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To examine health care utilization (HCU) and costs following brief cognitive behavioral treatment for insomnia (bCBTi).
Reviewed medical records of 84 outpatients [mean age = 54.25 years (19.08); 58% women] treated in a behavioral sleep medicine clinic (2005-2010) based in an accredited sleep disorders center. Six indicators of HCU and costs were obtained: estimated total and outpatient costs, estimated primary care visits, CPT costs, number of office visits, and number of medications. All patients completed ≥ 1 session of bCBTi. Those who attended ≥ 3 sessions were considered completers (n = 37), and completers with significant sleep improvements were considered responders (n = 32).
For completers and responders, all HCU and cost variables, except number of medications, significantly decreased (ps < 0.05) or trended towards decrease at post-treatment. Completers had average decreases in CPT costs of $200 and estimated total costs of $75. Responders had average decreases in CPT costs of $210. No significant decreases occurred for non-completers.
bCBTi can reduce HCU and costs. Response to bCBTi resulted in greater reduction of HCU and costs. While limited by small sample size and non-normal data distribution, the findings highlight the need for greater dissemination of bCBTi for several reasons: a high percentage of completers responded to treatment, as few as 3 sessions can result in significant improvements in insomnia severity, bCBTi can be delivered by novice clinicians, and health care costs can reduce following treatment. Insomnia remains an undertreated disorder, and brief behavioral treatments can help to increase access to care and reduce the burden of insomnia.
McCrae CS; Bramoweth AD; Williams J; Roth A; Mosti C. Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs. J Clin Sleep Med 2014;10(2):127-135.
Chronic insomnia impacts approximately 8% to 10% of adults in the United States population1 and carries substantial economic burden. Direct costs (i.e., costs directly related to treatment) have been estimated at $13.9 billion annually in the United States, with total treatment costs estimated at $77 to $92 billion.2 When indirect costs (i.e., lost productivity, insomnia-related accidents, increased medical problems) are included, annual costs exceed $100 billion.3 Evidence from outside the U.S. reveals a similar pattern. Specifically, a study in Quebec, Canada, found that the combined direct and indirect per-person costs of insomnia syndrome (insomnia complaint ≥ 3 nights/ week with > 1 month duration, dissatisfaction with sleep, and daytime impairment; prescription sleep medication ≥ 3 nights/ week) was approximately $5,010; with $293 attributed to direct costs and $4,717 in indirect costs.4 Those with insomnia symptoms (complaint ≥ 3 nights/week; prescription sleep medication < 3 nights/week or over-the-counter medication > 1 night/ week) also incurred significant costs: $160 in direct costs and $1,271 in indirect costs.
Direct comparisons of individuals with and without insomnia further highlight the economic impact of insomnia. In a study comparing age-matched individuals with and without insomnia, the average health care related costs incurred by young adults with insomnia was more than $900 greater on average over a 6-month period than the costs incurred by young adults without insomnia. For older adults with insomnia, that figure rose to more than $1,100 on average.5 Moreover, Sarsour et al. found that average health care costs were significantly greater for individuals with moderate to severe insomnia ($1,739) compared to those without insomnia ($1,013), representing an approximate 72% increase in health care costs.6
Current Knowledge/Study Rationale: Cognitive behavioral treatment for insomnia (CBTi) is a highly efficacious brief treatment for chronic insomnia. While significant health care utilization and financial costs are linked to chronic insomnia, there is limited research investigating the potential of CBTi to reduce health care utilization and costs.
Study Impact: Patients who completed and responded to brief CBTi had significantly reduced estimated health care costs following treatment. Brief CBTi has the potential to decrease health care utilization and costs related to insomnia.
Individuals with insomnia demonstrate increased rates of health care utilization (HCU), which contributes to increased insomnia-related health care costs. Compared to good sleepers, individuals with insomnia have more visits to general practitioners and medical specialists, twice as many hospitalizations, and use more medications than good sleepers.7,8 The common co-occurrence of insomnia with other conditions is an important consideration when examining HCU and associated costs as the rates of insomnia occurring in the context of other common medical and psychiatric conditions are much higher than that in the general population.9,10 For example, an epidemiological study revealed that approximately 38% of individuals with a comorbid condition exhibited insomnia compared to only 8% of individuals without a comorbid condition.9 Individuals with comorbid insomnia and major depressive disorder have demonstrated significantly greater direct health care costs (i.e., greater number of overall outpatient physician visits, depression-related visits, and a greater number of antidepressant prescriptions) than individuals with major depressive disorder alone.10 A recent study by Bramoweth and colleagues provides support for increased costs related to comorbid insomnia.11 Specifically, they found significantly greater estimated health care costs for young adults with insomnia comorbid with a medical or psychiatric disorder compared to those with insomnia alone and good sleepers.11 Two other recent studies also found evidence for increased costs linked to insomnia among comorbid samples. Sarsour et al. found people with insomnia (per the Insomnia Severity Index) and a psychiatric diagnosis had the highest health care costs.6 A study by Tian et al. found patients with major depressive disorder who were taking medication for insomnia had higher health care costs than those who were not taking such medication and a healthy control group.12
A next logical step in research examining insomnia-related HCU and health care costs is to examine the potential for treatment to reduce those costs. One study found that among Medicaid claims, the majority of the cost of insomnia treatment was for prescription drugs, with zolpidem and trazodone the most prescribed medications.8 Pharmacotherapy is the most common approach to treating insomnia13; to date, at least two studies have examined its impact on health care costs with mixed results. Jhaveri et al. demonstrated that several pharmacological interventions for insomnia (e.g., eszopiclone, indiplon, ramelteon, low-dose trazodone, zaleplon, zolpidem, and zolpidem extended-release) produced sizeable yet variable cost savings when accounting for sleep onset latency, wake after sleep onset, and sleep efficiency.14 For example, when using total sleep time as the efficacy measure, mean per-patient per-year cost savings linked to low-dose trazodone, zolpidem, and zolpidem extended-release were $1,022, $1,158, and $2,573, respectively.14 In another study, Snedecor and colleagues found minimally increased costs ($495 vs. $428; costs of medication, office visits, absenteeism, and loss of productivity) following treatment with eszopiclone (5 months) compared to placebo.15 However, eszopiclone users had an improvement over baseline in Quality Adjusted Life Years (QALY) while placebo had a decrease, and eszopiclone users had greater estimated productivity versus placebo at 6 months post-baseline ($689 vs. $333). Even though overall per-person costs were increased, eszopiclone was considered a cost-effective treatment.15 Costs and cost-savings linked to medication are complicated by the inconsistent duration of medication use in clinical trials, even more so in the real world. A brief review of the literature found duration of clinical trials of sedative hypnotics range from short (2 weeks16,17) to moderate (1-3 months18–20) to long (6 months15).
Cognitive behavioral treatment for insomnia (CBTi) is not as widely used as pharmacotherapy, but represents an attractive alternative for treating chronic insomnia. The potential for CBTi to reduce HCU and health care related costs has not yet been examined. This is unfortunate, because CBTi has been shown to be efficacious and effective in a variety of populations, including adults, older adults, and several comorbid patient populations (fibromyalgia,21 chronic pain,22 breast cancer,23 and cardiovascular disease). A meta-analytic review found CBTi to be more effective at reducing sleep onset latency than hypnotic medication.24 CBTi was equally as effective as hypnotic medication in improving other sleep-related outcomes (e.g., wake time after sleep onset, number of awakenings, sleep quality), with both approaches achieving an effect size (Cohen's d) greater than 0.80.24 Unfortunately, broader adoption of CBTi has been hindered by several factors, including the relatively limited number of clinicians trained to provide it and the fact that the length of traditional protocols (6-10 sessions) is not well-matched to the resources available in primary care settings where the majority of insomnia cases are seen.25–27 However, Manber and colleagues have described the successful training of mental health clinicians without sleep specialization to deliver CBTi in the VA healthcare system.28
In response to this, shortened protocols (i.e., ≤ 4 sessions) have been developed, and research has shown them to be efficacious and effective in treating insomnia in adults of all ages (see McCrae,29 Buysse,30 or Edinger and Sampson,31 for review). For example, Edinger and Sampson demonstrated that four sessions of CBTi resulted in clinically significant improvements in wake after sleep onset, total wake time, and sleep efficiency compared to sleep hygiene recommendations alone.31 Two other studies have found that brief behavioral treatment of insomnia (BBTi; 2 in person, 2 phone calls) resulted in clinically significant sleep improvements compared to information only and sleep hygiene education only controls.32 When the sleep outcomes found for brief CBTi studies were matched with previous research done with a typical 6 sessions, the results were comparable. In addition to sleep outcomes, brief behavioral protocols have been shown to produce significant improvements in several secondary outcomes. For example, Buysse and colleagues also found moderate effect sizes for other outcomes following brief BBTi, including improved anxiety, depression, and quality of life.30
HCU and other health related cost reductions represent other potentially important secondary outcomes that, unfortunately, have yet to be examined. Given evidence of brief behavioral protocols' impact on sleep, mood, and quality of life outcomes, demonstration of its ability to also reduce HCU and health care costs is particularly important. Such demonstration may provide additional impetus for efforts aimed at broader dissemination of this highly effective and efficacious approach to treating chronic insomnia.
The main objective of the present study was to examine HCU and health care costs following a brief CBTi (bCBTi) protocol, delivered in an outpatient behavioral sleep medicine clinic based in an accredited sleep disorders center within an academic medical center. Specifically, we measured HCU and costs—number of physician office visits, costs related to office visits (CPT costs), number of medications, and estimated health care costs and utilization (total costs, outpatient costs, and number of primary care)—over a 6-month period prior to and following delivery of a manualized bCBTi to patients with chronic insomnia. We conducted two types of comparisons based upon: (1) treatment completion (completers vs. non-completers), and (2) treatment response (responders vs. non-completers). For these comparisons, we hypothesized that patients who completed and/or responded to bCBTi would exhibit significantly greater decreases in their number of physician office visits, costs related to office visits, number of medications, and estimated health care costs than patients who did not complete treatment.
Eighty-four outpatients treated for insomnia at the Insomnia and Behavioral Sleep Medicine (IBSM) Clinic at the University of Florida & Shands Sleep Disorders Center in Gainesville, FL between 2005 and 2010 served as participants. Patients referred to the clinic were seen for an intake session that included an in-depth clinical sleep history interview and a standard battery of questionnaires (see Measures). Criteria for insomnia were consistent with the International Classification of Sleep Disorders, Second Edition,33 the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)34 and published research diagnostic criteria (RDC)35 and included: (1) complaint of difficulty initiating or maintaining sleep, or non-restorative sleep, for at least one month; (2) the sleep disturbance (or associated daytime fatigue) causes clinically significant impairment or stress; (3) the sleep disturbance does not occur exclusively in the presence of another sleep disorder; (4) the sleep disturbance does not occur exclusively in the presence of another mental disorder; and (5) the disorder is not due to the direct effect of substance use. All patients who met these criteria were offered bCBTi. Given that people with insomnia are approximately 10 times more likely to be depressed and 17 times more likely to be anxious than those without insomnia,36 patients with symptoms of anxiety and/or depression were offered bCBTi, unless their symptoms were severe enough to warrant immediate, alternative treatment (e.g., active suicidal ideation or intent, psychosis). Additionally, participants with comorbid medical or psychiatric disorders deemed too severe (e.g., active psychosis) for bCBTi and/or if bCBTi was contraindicated (e.g., active mania, uncontrolled seizures) were not offered treatment. In those cases, appropriate referrals were made.
This study was approved by the University of Florida (UF) Health Science Center Institutional Review Board (IRB-01) as a retrospective data/record review study. The study included a waiver of informed consent and a waiver of authorization to obtain protected health information. Eighty-four charts were reviewed for the current study.
Patients had to complete at least one session of bCBTi to be included. The study sample's demographic and health characteristics are provided in Table 1.
Demographic and health characteristics of the total sample and by treatment outcome group for outpatients with chronic insomnia treated with brief cognitive behavioral treatment for insomnia (bCBTi) between 2005-2010 in a behavioral sleep medicine clinic.
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The patients' charts were reviewed to obtain the following health care utilization (HCU) variables: number of office visits at UF/Shands, costs related to office visits (CPT costs), number of medications, and Chronic Disease Score (CDS).37 All HCU variables were measured during the 6 months before treatment began and the 6 months after treatment ended. The number of physician office visits and medications were determined by each patient's electronic medical records at UF/Shands. Only appointments at UF/Shands were available as part of the chart review process. Costs related to office visits were determined by the CPT code of each visit. CPT codes were linked to Medicare relative value payments in the state of Florida (not Fort Lauderdale or Miami) using 2011 reimbursement values (https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do).
CDS is an algorithm that estimates health care costs based on medications.37 Weights are given to different medication classes that represent different chronic diseases. Each medication class is associated with a cost based on regression models using automated data from a health maintenance organization. Medications are classified by American Hospital Formulary System (AHFS) categories. Additionally, gender and 10-year age groups are weighted and associated with costs. The CDS represents 6 months of health care costs and provides 3 estimates of HCU— total costs, outpatient costs, and number of primary care visits. Different weights for each medication class, gender, and 10-year age group are used to determine the 3 HCU estimates. CDS has previously been used to calculate HCU in an insomnia sample.11
Patients with insomnia who opted to pursue treatment were asked to complete 2 weeks of daily sleep diaries to establish their baseline sleep behaviors prior to their first treatment session. Patients also completed daily sleep diaries throughout treatment, beginning the first night of treatment until their final appointment. The sleep diary information was entered into a spreadsheet at the beginning of each session. The spreadsheet was used to create graphs depicting the patients' total sleep time and sleep efficiency (see Measures for definitions). The therapist reviewed these graphs with the patient to provide feedback, troubleshoot treatment adherence, and monitor therapy progress. Therapy consisted of brief, multi-component CBTi, and followed a treatment manual developed by the first author. Components of the treatment included sleep education, sleep hygiene, stimulus control therapy, sleep restriction, a brief (10-min) relaxation exercise, and cognitive therapy. An accompanying patient workbook was also used. To prevent patients from working ahead in the workbook, the workbook chapter corresponding to the topics to be covered during a particular session was handed out at the beginning of each session. Treatment was delivered by clinical psychology graduate students and predoctoral interns in UF's American Psychological Association accredited predoctoral and internship programs, respectively. All therapy was supervised by the first author, a licensed clinical psychologist who is also certified in behavioral sleep medicine.
Treatment generally lasted 4 to 6 sessions, depending on the individual needs of the patients, and occurred weekly. Session one consisted of general education about sleep, sleep hygiene,38 and stimulus control.39 Sleep hygiene recommendations were: (1) Avoid caffeine after noon; (2) Avoid exercise within 2 h of bedtime; (3) Avoid nicotine within 2 h of bedtime; (4) Avoid alcohol within 2 h of bedtime; and (5) Avoid heavy meals within 2 h of bedtime. Stimulus control recommendations were: (1) Don't use your bed or bedroom for anything (any time of the day) but sleep (or sex); (2) If you don't fall asleep within 15-20 minutes, leave the bed and do something in another room. Go back to bed only when you feel sleepy again. Clock watching with regard to this rule is not recommended. If you don't fall asleep within 20 minutes upon returning to bed, repeat this instruction as many times as needed; (3) If you wake up during the night and don't fall back to sleep within 20 minutes, follow rule 2 again; and (4) Avoid napping. Session 2 implemented sleep restriction, which involved tailoring the amount of time spent in bed to the participant's reported total sleep time. A time in bed (TIB) prescription was determined by adding 30 min to the participant's average total sleep time at baseline. If this was < 5 h, the TIB prescription was set at 5 hours. The therapist and participant worked together to set regular bed- and wake-times to help the participant follow the TIB prescription. The TIB prescription was reviewed at each session subsequent to session 2 and adjusted based on the average sleep efficiency demonstrated the previous week. If the average sleep efficiency was > 90% and the patient reported daytime fatigue/sleepiness, 30 minutes were added to the TIB prescription. If the average sleep efficiency was < 85%, 30 minutes were subtracted from the TIB prescription. Whenever a change was made in the TIB prescription, the therapist and patient discussed how to adjust bed and wake times to accommodate the new prescription. Session 3 involved a 10-min passive relaxation technique. An audio version of the therapist administering the relaxation exercise was given to the participant for daily home practice use (before bedtime and once during the day). Sessions 4 and 5 focused on cognitive therapy, which helped the patients identify and challenge dysfunctional beliefs and common worries about sleep as well as other thought patterns that interfered with sleep. The final session, often session 4 or 5, reviewed previously learned materials and established a relapse prevention plan.
Patients were classified as completers if they attended ≥ 3 sessions of bCBTi. If they only attended 1 or 2 sessions, they were classified as non-completers.
All patients completed a daily sleep diary for 14 consecutive days prior to starting treatment as well as throughout treatment. Sleep diaries provided subjective estimates of sleep onset latency (SOL; time from initial lights-out until sleep onset), wake after sleep onset (WASO; time spent awake after initial sleep onset until last awakening), time in bed (TIB; time from bedtime to final out-of-bed time), total sleep time [TST; computed by subtracting total wake time (SOL + WASO) from time in bed], and sleep efficiency percentage (SE = TST/TIB × 100%). Sleep diaries are a cost-effective method for monitoring sleep patterns and are recommended for the assessment of insomnia.35,40
Patients who completed treatment (≥ 3 sessions; see above) were further classified as responders if their sleep diaries from their last week of treatment indicated: (1) reduced symptoms—SOL and WASO—by 50% compared to baseline, or (2) if baseline SE was < 85%, SE increased by 10% points at end of treatment (e.g., SE 78% → 88%). If not, they were classified as non-responders.
The BDI-II is a 21-item self-report measure with questions scored 0 to 3, with higher responses indicating more severe depressive symptoms. Scores on the 21 items are summed to produce a total score range of 0-63. Scores < 14 indicate minimal depression, while scores ≥ 20 indicate clinically significant depression.41 The BDI-II has a high internal consistency and high test-retest reliability (α = 0.93).
The STAI-Trait scale is a 20-item self-report measure of tension, apprehension, and physiological signs of stress.42 Items are scored 1-4 and are summed for a total score range of 20-80. Higher scores indicate greater anxiety severity. The STAI-Trait scale has good internal consistency (α = 0.72-0.96) and good test-retest reliability (α = 0.82-0.94).
Data was inspected for extreme outliers (> 5 standard deviations above the mean) for the dependent variables, and this data was excluded from the final analyses. A preliminary inspection of the data revealed a relatively small sample of patients who qualified as treatment responders and a non-normal distribution of data across the outcome variables. Standard normalizing transformations were not effective in correcting the relatively negatively skewed patterns observed in the outcome variables. As is recommended for research with small patient samples,43 and data that is not normally distributed, nonparametric methods were used to analyze treatment outcomes. In this study, we utilized the related samples Wilcoxon signed-rank test to analyze the total difference in HCU pre and post-bCBTi. To examine between group differences, Mann Whitney U tests were used. Effect sizes were calculated using the following formula: Z/√ (# observations over 2 time points). The relative strength of these effect sizes were defined as: r = 0.1 to 0.29 as small, 0.3 to 0.49 as medium, and ≥ 0.5 as large.44
Forty-seven patients were classified as non-completers, and 37 were classified as completers. Of those who completed treatment, 32 were further classified as treatment responders and 5 as treatment non-responders. The non-responders group was not included as a separate group in any subsequent analyses, because the small size of the group prohibited drawing any meaningful conclusions from such analyses. Instead, between group analyses compared treatment completers to non-completers, and treatment responders to non-completers.
There were no significant group differences between completers, responders, and non-completers in demographic variables including age, gender, race/ethnicity, education, BMI, or number of health problems. In addition, there were no significant group differences in BDI-II score or STAI score among the 3 groups. Between group differences at pre-treatment on HCU measures were assessed. The only variable with a significant difference at pre-treatment was the CDS estimated number of primary care visits between completers and non-completers (p = 0.05), and responders and non-completers (p = 0.03).
Among treatment completers, there was a significant decrease in CPT costs (Mean difference [MΔ] = $195.86, SD = $569.51; p < 0.05, r = 0.26), number of observed office visits (MΔ = 0.37, SD = 4.02; p < 0.05, r = 0.28), and CDS estimated total costs (MΔ = $72.16, SD = $235.81; p < 0.05, r = 0.28). There were also trends toward decreased CDS estimated outpatient costs (MΔ = $38.84, SD = $116.88; p = 0.07, r = 0.25), and CDS estimated number of primary care visits (MΔ = 0.21, SD = 0.61; p = 0.07, r = 0.25). There were no differences in the total number of medications. There were no significant decreases for treatment non-completers (see Table 2). There were no significant between-group differences, and a comparison of relative change from pre-treatment between completers and non-completers did not reveal any significant differences.
Within-groupa differences in health care utilization (HCU) outcome variables at six months pre-treatment (Pre-Tx) and post treatment (Post-Tx) with brief cognitive behavioral treatment for insomnia (bCBTi) by treatment outcome group.
Among treatment responders, there was a significant decrease in CPT costs (MΔ = $210.39, SD = $488.06; p < 0.05, r = 0.30) and the number of observed office visits (MΔ = 0.89, SD = 4.47; p < 0.05, r = 0.27). There were also trends toward decreased CDS estimated total costs (MΔ = $54.23, SD = $228.82; p = 0.06, r = 0.28), CDS estimated outpatient costs (MΔ = $22.72, SD = $95.88; p = 0.08, r = 0.25), and CDS estimated number of primary care visits (MΔ = 0.21, SD = 4.47; p = 0.08, r = 0.25). There were no observed differences in the total number of medications (see Table 2). There were no significant between-group differences, and a comparison of relative change from pre-treatment between responders and non-completers did not reveal any significant differences.
This study found changes in HCU and costs in patients who received bCBTi delivered by predoctoral clinical psychology trainees in an outpatient behavioral sleep medicine clinic located within an academic medical center. Of the six HCU and cost variables examined, all but total number of medications either significantly decreased or trended toward a decrease from pre- to post-treatment. Strength of the findings (significant or trending) varied as a function of treatment completion and response. There were no significant changes in any of the variables for patients who did not complete the treatment (attended only 1 or 2 sessions). While between group comparisons were not significant, this clinic-based study may have lacked both sufficient power and adequate control (i.e., non-completers received some treatment) for detecting such differences. Despite these limitations, the findings of this study provide promising preliminary evidence of decreases in HCU and costs for both treatment completers and responders following bCBTi.
On average, treatment completers exhibited a significant decrease of almost $200 dollars in CPT-based health care costs, almost $75 in CDS estimated total health care costs, and approximately one-third of a primary care visit in the 6-month post-treatment period compared to the 6-month pretreatment period. Both CDS estimated outpatient costs and CDS estimated number of primary care visits trended toward significance. Not surprisingly, decreases in health care utilization and costs were larger in patients who responded to treatment. On average, treatment responders exhibited a significant decrease of almost $210 in CPT-based health care costs and almost 1 observed visit (i.e., 0.89 of a visit). CDS estimated total costs, outpatient costs, and primary care visits trended toward significance. In this small sample, it is worthwhile to note that the majority of treatment completers also achieved a treatment response, 86%. Due to the small sample size (n = 5), it was not possible to draw conclusions about the treatment completers who were non-responders.
For both treatment completers and responders, however, the measures of HCU and costs are likely an underestimate of true change. CPT-related costs represent an estimate of the number and type of office visits and are determined by the length and complexity of the appointment (e.g., cardiology exam vs. primary care annual visit). When the number of office visits decrease, or the complexity of visits decrease, costs to the patient will decrease, including direct costs such as co-pays and indirect costs such as travel, and time away from work. Because of the limitations of what CPT actually measures—Medicare reimbursement of medical procedures—it is an underestimate of actual cost-savings to the patient and may better represent a reduction in number of visits and procedures. CPT-related costs do not account for any out of pocket costs for which the patient may be responsible, again lending support that the CPT variable underestimates the direct health care costs of patients.
This underestimation holds true for CDS estimates of HCU. Estimated total health care costs were significantly reduced preto post-bCBTi for completers with a trend towards reduction for treatment responders. The CDS weights of chronic illness have not been adjusted for inflation of health care costs; as costs for chronic disease have increased over the years, so should the weights of the CDS variables. In the current study, an increase of weights for the CDS variables would likely result in even greater estimated costs during each six-month period and potentially a greater reduction of estimated health care costs from pre- to post-treatment. However, it is possible that a constant increase in HCU would result in the same amount of change from pre- to post-treatment.
While both CPT and CDS measures likely underestimate HCU, the difference in magnitude of the two measures is due to what is actually being measured. CPT measures Medicare reimbursement costs of medical procedures and office visits; CPT is a direct cost of health care reimbursement on the provider side and may indirectly measure patient costs. CDS is an estimate of total costs, outpatient costs, and the number of primary care visits based on an algorithm that includes costs linked to chronic illness, based on medication and costs associated with gender and age. CDS is an estimated cost of HCU for an individual, but does not distinguished between patient, provider, direct, and indirect costs. An adjustment for inflation, as well as updates to the medications linked to chronic illness, would allow CDS to provide a more accurate estimate and would likely be more closely correlated to CPT-based costs.
In addition to overall monetary costs, office visits were significantly reduced from pre- to post-CBTi for both treatment completers and responders. This variable is most valuable if interpreted at a health care system and/or population level. Less than one office visit reduction per person over six months may not be a meaningful change at the individual level for one 6-month period. By extrapolating the reduction of office visits to all patients who complete treatment, and then further extrapolating at the system and population level over longer periods of time, the cost-savings become much more meaningful in terms of health economics and health care services. Our findings are consistent with previous research that medication to treat insomnia can reduce HCU and costs, although the costs of the medication can cancel out any savings.14 While the costs of bCBTi may also cancel out any savings in the short term, the benefit of bCBTi over medication is that once bCBTi is complete, the costs of treatment cease. Cost of the diagnostic interview ($125.12) and four 50-minute sessions of bCBTi ($83.32/session × 4 sessions) was approximately $460 in our clinic (based on Florida Medicare relative value payments for 2011). When taking medication, the costs continue throughout treatment and may rise if medication changes, especially from generic to brand name, and as dose and frequency of use increases. Our results are also supported by a recent study using predictive modeling that found the treatment of insomnia, including pharmacotherapy and behavioral therapy, to be cost-effective and cost-saving.45
It is well established that people with insomnia have greater costs than good sleepers. Direct costs of insomnia for older adults have been estimated at $1,143 over a six-month period,5 while indirect costs (e.g., work absenteeism, lost productivity) may exceed $4,000 for those diagnosed with insomnia and $1,200 for those exhibiting insomnia symptoms.4 Furthermore, individuals with insomnia have been shown to incur greater lost productivity costs to employers, including decreased performance and on-the-job safety.46 Individuals with chronic insomnia and a comorbid medical or psychiatric condition have greater health care costs than those with chronic insomnia alone.11 The current study demonstrated that bCBTi can significantly decrease HCU in patients who complete and respond to treatment. Given our means of data collection, we were not able to measure change in indirect costs, but it is plausible that indirect costs, which are often greater than direct costs, would have been reduced as well. The results of this study suggest that the utilization of health care services by individuals with chronic insomnia7 can be reduced to some extent by delivery of bCBTi.
To our knowledge, this is the first study to show a reduction in HCU and costs following bCBTi. Results of this study indicate that not only was a relatively brief intervention effective in reducing insomnia severity, but it may also be capable of making a significant economic impact at the individual and health care systems level. These findings are consistent with previous research on effectiveness of brief behavioral insomnia treatments.30,32,47 Furthermore, a significant treatment response may not be necessary to impact HCU and costs—treatment completers saw a reduction—although a treatment response may augment the cost-savings. Furthermore, the intervention was delivered by clinical psychology doctoral students and predoctoral interns, only some of whom had a background and previous training in insomnia and behavioral sleep medicine interventions. This lends support that bCBTi may be an easily disseminated intervention with minimum training required.32,48
There were several limitations associated with this research study. This sample was small and consisted of primarily middle-aged and older Caucasian adults, many with several comorbid medical conditions such as hypertension, cardiovascular disease, and diabetes. The prevalence of comorbid medical conditions may have been an important confounding variable in accurately estimating change in HCU and costs related to bCBTi; however, in the real world, comorbid disorders are unavoidable and contribute to HCU. Most insomnia cases are comorbid in nature.49 Including patients with comorbid disorders increases ecological validity, as the patient sample is representative of the types of insomnia patients seen in primary care settings— patients with multiple medical and/or psychiatric comorbidities. It is possible that younger populations may see greater HCU reductions post-treatment; conversely, younger persons in better health likely have lower health care utilization and costs in the first place. Thus, it is important to study the use of bCBTi protocols and to examine health care costs in comorbid samples, such as the one used in this study, despite the methodological challenges they pose. Also, a more diverse sample would be needed to make more generalizable conclusions.
Another issue with the current study, as well as studies of HCU and costs in general, is working with monetary data that is rarely normally distributed. As mentioned in the statistical analysis section above, standard normalizing transformations were not effective with our negatively skewed data. As a result of the small sample size and the non-normal distribution of our outcome variables, it was necessary to utilize nonparametric analyses. Results, therefore, show large standard deviations, often larger than the means, due to the negative skewness even with significant outliers removed. However, this reporting of HCU data is consistent with other studies of insomnia and costs.11,12,14,50 Additionally, while significant differences in costs pre- and post-treatment were identified, effect sizes were small. The study was not adequately powered to find meaningful change in HCU, and effect size was influenced by the high variability (i.e., large standard deviations) of the cost data. With the use of nonparametric analyses, it can be more difficult to ascertain the magnitude of the effect being observed. Future research would benefit from a larger sample in order to overcome these limitations.
It is also important to note that this study was a retrospective chart review, and not a randomized controlled trial (RCT). This study used an existing clinical sample and as a result, did not use the extensive, screening protocol often used in RCTs. Also, comparison of completers and responders to non-completers was likely an inadequate control, as the non-completers filled out two weeks of sleep diaries and completed one or two sessions. The use of patients from a specialty clinic housed within an academic medical center is also limiting, because the impact of bCBTi on HCU may differ in other settings, and HCU and cost information were not available for any care received outside our system. Nonetheless, this study provides valuable preliminary data on the ability of bCBTi to reduce HCU and costs. Multiple measures of cost would be beneficial, such as direct costs (e.g., CPT, co-pays), indirect costs (e.g., travel, missed work), estimated costs (e.g., CDS), and cost-effectiveness metrics (e.g., QALY) that can be compared against industry-established standards. Additionally, because data was extracted from patient medical records within an academic medical setting, inconsistencies among patients and missing data limited the statistical analyses performed.
Another limiting factor was that the CDS variable was an estimate of HCU that relied on an algorithm based on medications listed in the patients' electronic medical records. Although the CDS as a measure of HCU is a validated method,37 it is unlikely that all medical conditions and associated costs of a patient can be accurately accounted for by medication alone. Also, not all medications may have been included in the records as many patients see providers from different health care systems. Additionally, the CDS algorithm does not include many over-the-counter medications. More detailed information, such as cost information from insurance plans, co-pays, travel time and travel costs, time away from work, and impact of insomnia on productivity (e.g., absenteeism and presenteeism) are needed for more accurate measurement. As such, the variables reported in this study are likely an underestimate of true HCU and costs. With additional cost information, either a cost-effectiveness analysis and/or cost-utility analysis could be performed to better estimate the economic value of implementing brief cognitive behavioral interventions for insomnia.
Predoctoral level clinicians delivered the treatment in this study. Thus, it is possible that bCBTi delivered by a doctoral-level clinician, or a more experienced behavioral sleep medicine clinician, may lead to greater reduction of HCU and costs. However, if treatment outcome is similar between doctoral-level and predoctoral clinicians, other health care providers (e.g., physician assistants, social workers, nurse practitioners/ nurses) may be well-suited to provide brief, cost-effective treatment as well. However, it is important to recognize that the brief treatment protocol used was developed by and supervised by the first author, a doctoral level clinician with over 16 years' experience delivering behavioral and cognitive behavioral treatments for insomnia. Thus, supervision may be another important component to consider when studying the impact of bCBTi on HCU and costs.
Lastly, the time intervals used to estimate change in HCU and costs may not have been sufficient to see the full economic benefits of treatment. It is plausible that reductions in HCU following treatment completion and response to brief cognitive behavioral treatment for insomnia are not fully realized until well beyond six months. For example, those with medical and/or psychiatric comorbidities might be motivated by their success with bCBTi to pursue treatment of their other medical conditions, which may result in further reduction of costs long term. CBTi has been shown to reduce the use of medication27 and psychiatric symptoms,51 and these factors, not measured in the current study, would likely contribute to even further reductions of HCU and costs following bCBTi. However, it is also possible that given longer periods of time post-treatment, HCU will return to pre-treatment levels. It is important to note that no standard time frame for measuring change in costs has been established, and this area of research, especially in insomnia, is relatively new. One study of costs pre- and post-treatment for seasonal affective disorder measured costs at four weeks before treatment initiation and four weeks before treatment ended.52 A review of the literature found that health care costs are generally measured in 6-month or 12-month time frames.4–6,14,53 Future research should aim to measure changes after longer time intervals to better evaluate the impact of bCBTi on HCU and costs.
This was not an industry supported study. The authors have indicated no financial conflicts of interest. This study did not involve off-label or investigational use of any pharmaceutical or medical treatment. Work was performed at the University of Florida, Gainesville, FL
Dr. Bramoweth began work on this study as a predoctoral intern at the University of Florida (UF). Thus, his work was partially supported by the Department of Clinical and Health Psychology at UF. He continued this work as a postdoctoral fellow, and as a result, his effort on this study was also partially supported by the VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC, Director: D. Oslin; Pittsburgh Site Director: G. Haas), VA Pittsburgh Healthcare System. The contents do not represent the views of the Department of Veterans Affairs or the United States Government.
Jacob Williams and Caterina Mosti's efforts on this study were partially supported by awards (NIH/NIAMS, AR055160 and AR055160-S1; Christina S. McCrae, PhD, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAMS.
Alicia Roth's efforts on this study were partially supported by awards (NIH/NHLBI, HL087831 and HL087831-S1; Christina S. McCrae, PhD, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NHLBI.
The authors offer special thanks to Jason G. Craggs, PhD (database design and development), the predoctoral clinical psychology trainees who provided the brief cognitive behavioral treatment for insomnia, and the patients seen in UF's Insomnia and Behavioral Sleep Medicine clinic.
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Cape Cod
Find some great read and check out my titles along the way! The Grand Prize is a $100.00 Amazon Gift Card
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Definitely a good, engrossing read that is worth a look. I enjoyed it, and thought the concept was fresh and entertaining.
Carole Ann Moleti lives and works as a nurse-midwife in New York City, thus explaining her fascination with all things paranormal, urban fantasy, and space opera. Her nonfiction focuses on health care, politics, and women's issues. But her first love is writing science fiction and fantasy because walking through walls is less painful than running into them.
Excerpts of her memoir have been featured in a variety of literary venues. The first book in Carole's Cape Cod paranormal romance novel series, The Widow's Walk, was published by Soulmate. Her short fiction appears in the Toil, Trouble and Temptation Anthology by Mocha Memoirs Press. Short stories set in the world of her novels are featured in Haunted: Ten Tales of Ghosts, Bites: Ten Tales of Vampires,Beltane: Ten Tales of Magic, and Seers: Ten Tales of Clairvoyance.

subset: commoncrawl


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Pimpette 101: Detroit Pimpstress Schooling Her Strag To Step Her Pucci Game Up!
One of our viewers sent us this clip of a female pimp putting her business out like that in 8 Mile of Detroit.
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Conversor csv outlook 2003pekerjaan
Hello! Who can write me a script, which is catching the csv file from my wholeseller to my ftp server? With Cron every 20 minutes? My wholeseller has an open api to catch it. Here is the documentation: [log masuk untuk melihat URL] Thanks!
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...(escritura) debe activarse. Si WE está activado, la salida L (lectura) debe permanecer inactiva. Si CS y OE están activados, la salida L (lectura) debe activarse. 3. Un circuito conversor para un display de siete segmentos, que se utilizará para visualizar posteriormente el dato disponible en la memoria RAM. La entrega consiste en un documento que presente
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Necesitamos pasar esta información en PDF a formato EXCEL con un programa o servicio manual. No vale cualquier OCR y además son ficheros normalmente de más de 100 MB en PDF. Adjunto una muestra, como ejemplo. El excel debe de tener las siguientes columnas como mínimo: U y teléfono en el mismo orden que el listado. Necesito una muestra de una o dos páginas...
need to add mailbox and do some additional takss
Sitio web para altcoins: Debe mostrar la cotizacion actual de la moneda con respecto al dolar, euros y peso arg, ademas de tener un conversor de moneda. La cotizacion es ficticia por lo tanto deberia poder fluctuar en forma aleatoria, pero segun parametros preestablecidos (valor del altcoin con respecto a las otras monedas, tiempos entre flucutaciones
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Build Email Templates in HTML or WYSIWYG that work with memberclicks email exchange
Hi, I need to build simple macro in Excel that will create tasks in Outlook calendar and will as well release them and send into mails address that will be in the excel file. In excel file will be only important data needed for creation every task automatically. Example of the excel file in the attachment. Regards, Karolina
Length - 3000 Words Submission Method Online - Use a written report (A4) format with a structure of numbered hierarchical of headings and sub-headings. All sources must be referenced appropriately, and all figures and tables must be numbered, titled and integrated into the body of the report. Assessment Criteria - Historic economic indicators/statistics analysis (25%) Sector analysis and synthe...
Need outlook calendar integration with our product which is restful web service driven web application. Please only bid if you have done this before and ready to show me a demo
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Quickbooks online pdf to microsoft outlook or thunderbird email problem. Not sure if this is possible but looking for a print driver that i can use to go print and it will open up my email client whatever is "default" and it will attach it. If there is a way to some how design and auto fill information that would be ideal. Not sure of the process
...SendGrid "sender authentication". I added CNAME to my DNS manager, then I do white label. But some recipient cannot view the image properly. They are using various version of Outlook. I understand some of them block the image in their security setting.a I am looking for the method to increase possibility to show the image properly to as many people as
For Arvin Outlook creation and calendar integration
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Set up my email in MS Outlook on my computer
I want to test somethings with Microsoft Office Outlook and VBA. I want to generate a message box when a mail item is put into a specific folder. I hope someone can help me an tell me my mistake. The code, which I put into ThisOutlookSession, is here, but it does not work: Private Sub objInbox_BeforeItemMove(ByVal Item As Object, ByVal MoveTo As MAPIFolder
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Need to do group by subjects of the emails in inbox and sent and archive those emails in one folder automatically for every 10 days
Find a solution for IMAP connection problems on a Windows Small Business Server 2003. Using Microsoft Remote Connection Analyzer, the following test results are shown below. I suggest we are using a remote desktop application to work on the problem (directly on the server): [log masuk untuk melihat URL]: Unable to read data from the transport connection:
Help me integrate Outlook Notification API into my app. Note, Outlook is already integrated, I just need help with the notification API [log masuk untuk melihat URL]
For a collaboration project, we need a tool to export from Microsoft Exchange Server, the calendars of users of the server, in text format. Two input options: either the username for which the calendar will be exported, or, exporting calendars of all users of the system.
For a collaboration project, we need a tool to export from Microsoft Exchange Server, the calendars of users of the server, in text format. Two input options: either the username for which the calendar will be exported, or, exporting calendars of all users of the system.
For a collaboration project, we need a tool to export from Microsoft Exchange Server, the calendars of users of the server, in text format. Two input options: either the username for which the calendar will be exported, or, exporting calendars of all users of the system.
I have an Outlook Add-in which is pretty straight forward coding wise, not large, written in VB6. It used to work fine years ago however with 2013 and upwards it is not being loaded. It can be selected via the Addin Browse but when Outlook starts it is being kicked to the - Inactive Application Add-ins Need this fixed within a few hours please.
Buongiorno, attualmente ho uno script in Vb che parte all'accesso di ogni utente quando si logga in active directory. Questo script crea una firma in ogni outllok dell'utente prendendo le informazioni dall'active directory (numero, mansione, etc).Io ho creato lo script ma non esce correttamente? Verrà fornito il layout grafico e lo script vin qui fatto. Qualcuno mi può...
We are a small manufacturer who wishes to automate our project management tasks of up to 50 orders at any given time in various stages of completion. Avoid duplication of client data while managing up to 10 team members and tie into Quickbooks Accounting
hi there, i'm looking for someone to configur my exchange server 356 to my outllok office
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I need an Outlook signature coded so that the signature does not break.
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I wrote a scientific research article about all types of renewable energy, based in historical and technical datas to compare with today panorama.
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Dear applicants...all further replies from client in Zoho CRM. Thus, all communication history with a lead is stored FULLY in Zoho. Currently, we get all further replies from client only to Outlook email under which Zoho account is registered. And we cannot monitor history in full. Very urgent! Best regards, Patrice Coutard, BodyO CEO and Founder
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We have a small AdWords account which we have run internally since about 2008. Our current spend is about A$15,000 per annum but we have recently received funding to dramatically increase the output of our factory and as a consequence we are looking to improve our current campaigns and then (over the next twelve months) significantly increase our spend. We do not feel we have the expertise to mana...
We are looking to develop a set of macros that help us track emails in Outlook. The project will require the below skills: Excel VBA, Excel Macros, Visual Basic, Microsoft Outlook, Excel
Hi, need someone who can update my excel file to import in woocommerce for create products. Thanks Sascha


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Woof and Roll Pet in a Bag 12-Pack Set
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Okay, not every single one, but I did just watch and break down 43 quarterbacks toda.... since the last time I woke up. I ended up writing about 18 of them in the SDB article below. Found some pretty interesting players. My new late round favorite is Ryan Aplin.
http://seahawksdraftblog.com/the-2013-l ... back-class
Now excuse me while I pass out.


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Check out the Carbon County Museum Calendar of Events for great educational activities.
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See historical photos, unique objects from our collection and gallery exhibits.
Educational opportunities to present the history and culture Carbon County to kids of all ages.
Hugus-Ferguson Update:
Completed Summer 2017
- New roof completed by L.M. Olson
- North wall and window opening rebuilt
- Facade work continues
Asbestos abatement and clearing of first level completed, development and design phase has begun...
Share your Hugus-Ferguson stories and memories with us!
Print and fill out the forms through the links below, and either bring them into the museum or please send by mail.
Blank Map of Hugus-Ferguson Building First Level
Share your Hugus-Ferguson Building Memories!
Home On the Range
Step back in time to the 1930s and visit the TE Ranch, down on Troublesome Creek in Difficulty Township.
Carbon County Museum is proud to have a permanent exhibit space dedicated to kids: the Discovery Zone!
Thomas Edison
Thomas Edison visited Carbon County as a stargazer. His 1878 trip to Rawlins is well documented.
See all Carbon County Museum Permanent Collections
Carbon County Museum 904 West Walnut StreetRawlins, WY email@example.com(307) 328-2740
The museum collection includes over 30,000 artifacts and archive items. Admission is free and open year round. © Carbon County Museum - All Right Reserved.
Museum Web Site Design By: Waves Web Design


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The defendants in Association of Christian Schools International et al. v. Roman Stearns et al. have prevailed. The case, originally filed in federal court in Los Angeles on August 25, 2005, centered on the University of California system's policies and statements relevant to evaluating the qualifications of applicants for admission.
Among Canadians, 58 percent accept evolution, while 22 percent think that God created humans in their present form within the last 10,000 years, and 20 percent are unsure, according to a new poll from Angus Reid Strategies. The poll was conducted among a nationwide random sample of 1007 Canadian adults interviewed on-line on July 29 and 30, 2008, and its margin of error is +/- 3.1%.
Selected content from volume 27, numbers 5-6, of Reports of the National Center for Science Education is now available on NCSE's website, featuring reports on a disastrous excursion for "intelligent design" in Oklahoma, developments in the Answers in Genesis schism, and the failed attempt to earmark $100,000 in taxpayer funds to a creationist organization in Louisiana. Additionally, RNCSE's editor Andrew J. Petto considers "The History of Life as a Walk in the Park" -- with color photographs of J.
In a statement submitted to the platform committees of both the Democratic National Committee and the Republican National Committee, the Anti-Defamation League reiterated its position on creationism and intelligent design:
National Center for Science Education, Inc.
1904 Franklin Street, Suite 600
Oakland, CA 94612
fax: 510-788-7971
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Remember the story we brought you in early July about BMWs disappearing (being stolen actually) in less than three minutes?
Well if you don't, here's a quick recap — car thieves in the U.K. used an over-the-counter key fob to bypass the security systems of several BMWs in a matter of minutes. The fob was able to deactivate the luxury cars' current settings so criminals could make a quick getaway and not leave a trace of evidence that the car was stolen.
Worried that BMW doesn't care if your $30,000 investment is growing feet and running off in the middle of the night? Well rest easy, because BMW is making some serious changes to ensure that your luxury vehicle is protected.
In a statement, BMW made it clear that they want to ensure the protection of their customer's vehicles: "All our cars meet all security standards and regulations, but as responsible manufacturers we are looking at ways of mitigating against this new kind of attack."
The automaker said that actions they're taking include enhancing the security on models previous to the 2011 series, and contacting owners to ensure they get the necessary work taken care of on their vehicle.
Don't be a victim of this high-tech crime — replace that standard security system and protect your $30,000-plus investment!
Remember that we told you back in July that there's a lesson here for car owners: Thieves will always find a way to get into your car – what you need is real-time awareness of when/where someone tries to violate your vehicle.
We asked our engineers and experts here for the best tips on just what these criminals are doing and how car owners can fight back against them.
They told us:
Number 1. In order to steal a car, the thief doesn't need to reprogram the key right away. The criminal just needs to bypass the vehicle immobilizer quickly using potentially bulkier equipment — and drive away. Key reprogramming can be dealt with later at a secure location with less time constraint (let's say 15-30 minutes).
Number 2. BMW security has a hole: It employs a relatively weak, 48-bit Hitag system that can be hacked in under 3 minutes using computer hardware costing less than $10,000. There is also a known weakness in the randomization of the security key and its dependency on the CAS (one of the vehicle's modules) dump. Such a dump is available over OBD connector. In other words, all components for a system are available on the Internet and putting the system together does not require a lot of technical skill.
Our experts were quite sure that BWM engineers are well aware of these shortcomings and are working on tighter the security and probably on upgrading their encryption method as well. That will address BMW's security issue — but also will make any key-cracking job harder.
Number 3. In order to deploy such a system, one needs to bypass the vehicle alarm system. The OEM one-way security is susceptible to jamming while more sophisticated two-way systems provide real-time status feedback and have additional sensors, etc.
Get connected to your vehicle and get ahead of the criminals: Thieves will always find a way to get into your car – what you need is real-time awareness of when/where someone tries to violate your vehicle.
Watch a BMW go in under 3 minutes and a BBC report here:
BMW Owners Hit by High-Tech Theft
See the whole quick-as-lightening BMW theft video below:


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Post-2015 goals must suit new contexts, UNDP chief saysFeb 27, 2013
Helen Clark calls for 'reinvigorated, transformational' agenda
Bogota — New global development goals must reflect current realities while sustaining the vision and momentum of the original Millennium Development Goals (MDGs), UN Development Programme (UNDP) Administrator Helen Clark said Wednesday.
"The food, fuel, climate, economic, political, and security crises of the first 12 years of this century have reminded us of how fragile development gains can be in the face of shock and adversity," she said in opening remarks here to a global conference on "Making the MDGs Work."
The conference, hosted by the Government of Colombia, comes just over 1,000 days before the 31 Dec. 2015 target set by the 2000 Millennium Declaration, in which 189 national delegations pledged to work toward eight goals such as reducing child and maternal mortality, expanding access to clean water and sanitation, and tackling acute hunger.
"What the MDGs have taught us is to aim high and think bigger. The well-being of people and the planet we share depend on that," Ms. Clark said. "The post-2015 framework can be seen as the next stage of implementation of the vision of the Millennium Declaration. To rise to that challenge, the international community needs to agree on a reinvigorated and transformational global agenda," she said.
"The post-2015 development framework will need to reflect the new global context fully, while remaining committed to the unfinished business of the MDGs. In the years since the Millennium Declaration was signed, much has changed," she said.
"Projections suggest that in 2015 almost 1 billion people will still live in extreme poverty. Many still will not have clean water or improved sanitation. Many will still be suffering from hunger, malnutrition, the burden of preventable ill-health, gender discrimination, and more. Whether or not global MDG targets are met, such suffering is inconsistent with the vision for dignity, equity, freedom, peace, and prosperity of the Millennium Declaration."
Large-scale effort to accelerate progress
Large-scale consultations on the MDGs and what will succeed them began in 2012. The United Nations has held or scheduled national-level dialogues in 74 countries as well as 11 consultations around themes ranging from health and education to governance. An online global conversation is ongoing through social media.
"Everything learned from what it takes to achieve the MDGs is relevant to throwing ourselves behind the global development agenda that follows. It has never been more important to have robust evidence of what makes the MDGs work," Ms. Clark said.
The MDGs originated as a pathway toward to advance human rights, development, and peace, offering measurable, time-bound goals, targets, and indicators, Ms. Clark said, "and a unifying vision for policymakers, development experts, and civil society. The goals' clarity, conciseness, and measurability brought diverse actors together around a common cause."
"By defining the desired outcomes in human development terms, the MDGs placed the wellbeing of people at the very centre of development efforts," she said.
Notable achievements include a drop by half since 1990 in the number of people living in extreme poverty, on under US$1.25 per day. Access to improved water sources has expanded and universal primary school enrollment a goal now within reach for boys and girls.
The world has also achieved significant gains in tackling HIV/AIDS, malaria, and tuberculosis, while progress toward reducing maternal mortality, ending acute hunger and malnourishment, and improving sanitation has lagged.
National ownership and dedicated policies are required to achieve further gains, Ms. Clark said.
"The remaining children not enrolled in primary school, for example, may be physically unable to join due to disability, or be working, or in groups which suffer discrimination, or be inhibited from attending for a range of other reasons unrelated to the physical proximity of schools and teachers," she said. "Overall the next global development agenda needs to address the significant problem of inequality which has stood in the way of reaching the MDG targets."
Acceleration Framework
Forty-five countries are now using the UN Development Group's MDG Acceleration Framework (MAF)—developed by UNDP and piloted in 2010 by UN Country Teams—to identify pragmatic solutions to expedite progress on lagging MDGs.
"These plans are not pilot projects. They are designed from the outset to reach the entire target population. While not enough time has passed to see national averages shift, it is clear that, when backed by strong political leadership and concerted support for implementation, the MAF approach works," Ms. Clark said.
Colombia, for example, is using the MAF across 76 territories, departments, and municipalities to respond to local priorities for reducing poverty, advancing gender equality, and addressing health shortfalls in the poorest and most disadvantaged communities.
Cambodia has become the first country to use the MAF to focus on women's economic empowerment at the national level. In the Central African Republic, the MAF helped establish an integrated and multi-sectoral approach to food security and nutrition.
Discussions in Bogota this week will be reflected in a global report in September, to be released ahead of the UN General Assembly's Special Event on the MDGs.


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Beware of so called Andrew Runnells. He has contacted few of the second hand sellers recently.
Thanks for your response and your elaborate explanations. The pics are quite OK. I am pleased with the present condition. I am purchasing it for my eldest son as a birthday gift, so I am counting on your words that you are selling me a good one.
How do you intend to ship it? Do I make arrangements for the shipping personally? What is your final offer? Where are you based?
I am presently out of town on a contract at the moment. I will however instruct my wife to make arrangements for the payment by check.
So please endeavour to get back to me as soon as possible for further proceedings.


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WASHINGTON (AP) ? Senators are finalizing a deal that could add dramatic security improvements to the U.S.-Mexico border and smooth the way for bipartisan Senate passage of far-reaching immigration legislation backed by President Barack Obama.
The deal doubling Border Patrol agents and adding hundreds of miles of fencing along the Southwest border has already won support from four undecided Republican senators who are now likely to back the immigration bill when it comes to a final vote. On Friday, senators were in final negotiations on other elements of the deal, including provisions on Social Security and other benefits, that could bring still more GOP support on board.
The amendment was expected to be formally unveiled in the Senate Friday and come to a vote early next week, with the overall bill headed for a final vote several days later. The legislation opening the door to citizenship for millions appeared within reach of securing the broad bipartisan majority that its authors say is needed to ensure serious consideration by the GOP-controlled House.
However, the outcome there remains far from certain because many conservatives are opposed to offering citizenship to people who came to this country illegally.
"We really have tried to secure the border in a way that we hope can get bipartisan support and that Americans want," Sen. John Hoeven, R-N.D., an author of the amendment, told The Associated Press in a phone interview Friday. "We're hopeful to have a good bipartisan majority."
Sen. John McCain, R-Ariz., said on Fox News Channel Friday that "if there's anyone who still will argue that the border is not secure after this, then border security is not their reason for opposing a path to citizenship for the people who are in this country illegally."
"Is it more than I would have recommended? Honestly, yes," McCain said. "But we've got to give people confidence."
Hoeven developed the amendment along with Republican Sen. Bob Corker of Tennessee, in consultation with McCain, Sens. Lindsey Graham, R-S.C., Chuck Schumer, D-N.Y., and other members of the so-called Gang of Eight senators who wrote the immigration bill. It prevents immigrants now here illegally from attaining permanent resident status until a series of steps have been taken to secure the border.
These include doubling the Border Patrol with 20,000 new agents, 18 new unmanned surveillance drones, 350 miles of new pedestrian fencing to add to 350 miles already in place and an array of fixed and mobile devices to maintain vigilance, including high-tech tools such as infrared ground sensors and airborne radar.
The new provisions would be put in place over a decade, in line with the 10-year path to a permanent resident green card that the bill sets out for immigrants here illegally. During that time, the immigrants could live and work legally in a provisional status.
Hoeven said the 10-year cost of the border security amendment included $25 billion for the additional Border Patrol agents, $3 billion for fencing and $3.2 billion for other measures.
It's "border security on steroids," said Corker, who along with Hoeven had been uncommitted on the immigration bill. Both are now prepared to support it, assuming their amendment is adopted. Sens. Dean Heller, R-Nev., and Mark Kirk, R-Ill., also announced their support for the deal Thursday.
White House press secretary Jay Carney said the border deal "would constitute a breakthrough" on immigration. "We're pleased that Republicans and Democrats continue to work together toward comprehensive immigration reform," he said.
The legislation had been expected to be formally unveiled in the Senate late Thursday, but that was delayed as senators and aides negotiated an array of issues, some that will be included in the amendment and some not, as they sought to iron out final obstacles to passage of the overall bill.
Sen. Orrin Hatch, R-Utah, who's pursued amendments related to Social Security, welfare, health care and taxes, was expected to see some of his concerns answered with provisions blocking immigrants from claiming credit for Social Security taxes they paid while working without lawful status, ensuring immigrants can't get welfare until after holding permanent resident status for five years and barring health care tax credits from going to people here on student or tourist visas.
Hoeven said Friday that Republicans have encountered opposition from Democrats and the White House to getting Hatch's provisions in the bill and were still working on that. He said they also were pursuing language on steps sought by Sen. Rob Portman, R-Ohio, to strengthen a system called E-Verify that employers use to check their workers' legal status, which will become mandatory under the bill. Changes to a new agriculture worker program in the bill, sought by Sen. Saxby Chambliss, R-Ga., among others, were not expected to make it into the amendment, Hoeven said.
The deal on border security came together quickly over the past several days after talks had bogged down over Republicans' insistence that green cards be made conditional on catching or turning back 90 percent of would-be border crossers. Schumer, other Democrats and Obama himself rejected this trigger, which they feared could delay the path to citizenship for years. Obama made his objections known in a phone call to Schumer from Air Force One during his trip to Europe for the Group of Eight summit earlier in the week, according to a Senate aide who spoke on condition of anonymity to discuss private deliberations.
The breakthrough came when the Congressional Budget Office released a report Tuesday finding that the bill would cut billions of dollars from the deficit. Schumer's top immigration aide, Leon Fresco, had the idea of devoting some of those billions to a dramatic border build-up.
Graham, who helped run interference between Corker and Hoeven and Democrats in the group, said that with the budget office finding in hand, he sat down with Schumer and Corker and said, "OK, let's go big."
The idea immediately appealed to the left and the right.
For Republicans, it provided concrete assurances that the bill would aim to achieve a secure border. For Democrats, it offered goals that, if dramatic, were achievable and measurable.
Still, not everyone was won over.
Shortly before Corker and Hoeven went to the Senate floor to announce their agreement Thursday afternoon, five leading Republican opponents of the bill held a news conference to denounce the deal as little more than an empty promise.
"In short, I think this amendment is designed to pass the bill but not to fix the bill," Sen. David Vitter, R-La., said.
About 10 Republicans have indicated they will vote for the bill, far more than enough to ensure it will have the 60 votes required to overcome any attempted filibuster by last-ditch opponents. Democrats control 54 seats, and party aides have said they do not expect any defections.
In addition to the border security components and eventual citizenship for the estimated 11 million people living here illegally, the immigration bill would create new work visa programs and expand existing ones to allow tens of thousands of workers into the country to work in high- and low-skilled jobs.
Source: http://news.yahoo.com/senate-immigration-bill-boosted-border-deal-073020424.html
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- About Company
Famco is a leading manufacturer of high speed mechanical shears for cutting metal, circuit board and other plastic materials. Since 1975, Famco has been the preferred source for high production mechanical shears, squaring shears, air and hydraulic shears and a variety of arbor, foot and air presses. The manufacture of high speed cut-to-length shears is supplied to large OEM builders and known throughout North America. Famco, an American manufacturer also produces the Gorton/Lars pantograph and cutter grinder and Milwaukee Slide & Spindle precision standard and special slide assemblies.
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Why CIOs Hire Bad Employees 09
We're sure at one point you've looked at one of your workers and thought, "How the heck did he ever end up in my IT department?" Every IT department has a couple of bad apples. In fact, 46% of rookie hires won't survive their first 18 months on the job, according to industry research. And 22% of turnover occurs within the first 45 days. These failures come at a high price: The cost of a bad hire can range from 1.5 to 3.5 times the salary of the employee in question. Clearly, this is something you'd like to avoid, but too many CIOs fall into the same, classic traps that keep them from making good recruitment decisions, according to Janco Associates. These mistakes demonstrate that optimal hiring practices require managers to walk a fine line. You can't do it all on your own in interviewing and evaluating, but over-delegating can hurt too. You want to come up with a measurable system, but many necessary qualities are purely subjective calls. To help lend guidance, here's Janco's list of 10 common mistakes made--and how to avoid them.
You Try to Quantify Everything
Metrics alone can't measure the total value of a potential employee. You need to go with your gut after thorough screening, interviewing and reference checking.
IT Solutions Builder TOP IT RESOURCES TO MOVE YOUR BUSINESS FORWARD
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Pioneer Natural Resources Co. (PXD) Falls 4.15% for February 08Equities Staff Follow |
One of the S&P 500's big losers for Monday February 08 was Pioneer Natural Resources Co. (PXD). The company's stock fell 4.15% to $113.87 on volume of 3.28 million shares.
The stock opened the day at 117.19 and traded between a low of $112.04 and a high of $117.44. The stock finished the day down $4.93 per share. Pioneer Natural Resources Co. has an average daily volume of 2.79 million and a total float of 149.38 million shares. The 50-day SMA for Pioneer Natural Resources Co. is $126.66 and its 200-day SMA is $134.72. The high for the stock over the last 52 weeks is $181.97 and the low is $103.50.
Pioneer Natural Resources Co is an independent oil and gas exploration and production company with operations in the United States.
Pioneer Natural Resources Co. is centered in Irving, TX, and has 4,075 employees. Today's trading day leaves the company with a market cap of $17.01 billion. The company has a P/S ratio of n/a, P/B ratio of 1.9, and a -18.1.
For a complete fundamental analysis analysis of Pioneer Natural Resources Co., check out Equities.com's Stock Valuation Analysis report for PXD. To see the latest independent stock recommendations from Equities.com's analysts, visit our Research section.
The S&P 500 represents the industry standard for large-cap indices. While the Dow Jones Industrial Average (DJIA) may be the most visible stock market index in the country, the S&P 500 has long been relied on by industry insiders and fund managers as the more reliable gauge of portfolio performance.
While the DJIA is price-weighted and only includes 30 stocks, the S&P 500 uses a weighting system that factors in market cap and the size of a company's free float while including some 500 stocks for a more comprehensive look at the broader markets' performance. Its performance is far more representative of the large- and mega-cap stocks for any period of time.
For more news on the financial markets, go to Equities.com. Also, learn more about our independent proprietary equity research reports and our robust do-it-yourself Stock Valuation Analysis reports in our Research section.
All data provided by QuoteMedia and was accurate as of 4:30PM ET.
DISCLOSURE: The views and opinions expressed in this article are those of the authors, and do not represent the views of equities.com. Readers should not consider statements made by the author as formal recommendations and should consult their financial advisor before making any investment decisions. To read our full disclosure, please go to: http://www.equities.com/disclaimer