joe Sullivan is an accomplished inventor, innovator, engineer and entrepreneur who launched Vohtr with the goal of forever changing how companies collect and act upon employee feedback. Throughout his career, including a 14-year tenure with Merck, he has earned a reputation for thinking outside the box and challenging the status quo.
As CEO of Vohtr, Joe developed a fun and engaging system to ensure employees know their voices are heard, while providing management with the real-time insight they need to drive immediate improvements. Joe is a patent holder and earned a B.S. in chemical engineering from Virginia Tech and conducted postgraduate research in chemical engineering at Clemson University.


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What is Pradhan Mantri Suraksha Bima Yojna?
Pradhan Mantri Suraksha Bima Yojana (PMSBY) is one of the popular security schemes which was announced by the government of India in the budget of 2015. The other two being Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY) and the Atal Pension Yojana (APY).
It is basically an accident insurance scheme which provides a one-year accidental death and disability cover to the insured. It allows insured to renew the same annually.
Eligibility: ABank saving account holders between 18 years (completed) and 70 years (age nearer birthday) who give their consent to join/enable auto-debit, as per the modality, will be enrolled into the scheme.
Policy period: The cover shall be for one year period starting from 1st June 2015 to 31st May 2016 for which option to join/pay by auto-debit from the designated savings bank account on the prescribed forms will be required to be given by 31st May 2015 - extendable up to 31st August 2015. For the saving A/c holder joining after 31st May 2015 and on or before 31st August 2015 the cover shall end on 31st May 2016.
Premium: Rs. 12/- + service tax (per annum).
Payment Mode: The premium will be directly auto-debited by the bank from the subscriber's account. This is the only mode available.
It will offer a cover for 1-year that will be starting from June 1 to may 31 of the subsequent year. It comes along with the option of auto pay which has to be given by May 31 of every year. Those who want to continue the same after the first year have to inform about it earlier for auto debit before May 31 for successive years.
As on May 14, 2018, around 13.53 crore people had already enrolled under the same. Almost 1.5 lakh people are joining it on a weekly basis.
What is all covered in PMSBY?
Under PMSBY, a risk coverage of Rs 2 lakh will be there to assist you. In case of accidental death and permanent total disability, and Rs 1 lakh for permanent partial disability. Permanent total disability is defined as total and irrecoverable loss of both eyes or loss of use of both hands or feet or loss of an eyesight and loss of use of a hand or a foot.
You can buy this cover as an addition to another insurance plan that you own. IT is not a health policy so there will no reimbursement or coverage for hospitalization expenses that followed by accident, resulting in death or disability.
Accidents or disability that takes place because of natural calamities will be liable to get the required coverage. While death that takes place because of suicide will not be liable to get the cover and even the murders are not covered. Partial disability without irrecoverable loss of an eyesight or disability is not covered. Also, the family would not be liable to receive any benefit if the insured commits suicide.
People who fall in the age group of 18-70 years will be liable to buy the PBSMY. If you have multiple bank accounts then you will be able to join the scheme from a single bank account. Thos who carries a joint account, all holders will be liable to join the scheme. Even NRIs are eligible, but if a claim arises, the claimed benefit will be paid to the beneficiary/nominee only in Indian currency.
How much is the premium and how to pay ?
To avail such benefits, you have to pay Rs 12 as the premium that will be directly deducted from your bank account through the auto debit facility. It should be done in one installment on or before June 1 every year. However, in such scenario where the auto debit takes place after 1 June, the coverage will begin from the date of auto debit of premium.
The annual renewal dates will be June 1st of every subsequent year. Even, if someone is enroled with more than one bank then the claim will be settled with one bank account and the other premium may get forfeited. The premium will be reviewed based on annual claims experience.
Also, there would not be any policy certificate issued to an individual subscriber as the participating banks will be the master policyholders.
Where to buy the scheme from?
You can avail of the scheme through Public Sector General Insurance Companies (PSGICs) and other general insurance companies, in collaboration with participating banks. The banks are open to engaging any general insurance company for implementing the scheme for their subscribers.
To join, you can download the form from http://www.jansuraksha.gov.in/Forms-PMSBY.aspx, and submit it to your banker. Some banks have initiated an SMS-based enrolment process too. It can be done through net banking also.
Customer will get a confirmation message for receipt of the response.
For processing the application, the demographic details and the nominee name, nominee relationship and nominee date of birth will be taken from the details present in the savings account.
In case, the beneficiary details are not available in core banking records, the confirmation will not be taken ahead for processing. A customer can also apply through the nearest branch/net banking.
In case, the auto debit of the premium fails because of some insufficient funds or other reasons, the insurance cover ceases to be in force.
Log in to net banking.
You will be shown PMSBY at the relevant space.
Select the account through which you can easily pay the premium. You can choose to replicate the savings account nominee or add a new nominee.
"I do not hold any other policy of the same".
Select 'Continue'. You will then be shown the complete details of the PMSBY policy you have registered for.
If you are okay with the policy registration details displayed, click on 'Confirm'.
Download the acknowledgment, that carries a unique reference number.
Do save the acknowledgment document for future reference.
Till what period is the cover for?
Closure of bank account or shortage of balance to keep the insurance in force.
In case a member is covered with more than one account and the premium is received by the insurer inadvertently, the insurer will be limited to one account and the premium will be forfeited.
PMSBY covers deaths that take place because of an accident and proved by documentary evidence. In case of incidents such as road, rail and similar vehicular accidents, drowning, death involving any crime, etc., the accident should be reported to the police. In case of incidents like the snake bite, fall from a tree, etc, the cause should be supported by hospital record.
In case of death of the account holder, the claim can be filed by the beneficiary or by his legal heir/s in case there is no nomination made by him. The disability claim will be credited in the bank account of the insured bank account holder. Death claims will be remitted to the bank account of the nominee/legal heir(s).


Your card can be used at over 60,000 participating pharmacies nationwide. The network includes all major pharmacy chains as well as thousands of independent pharmacies throughout the United States.
Pharmacies may not be familiar with every prescription program in which they participate. If the pharmacist does not recognize your card or if you encounter a problem at the pharmacy, DO NOT leave without having the pharmacy call the toll-free number printed on the ID card.
There are payments of up to $10.00 for drugs listed in Tier 1, up to $20.00 for brand name and select generic drugs listed in Tier 2 and up to $50.00 for brand name and select generic drugs listed in Tier 3. For the drugs not listed in Tier 1, Tier 2 and Tier 3 members will pay the network contracted price that has been negotiated. Please pay close attention to the quantities listed by each drug in Tier 1, Tier 2 and Tier 3. Quantities in excess of those listed will result in higher prices generic drugs. On non-preferred brand name drugs, members pay the network contracted price.
What is my average discount on Non-Preferred Drugs?
There is no guaranteed percentage savings on every prescription purchase. The price paid depends upon the pharmacy and the type and quantity of drug purchased. Pharmacies, just like other retail stores, compete against each other and may have special prices on some products. When this is the case, we cannot discount the pharmacy's already low price, but a member will receive the advantage of the pharmacy's special pricing. THE MEMBER ALWAYS RECEIVES THE LOWER OF THE CONTRACT PRICE OR THE PHARMACY'S PRICE.
Once a patent on a brand name drug expires, other drug companies may make a generic version of the drug, with the approval of the Food and Drug Administration (FDA). The FDA's standards for quality are the same for all manufacturers. This means the generic drug contains the same active ingredients as the brand name whose patent has expired, and that its safe, potent and effective.
The use of generic prescription drugs, whenever available, is most cost effective. Don't be shy – discuss your prescription options with your doctor. Ask whether an alternative, less expensive option would work for your condition.
How will I know if there's a generic equivalent available?
What is the difference between brand name and generic drugs?
The brand name is the trade name under which the product is advertised and sold, and is protected by patents so that it can only be produced by one manufacturer for a predetermined number of years. Once a patent expires, other companies may manufacturer a generic equivalent, providing they follow stringent FDA regulations for safety. Generic drugs are drugs for which the patent has expired, allowing other manufacturers to produce and distribute the product under a generic name. Generics are essentially a chemical copy of their brand name equivalents. The color or shape may be different, but the active ingredients must be the same for both. The preferred drug list contains only FDA-approved generic medications.
A preferred drug list is a list of recommended prescription medications that is created, reviewed and continually updated by a team of physicians and pharmacists. The preferred drug list contains a wide range of generic and brand name preferred products that have been approved by the Food and Drug Administration (FDA). Your doctor can use this list to select medications for your health care needs, while helping you maximize your prescription drug benefit. A medication becomes a preferred drug based on safety and efficacy, then on cost-effectiveness.
What is the difference between a preferred brand name drug vs. a non-preferred brand name drug?
A preferred brand name drug is a medication that has been reviewed and approved by a group of physicians and pharmacists, and has been selected for preferred status based on its proven clinical and cost effectiveness. A non-preferred brand name drug is a medication that has been reviewed by the same team of physicians and pharmacists who determined that an alternative drug that is clinically equivalent and most cost effective is available. These designations may change as new clinical information becomes available.


Week 6 was filled with upsets, as many big underdogs came through, even on the road. Given the way the 2017 NFL season is going, the unpredictability is here to stay.
The one position where the Broncos have depth is running back, with veteran Jamaal Charles and second-year man Devontae Booker behind Anderson. But Charles and Booker are more scatback types for passing downs, and only Anderson looks capable of both pounding the ball between the tackles and sliding out on the edge as a receiver.
McCoy, like Adam Gase when he was in Denver, thrives on being versatile and multiple. Neither is true of the Broncos' current personnel. When Lynch is healthy enough to play, he could offer a little wrinkle with potential zone-read plays. But that's about the only thing he could provide as a plus over Siemian, and that doesn't factor in all the further passing issues he would have.
So, you don't have to skip the entire schedule and save your energy for Falcons-Patriots on Sunday night, but you'd be forgiven if you did. To make things even spicier, both teams are staggering a little bit, more than they expected at this point. The loser will be leaning further toward crisis than they were before.
It takes time for the line to develop the chemistry it needs after NHL Jerseys China offseason changes. The play has been inconsistent this year as a result. That wasn't the case on Sunday. On Elliott's second touchdown, Cooper and Collins in particular – as well as tight end Jason Witten – blocked aggressively to create a clear lane for Elliott right up the middle.
While the bulk of the yards on the ground came from Elliott, blocking Raiders Cheap Jerseys helped the run game as a whole absolutely kill it against the Niners. The team ended up with 265 yards total on the ground.


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Harper-Karzai rift reveals PM's deep doubts about Afghanistan
Campbell Clark
Afghan President Hamid Karzai speaks in Kandahar on April 4, 2010.STAFF/Reuters
Revealing his deepening skepticism about Afghanistan's leader, Prime Minister Stephen Harper has upbraided Hamid Karzai for threatening to throw in his lot with the Taliban.
"We have men and women who are over there putting their lives on the line to help the population in its struggle against the Taliban," Mr. Harper told reporters Wednesday.
"These remarks are not helpful and in the context of the dangerous work our people are doing, they are completely unacceptable to Canada and, I'm sure, the same is true for all of our allies."
Mr. Harper's comments not only signal a lack of confidence in Afghanistan's increasingly erratic leader, they reflect what sources say is the Prime Minister's longer-standing skepticism about Canada's prospects of making an impact on the troubled process of nation building in Afghanistan.
Recent comments by Mr. Karzai have undermined confidence among the United States, Canada, and other allies. Last week, the Afghan President accused Western observers of fraud in last year's elections. This week, legislators reported that in private meetings on the weekend, Mr. Karzai twice threatened to quit and join the Taliban, apparently out of frustration at Western pressure. It was seen by many as an attempt to dispel perceptions that he is a puppet of the West.
"He said, 'If I come under foreign pressure, I might join the Taliban,' " Farooq Marenai, a legislator from the eastern province of Nangarhar, told the Associated Press. Mr. Karzai is further alleged to have said that the Taliban rebellion against a legitimate Afghan government "would change to resistance" against foreign occupation. Afghan officials have denied the President made the remarks.
Mr. Karzai's outbursts will not only deepen doubts in Ottawa about its Afghan partner, they are likely to undermine support from other NATO allies at a time when concerted pressure from them is the only thing likely to persuade Mr. Harper to extend Canada's military involvement in the Afghan mission.
Though it's widely believed that public opinion is all that keeps Mr. Harper from extending the military mission, the Prime Minister is in fact an Afghan skeptic, according to one person who has worked with him on the issue. Many in his government and the military favour extending the mission, but not the PM - and not just for political reasons. He wants results.
For almost two years, Mr. Harper has harboured deep doubts about the Afghan mission. He worries that extending it would mean throwing good money after bad, and, more importantly, lives with it. After years in which progress has been elusive, he doubts the impact Canada can have.
Mr. Karzai's recent erratic behaviour has contributed to those doubts, but only partly. Inside the Prime Minister's Office, the Afghan President has long been viewed as a leader who suffers mood swings and changes positions dramatically from one week to the next.
It was only the possibility of damage to Canada's reputation as a North Atlantic Treaty Organization ally that might have changed Mr. Harper's mind about extending the military mission beyond next year, one source said. Indeed, U.S. Secretary of State Hillary Clinton and British Foreign Secretary David Miliband appealed to Canada's sense of responsibility to its allies last week when they publicly asked Mr. Harper to keep Canadian troops in Afghanistan past next July's withdrawal deadline.
But with the Dutch now planning to withdraw and others expressing doubts, Canada can hardly be singled out for its exit strategy. Mr. Karzai's outbursts, blaming Westerners for election fraud and threatening to switch sides, will do nothing to change the minds of those who have decided to quit Afghanistan.
The United States, which has been calling on its allies to contribute more to the mission, called Mr. Karzai's latest remarks "troubling." State Department spokesman P.J. Crowley warned they would undercut support in the United States and elsewhere.
There are efforts to mend fences. Mr. Karzai's spokesman has denied he ever made the remarks. The two top officials in Afghanistan's domestic election agency, accused of being biased toward Mr. Karzai in last year's fraud-plagued elections, have resigned - acceding to a long-standing demand of Western allies. The White House said Mr. Karzai's scheduled May 12 visit to Washington will go ahead as planned.
But the episode will not be forgotten by governments who have been pressing the Afghan leader to make good on promises to clean up corruption, and warning that unless he does, their mission will fail. European governments who face their own skeptical publics may be discouraged from increasing their commitments. The United States and Britain will find it harder to argue that Canada must re-up its NATO commitment as the doubts of allies deepen.
Mr. Harper's government knows it has no choice but to deal with Mr. Karzai. But at the same time, Canada is becoming one of his most vocal critics. And the Afghan President's blasts at his allies are cutting away any chance of changing the mind of a skeptical Prime Minister before next year's withdrawal.
Follow Campbell Clark on Twitter: @camrclarkOpens in a new window


Who says decorating stops at the ceiling?
If you ask me, the ceiling is the fifth wall in a room… and it should not, nay will not stand for being ignored anymore!
Statement ceilings are a huge trend in 2018, so I've rounded up some of my favorites — like the one (above) from Rue Magazine — for inspiration for simple but detailed, unique designs!
Check out 21 incredible ceilings (below)!
This rustic wooden beamed ceiling is the perfect recipe for setting a cozy vibe.
Transforming the ceiling into an accent wall. Bravo!
I love how the bookshelves mimic the design of the ceiling. This room is fun everywhere you look!
Another example of using accents from the ceiling into the room, like with the bookshelves and chandelier pictured here. So COCOCOZY!
The unique detail of this ceiling breaks up all the white, adding texture.
This is what high white beam dreams are made of!
Oh hello, dreamy kitchen! Love the paneling on this light and bright angled ceiling.
Who knew tree stumps could be used for epic ceiling paneling?
With its wooden beams, modern light fixtures and white, bright and airy vibe, this hallway is an absolute Y E S in my book.
When rustic meets chic. This elegant bathroom features a paneled ceiling and chandelier paired with minimalist decor to create an ambiance that's simple, sophisticated, and oh so Insta-worthy.
Love the idea of utilizing the ceiling's beams to incorporate more decor like they did here with the Fish Market sign.
How incredible is this minimalist yet intricate design? Yes please.
Height for days! This 19th century Art Nouveau apartment in Copenhagen houses 13-foot high walls and I just can't get enough of the stunning painted ceilings!
The ivy ceiling takes this Italian dining experience to the next level!
The designers over at the Chicago Athletic hotel did a spectacular job of preserving the building (from 1893!), while maintaining a modern-day luxury feel.
This is one of my all-time favorite East Hampton kitchens! Can you even imagine it without this distinct ceiling?
A love story featuring the fifth wall!
Create eye-catching, but not overpowering designs by using wallpaper that covers the wall and goes over the ceiling.
Everything (including the ceiling) in this Greek-island home by Isabel López-Quesada perfectly complements each other.
A great example of using the beamed metal ceiling to add texture and color.
The sky's the limit when it comes to ceilings! Keep reaching for new heights!
P.S. Where are other areas in your home you're looking to make a statement? Let me know over on Instagram @cococozy!


The WONDERful new Disney Wonder!
Welcome to Living The Disney Dream! I am excited to share an inside view of my Disney life. Through this site, I will post live trip reports, planning tools, and the latest news for all things Disney! See ya real soon!


Bottled wine created especially for cats has gone on sale in Japan. It may sound as a joke but it is true.
A pet supplement company B&H Lifes came up with "wine exclusively for cats" that is called "Nyan Nyan Nouveau." In Japanese, "nyan nyan" (ニャンニャン) refers to a cat's meow. Here, it refers to cats.
Apparently Nyan Nyan Nouveau doesn't have any alcohol in it. It is much like Japanese "kid's beer" and it doesn't contain any booze. The drink contains juice made from Cabernet grapes, Vitamin C as well as catnip for a beverage that supposedly tastes like red wine.
B&H Lifes decided to develop the drink for those who wanted to celebrate birthdays/Christmas with their cats.
Nyan Nyan Nouveau is priced at 399 yen (US$4) a bottle,limited to one thousand bottles. Unlike real wine, it doesn't get better with age. B&H Lifes also recommends drinking the beverage within a year.