text:
- Research article
- Open Access
- Open Peer Review
Overutilization of ambulatory medical care in the elderly German population? – An empirical study based on national insurance claims data and a review of foreign studies
© van den Bussche et al. 2016
- Received: 9 August 2015
- Accepted: 21 March 2016
- Published: 14 April 2016
By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healtcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.
The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.
Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.
We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.
- Primary care
- Health services utilization
- Frequent attenders
- High utilizers
- Multimorbidity
- Elderly population
By definition, high utilizers (synonymous with "high users" and "frequent attenders") receive a large proportion of medical services and therefore produce relatively high costs [1, 2]. In an earlier study we found that the elderly statutorily insured population in Germany has an average of 27.9 practice contacts per year (SD 23.6; median 23), spread over 4.8 physician practices (SD 3.3; median 4) [3]. This number of practice contacts is about two thirds higher than the 16 to 18 contacts found for the insured population as a whole during the first decade of the 21st century [4]. A specific look at the 60 % of the elderly population that is multimorbid – defined as suffering from ≥ 3 chronic diseases from a list of 46 – revealed that this sample of patients had 36.3 contacts/year (SD 24.5; median 31), almost 30 % more than the average, whereas the number of different practices contacted by this sample (5.7) was only slightly higher (SD 3.3; median 5) [3].
In the majority of studies from other countries, high utilization is associated with chronic diseases and multimorbidity [5–7]. In several studies, associations were found between high utilization and psychological stress, psychiatric syndromes, and medically unexplained symptoms ("MUS") [8–11]. On the other hand, studies on the influence of somatic diseases on frequent attendance are rare. Several studies also report a high sensitivity towards health and disease in high utilizers, which may lead to complaints and increased health fears. This is especially true in cases where the psycho-social explanations given by patients concerning the source of their illness are not accepted by their physicians [12, 13]. In several studies it was also noted that patients were critical of what they perceived as excessive somatic diagnostic examinations and an ineffectiveness of their physicians' treatments [14–16].
Our previous study, mentioned above [3], showed an almost linear association between the number of chronic conditions and the number of physician contacts. However, high standard deviations were found for each number of chronic conditions. This result posed the question of the reasons for this degree of variance, leading to an in-depth examination of the high utilizers (abbrev: HU) in every subsample. Therefore, this study tries to answer the following questions: a) Which proportion of the elderly population are high utilizers of ambulatory care in Germany? b) Can different types of high utilization be identified? c) Which socio-demographic factors and morbidity patterns are associated with high utilization? d) To which extent are data from other countries comparable to the German data?
The German ambulatory healthcare system
In order to interpret data on healthcare utilization in Germany and understand the conclusions of this study, a brief introduction to the structure of the German healthcare system is provided here [17]. Health insurance is mandatory for the entire German population today, either within a "Bismarckian" statutory health insurance scheme or - for about 10 % of the population - a private one. The number of healthcare resources – physicians, nurses, physiotherapists etc. – per person is among the highest in Europe. This is also the case for inpatient hospital care [18, 19]. Ambulatory care and inpatient hospital care are separate sectors with separate budgets within the healthcare system. As a result, only few hospital physicians work simultaneously in ambulatory care and vice versa. A dense supply of both primary and specialist services exists in ambulatory care, mainly provided by physicians in solo or small group practices. General practitioners (GPs) also care for patients in nursing homes. The group of primary care physicians (PCPs) in ambulatory care consists of all GPs and those general internists opting to work as a PCP at the moment of opening their practice, which is the case for approximately 60 % of the latter. Remuneration is based on complex algorithms consisting of capitation fees (especially for PCPs) combined with fees-for-service (especially for specialists), limitations for performance maxima per quarter and extrabudgetary incentives. The average physician to population ratio is currently 1:1,433 for PCPs and 1:1,218 for specialists [20]. In metropolitan areas, the density of specialists in the ambulatory sector is already much higher than that of PCPs.
All physicians in practices work as entrepreneurs in a market characterized by free access to all medical disciplines without compulsory gatekeeping, although most referrals are based on a document of another physician, usually the GP, especially among the elderly. Starting in 2004, visits to specialists without a referral from a GP were to be curbed by the introduction of a co-payment of €10 in each quarter. This measure was abolished at the end of 2012. In addition to physicians' practices, hospital emergency and outpatient units also provide a growing number of ambulatory services.
The study is based on the health insurance claims data of a primary care population consisting of all members aged 65 and over (n = 123,224) from a statutory health insurance company operating nationwide in Germany, the Gmünder ErsatzKasse (GEK). The GEK insured 1.7 million people in 2004, a figure corresponding to approximately 2.4 % of the statutorily insured German population. The year 2004 was chosen for two reasons: a) to allow comparisons with our previous studies on multimorbidity and utilization of ambulatory care [3, 21], and b) because precise data on the utilization frequency in ambulatory care were only published until 2007; since 2008, contacts with physicians are no longer recorded and have been replaced by case counts per quarter, implying one count per quarter regardless of the real number of contacts during the quarter. Therefore, claims data based utilization research in Germany can only reply on older data and draw estimates from them for the current situation (see discussion chapter). As in the years before 2008, there are good reasons to presume a further growth of utilization, e. g., because of the increasing average age of the population.
The claims data were provided by the GEK in a pseudonymous form. Insurants were included in this study when they were aged ≥ 65 years, were insured for the whole year of the investigation, and had at least one contact with one ambulatory care physician during that year (96 % of the total sample). The 4 % non-users were excluded because they do not appear in the dataset of the year under investigation.
Utilization of ambulatory medical services was ascertained through the number of contacts per year in all contacted practices, and the number of different physician practices contacted. The term "contact" includes all kinds of utilization, such as personal consultation in the office and/or during home and nursing home visits, regardless of their length, as well as some contacts with the practice staff (e.g., for prescription renewals) and/or telephone contacts with the physician, the latter being infrequent in Germany. Contacts deserved a presence of the patient in the practice, or with the physician. Appointments by phone and/or administrative work including contacts with other physicians concerning a specific patient were not counted as contacts. Several combinations and gradations within an encounter are possible. Therefore we preferred the term "contact" over "visit" or "consultation", and we use the term "practice" to cover the contacts with all practice members.
Usually, contacts with N different practices contacted per year means contacts with 1 GP and N-1 specialists (except for type C defined below by contacts to more than 1 specialist of a particular discipline). As a subgroup of the insurants that contacted several practices of the same medical specialization during the year of observation, particular consideration was given to those who contacted ≥ 3 practices of the same specialization (with the exception of primary care or internal medicine). This criterion corresponds to 5.1 % of the sample (n = 6,224). The criterion of ≥ 3 practices of the same specialization was chosen because a cutoff of two contacts would have defined all those seeking a second opinion or visiting a holiday replacement physician as high utilizers.
Insured persons with ≥ 50 contacts with ambulatory care physician practices within a year (HU-type A),
Insured persons with one or more contacts to ≥ 10 different physician practices within a year (HU-type B),
Insured persons with one or more contacts to ≥ 3 different physician practices of the same medical specialization (except for general practice or internal medicine) within a year (HU-type C).
Since an insured person can belong to more than one of these three high utilizer types, seven subtypes can be identified (A--, B--, C--, AB-, ABC, AC-, and BC-). These seven subtypes are free of any overlap.
In order to analyze multimorbidity, we used a list of 46 ICD-10 diagnoses or diagnosis groups, which covered all chronic conditions with a prevalence ≥1 % in the age group ≥ 65 years in the GEK dataset. The process of creating this list is described in detail in a previous publication [21]. A person was defined as chronically ill if he or she had at least one chronic condition from this list over ≥ 3 quarters of the observation year, and defined as multimorbid if he or she had ≥ 3 chronic conditions from this list over ≥ 3 quarters of the observation year. Nursing care dependency was assumed when services of a statutory nursing care insurance scheme, a parallel agency to the statutory health services insurance, were received for at least six continuous months during the observation year. This criterion is used as a proxy for disability, but it should be understood that this underestimates the prevalence of disability because disability with no or little impact on activities of daily life ("ADL") does usually not lead to the receipt of benefits from nursing care insurance.
The main statistical analyses consist of multidimensional frequency tables with the corresponding percentages. Arithmetic means and medians, standard deviations, and confidence intervals were calculated for all continuous variables. A linear regression model was developed in order to determine the independent effect of patient characteristics on physician utilization (age, gender, nursing care dependency [yes/no], and the logarithm of the number of chronic conditions). Because of the interaction between age and gender, four combinations were analyzed with the subsample of men aged 65 to 74 years as a reference. The odds ratios express the relative chance of a variable to predict a person's relationship to a HU-subgroup under the control of all other variables.
To detect the prevalence of single chronic conditions in high utilizers, relative risks were calculated. The relative risk expresses to which extent a variable (in this case: a chronic condition) is associated with a specific risk (in this case: high utilization). Relative risks are comparable to odds ratios, but they are less dependent on prevalence differences between diseases than odds ratios [24, 25].
As for the literature review, we searched PubMed and Medline for articles about utilization in ambulatory medical care. We used the following terms (combining them with "and" and "or"): ambulatory care/outpatient care/primary care, doctor/physician – patient contact, utilization/use/frequency, and elderly/multimorbidity. We limited our results to papers written in English, German, French and Dutch, and to papers published after 1990. We also searched the www for statistical reports of governments, insurers and physician organizations. We included all studies and reports pertaining to the topic.
All analyses were performed with the SAS statistical software (version 9.2) and SPSS 16. Figures were created using R (version 2.15.1) and Windows Microsoft Excel 2003.
The study was approved by the Ethics Committee of the Medical Association of Hamburg (approval no. PV3057).
Study population
The total study population consists of 123,224 patients, 57.8 % of which were male. The mean age was 70 years (70 for men and 71 for women). 60 % of the total population was multimorbid according to the criterion of ≥ 3 chronic conditions (average number of chronic conditions 3.6 [3.9 for females and 3.5 for males]). The percentage of nursing care dependent persons was 13.4 (16.0 for females and 11.4 for men).
In the HU-sample, the mean age was 73.0 years (median (Md) 72) compared to 71.7 years (Md 70) in the non-high utilizer sample (NHU-sample). The average number of chronic conditions was 5.8 (Md 5) in the HU-sample compared to 3.1 (Md 3.0) in the NHU-sample; as a result, the percentage of multimorbid persons was 84.7 in the HU-sample compared to 52.8 in the NHU-sample. 11.7 % of the high utilizers were nursing care dependent, compared to 4.1 among the non-high utilizers.
Prevalence and typology of high utilization
Nineteen percent of the insured elderly were high utilizers according to the study criteria. HU-type A was found in 14.2 % of the elderly population and 74.4 % of the HU-sample, respectively; HU-type B in 8.9 % of the elderly population and 46.4 % of the high utilizers. HU-type C was the least frequent (5.1 % of the elderly population and 26.4 % of the HU-sample). Thus, more than a quarter of high utilizers contacted three and more physicians of the same discipline (general practice and internal medicine excluded) per year. The addition of the three types of high utilizers amounts to 147 %, which implies that more than one high utilization criterion applies to a substantial percentage of the HU-sample.
High utilizers had an average of 61.9 practice contacts per year (A: 70.7, B 62.9, and type C 57.7 contacts), three times more than non-high utilizers. The average number of contacted practices in the HU-sample was 9.0 (A: 8.8, B: 12.0, C 10.5), compared to 3.8 in the NHU-sample. Differences between the three types were relatively small with regard to age and gender, and this also applies to these respective differences between the HU- and the NHU-sample. Compared with type A, persons belonging to types B and C were somewhat younger, less multimorbid, and less dependent on nursing care.
Characteristics of high user types and subtypes
Sample size (%)
99,634 (80.9)
23,590 (19.1)
17,552 (14.2)
10,958 (8.9)
6,224 (5.1)
9,859 (8.0)
4,555 (3.7)
2,460 (2.0)
678 (0.6)
2,952 (2.4)
991 (0.8)
2,095 (1.7)
Percentage of high users (%)
Mean contacts with practices (SD)
19.9 (12.8)
61.9 (28.1)
70.7 (27.0)
62.9 (30.4)
57.7 (37.5)
66.3 (22.2)
72.2 (23.2)
83.0 (39.5)
76.2 (38.9)
39.2 (7.1)
39.3 (6.8)
30.9 (9.9)
Mean contacted practices (SD)
3.8 (2.3)
9.0 (3.5)
8.8 (3.8)
12.0 (2.3)
10.5 (3.7)
6.3 (2.1)
11.9 (1.9)
13.7 (3.2)
8.0 (1.1)
10.8 (1.2)
11.5 (1.6)
7.1 (1.4)
Multimorbid patients (%)
52,559 (52.8)
19,989 (84.7)
15,664 (89.2)
9,333 (85.2)
4,917 (79.0)
8,665 (87.9)
4,180 (91.8)
2,220 (90.2)
599 (88.3)
2,227 (75.4)
706 (71.2)
1,392 (66.4)
Females (%)
41,297 (41.4)
10,920 (46.3)
8,084 (46.1)
5,184 (47.3)
2,614 (42.0)
4,641 (47.1)
2,153 (47.3)
1,047 (42.6)
243 (35.8)
1,512 (51.2)
472 (47.6)
852 (40.7)
Mean age
Age ≥ 75 years (%)
28,603 (28.7)
8,849 (37.5)
7,375 (42.0)
3,264 (29.8)
1,899 (30.5)
4,710 (47.8)
1,562 (34.3)
830 (33.7)
273 (40.3)
678 (23.0)
194 (19.6)
602 (28.7)
Nursing care dependents (%)
4,046 (4.1)
2,749 (11.7)
2,630 (15.0)
477 (4.4)
333 (5.4)
2,111 (21.4)
261 (5.7)
155 (6.3)
103 (15.2)
44 (1.5)
17 (1.7)
58 (2.8)
Mean chronic conditions
Significant (p < 0.01) odds ratios with their 95 % confidence intervals (in parentheses) for the affiliation to a high user type
High users total
Type A
Type B
Type C
Males aged ≥ 75
Females aged 65–74
Females aged ≥ 75
Nursing care dependency
Number of chronic conditions
Types B and C were only marginally related to multimorbidity, as every additional chronic disease increases the chance of belonging to type B by only 4 % and decreases the chance of belonging to type C by 6 %. Being dependent on nursing care even reduces the chance by 72 % for type B and 57 % for type C. On the other hand, type A was closely associated with multimorbidity and nursing care dependency, as the chance of belonging to this type grew by 23 % for every additional chronic disease, whereas being nursing care dependent increased this chance by a factor of 7. HU-type C was almost independent of the number of chronic conditions and of nursing care dependency in particular, as the latter lowered the chance of belonging to C by more than 50 %. In sum, HU-types B and C differed substantially from HU-type A with regard to their relation to age, sex, multimorbidity, and nursing care dependency.
Which chronic diseases are associated with high utilization?
Prevalences and relative risks (with their 95 % confidence intervals) of the 10 diagnoses with the highest risk for high use according to high use types
High use total
(n = 23,590)
High use type A
(n = 17,552)
High use type B
(n = 10,958)
High use type C
(n = 6,224)
n (prev)
n (prev)
n (prev)
n (prev)
Urinary incontinence
1488 (6.3)
3.3 (3.1–3.5)
Urinary incontinence
1317 (7.5)
3.9 (3.7–4.2)
1177 (10.7)
3.3 (3.1–3.5)
1860 (29.9)
3.4 (3.3–3.6)
1059 (4.5)
3.1 (2.9–3.4)
932 (5.3)
3.7 (3.4–4.0)
2906 (26.5)
3.0 (2.9–3.2)
Renal insufficiency
511 (8.2)
3.4 (3.1–3.8)
2327 (9.9)
3.0 (2.8–3.2)
Renal insufficiency
1466 (8.4)
3.5 (3.3–3.7)
Anxiety disorder
345 (3.1)
3.0 (2.7–3.4)
302 (4.9)
3.4 (3.0–3.8)
Renal insufficiency
1677 (7.1)
3.0 (2.8–3.2)
1978 (11.3)
3.4 (3.2–3.8)
469 (4.3)
3.0 (2.7–3.3)
Sexual disorder
186 (3.0)
2.9 (2.5–3.4)
5660 (24.0)
2.8 (2.7–2.8)
1175 (6.7)
3.4 (3.2–3.7)
Somatoform disorder
880 (8.0)
2.9 (2.7–3.1)
529 (8.5)
2.6 (2.4–2.8)
1252 (5.3)
2.7 (2.5–2.9)
Parkinson's disease
556 (3.2)
3.2 (2.9–3.5)
Sexual disorder
312 (2.8)
2.8 (2.5–3.2)
267 (4.3)
2.4 (2.2–2.8)
Parkinson's disease
619 (2.6)
2.6 (2.4–2.9)
890 (5.1)
2.9 (2.7–3.1)
524 (4.8)
2.7 (2.5–3.0)
Urinary incontinence
270 (4.3)
2.3 (2.0–2.6)
1065 (4.5)
2.6 (2.4–2.8)
4402 (25.1)
2.9 (2.8–3.0)
Urinary incontinence
547 (5.0)
2.6 (2.4–2.9)
Severe vision loss
1570 (25.2)
2.3 (2.2–2.4)
Anxiety disorder
623 (2.6)
2.5 (2.3–2.8)
Anxiety disorder
522 (3.0)
2.8 (2.6–3.2)
Bowel diver-ticulosis
685 (6.3)
2.6 (2.4–2.8)
Gynecological complaints
554 (8.9)
2.2 (2.0–2.4)
Heart valve disorders
1329 (5.6)
2.4 (2.3–2.6)
Heart valve disorders
1126 (6.4)
2.7 (2.6–2.9)
Migraine/chron. headache
449 (4.1)
2.6 (2.3–2.9)
Anxiety disorder
137 (2.2)
2.1 (1.8–2.5)
Epidemiological summary
According to the criteria used in this study, it is estimated that, depending on the study population (see strengths and weaknesses section) some 20 % of the ≥ 65 year-old, statutorily insured German population are to be considered high utilizers of outpatient care. This figure corresponds to approximately 3.5 million persons covered by statutory health insurance. The frequent attenders in this study had on average 62 contacts with an ambulatory care practice (1.2 contacts per week) spread over 9 different physicians, usually 1 GP and 8 specialists, per year. Two main HU-types were found. The first type (HU-type A) is characterized by the large average number of practice contacts (71/year = 1.4 contacts/week), found predominantly among the oldest age group (42 % ≥ 75 years), in patients with a high percentage of multimorbidity (89 %), and relatively often in need for nursing care (15 % as compared to 11 % in the general population in this age group). This type corresponds to the traditional public conception of a high utilizer as a very old person suffering from multiple burdening diseases that require continuous medical and nursing services. The other HU-types - a combination of HU-types B and C - were comparably prevalent but consisted of a significantly younger age group (30 % ≥ 75 years) that was somewhat less frequently multimorbid (83 %), and which particularly less frequently received nursing care (5 %). These HU-types consulted many different physicians (11 - 12 per year), often from the same specialization (36 %). These types of high utilization are frequently called "doctor (s)hopping" in the literature [26, 27]. Remarkably, gender differences were not found.
The criteria for this typology were set deductively on the basis of the empirical distribution of the data. Therefore it should be kept in mind that using stricter or more tolerant criteria for frequent attendance would have lead to different results. For example, using ≥ 8 instead of ≥ 10 different practices as a cutoff for HU-type B would have raised the percentage of B from 9 to 12 % of the elderly population; inversely, a cutoff of ≥ 2 instead ≥ 3 practices of the same discipline would have raised the percentage of C-type high utilizers from 5 to 24 %. In other words, a quarter of the elderly contacts ≥ 2 specialist practices of the same discipline per year.
Morbidity patterns of high users
High utilization of statutory ambulatory care is related to specific diagnoses. All 46 ICD-10 diagnoses for chronic conditions investigated in this study showed a minimum odds ratio of 1.3 for belonging to the high utilizer sample, and 27 of 46 had a respective odds ratio ≥ 2. Also, complex associations were found between diagnoses and HU-type. On the one hand, several chronic conditions were found in the list of top 10 relative risks for all three HU-types A, B, and C, albeit at different positions in the list for each type. This is the case for urinary incontinence, cancer, anemia, neuropathy, chronic polyarthritis, and anxiety (see Table 3). In diagnoses like cancer, the most prevalent disease of the ABC-subtype, the combination of serious somatic disease, psychological stress, and the search for further treatment options could be the reason for often contacting several practices, including those of the same specialization. Neuropathy also, the top ranking disease in type B, might fall under the category of symptoms that are difficult to treat, resulting in consultations with multiple physicians. On the other hand, certain groups of chronic conditions are specific for single types of high use. Dementia and Parkinson's disease, for example, only appear among the diseases associated with many contacts (type A) but not with consulting many specialists; in the case of dementia, contacts are centered mainly around the GP [28]. Furthermore, several syndromes with a possibly psychiatric background are found especially in HU-types B and C, such as somatoform disorders, sexual problems, anxiety, and migraine/headache. Very probably, these patients migrate through the care system and contact many different specialists because of a lack of satisfaction with the explanations or treatments offered to them. The relevance of psychiatric and psychosomatic factors for "doctor (s)hopping" has been confirmed in many international studies [13, 16, 27], as well as in German studies. In a representative study of the general population in Germany, Mewes et al. found a higher level of somatization and/or post-traumatic symptoms to predict high utilization [29]. Schneider et al. found a higher utilization rate of GP practices by patients with recorded psychiatric diagnoses compared to those with somatic diagnoses [30]. Apart from morbidity, for a patient to become a high utilizer of a particular type is probably dependent on additional factors, such as the burden of comorbidity [8], and vulnerability [31]. Furthermore, personality variables (e.g., subjective disease concepts [32]), personality traits [33], situational factors (e.g., regional service supply differences or previous experiences with the healthcare system) might play a role. Further research is needed in order to identify such factors.
German utilization figures in international comparison
Studies on physicians' work load in ambulatory medical care, length of consultations, number of contacts and contacted physicians per year, referral frequency to specialist care with special reference to high use among the (multimorbid) elderly
Patients per week (consultation length in minutes)
Contacts per year
Contacted physi-cians per year
Referrals to specialists per year
Definition of contact In- and exclusions Definition high use
General practice patients age ≥ 18 (mean age: 40–48)
Not examined
Not examined
17.9 % (ES) −5.6 % (GE) of consultations
Encounters in practice premises, plus twice the number of home visits, plus half the number of telephone contacts; high use not examined
Koch et al. [40]
Eleven (seven reported here)
Survey among PCP
Not examined
Not examined
Not examined
"Visits"; no further specification of contact type; high use not examined
Starfield et al. [7]
5 % Medicare sample age ≥65 according to 3 comorbidity degrees
Not examined
Lowest comorbidity degree: 3.9 (2.1 PCP, 1.8 NPCP)
highest comorbidity degree: 15.6 (6.6 PCP, 9.0 NPCP)
Not examined
Not examined
PCP: geriatricians included; contacts in physician practice + ED + OPD were counted
highest comorbidity degree: persons with ≥ 10 chronic conditions
Starfield et al. [42]
patients aged ≥65 in Medicare managed care
Not examined
Not examined
GPs and internists included (same year hospitalized patients excluded); high use not examined
National Center for Health Statistics [44]
National sample aged ≥65
18.1 min
7 (all physicians in practice; 6.1; OPD + ED: 0,9)
Not examined
Not examined
High use not examined
Survey of national sample of physicians
Not examined
patient age ≥ 65: 7,4
Not examined
Referral rate. 10.7 of visits
Visits to practices and CHCs only; telephone contacts and (nursing) home visits excluded; high use not examined
Barnett et al. [63]
National sample aged ≥65
Not examined
Not examined
All physicians: 8.6 % (PCP: 9.9 %, NPCP: 7.3 %)
Contacts in physician practices + OPD were counted; institutionalized patients excluded; high use not examined
National sample aged ≥ 15 years with ≥ 1 chronic condition
Not examined
Not examined
80 % referred
GPs + GP-assistants; no further specification of contact type; high use not examined
Cardol et al. [64]
Primary care patients ≥65
PCP: 10,2 min
Age ≥65: PCP 16.4
(age 65–74: PCP 11.6)
Not examined
Not examined
Visits + home visits + telephone + paperwork by GP + GP-assistants (telephone contacts account for 11 %); high use not examined
van Oostrom [38]
Primary care patients, age ≥65
Not examined
≥2 chronic conditions
+ age 65–74: PCP 19.6
+ age ≥ 75: PCP 24.0
Not examined
mm: 36 % referred with 0,5 referrals/year
Consultations, telephone contacts (9.8 % for mm) and home visits; high use not examined
van den Berg [65]
Primary care patients; all ages
1987 & 2001
2001: 9.8 min
Not examined
Not examined
Not examined
Practice consultations only; high use not examined
Nie et al. [39]
Canada (Ontario)
Insured population aged ≥ 65
Not examined
10.3 (=6.2 PCP, 4.1 NPCP + ED); hu = 43.6 (PCP 20.7, NPCP 22.9)
Not examined
Not examined
"Office visits"; no further specification of contact type; hu-cutoff: ≥ 26 contacts (≥15 PCP visits, ≥ 11 NPCP visits, ≥ 5 ED visits) = 5,5 % of study population
Demers [26]
Canada (Quebec)
Insured general population
Not examined
Not examined
"Encounters" not further specified;
hu-cutoff: contacts with > 20 physicians (=0.06 % of patients)
Reid et al. [66]
Canada (Brit. Columbia)
General population ≥ 18 years
Not examined
hu: 50.3, nhu: 9.0
hu: 9, nhu: 2.7
Not examined
"Encounters" not further specified; ED-visits excluded; hu-cutoff: most costly 5 % of users of fee-reimbursed services
Broemeling et al. [67]
Canada (Brit. Columbia)
Insured general population ≥ 18 years
Not examined
≥1chronic condition: 11.5 (8,5 PCP + 3.0 NPCP)
maximum hu: 28.1 (19.3 PCP + 8.8 NPCP)
Not examined
Not examined
"Visits"; no further specification of contact type; hu-cutoff: 5 % of total population, 11.6 % of persons with chronic conditions
Britt et al. [68]
Survey among GPs
15,3 min
Not examined
8.4 % of encounters with GP
Not examined
Consultations, home visits, nursing home visits included; high use not examined
Busato et al. [69]
Primary care sample age ≥ 40
Not examined
3.0 (PCP only)
Not examined
Not examined
Specialist consultations & ED visits excluded; high use not examined
Bähler et al. [34]
Helsana Group insurants age ≥ 65
Not examined
All physicians: 13.1 (mm: 15.7, nmm: 4.4)
PCPs: 6.1 (mm: 7.4, nmm: 1.9)
NPCP: 4.3 (mm: 5.1, nmm: 1.8)
All physicians: 2.9 (mm: 3.3, nmm: 1.5)
PCP: 1.1 (mm: 1.2, nmm: 0.6)
NPCP: 1.8 (mm: 2.1, nmm: 0.9)
Not examined
Consultations, home visits, OPD contacts, phone contacts (all physicians: 5.7 %) included; nursing home visits excluded
mm : ≥ 2 chronic conditions; high use not examined
Population sample age ≥ 65
Not examined
Not examined
Not examined
Visits ("Besuch einer Praxis") included; no further specification of contact type;
high use not examined
Neal et al. [36]
United Kingdom
Sample from 4 primary care practice
Not examined
Not examined
Not examined
Visits and outpatient contacts; no further specification of contact type; high use not examined
Salisbury et al. [70]
United Kingdom
Primary care sample age ≥ 18
Not examined
mm: 9.4, nmm: 3.8
Not examined
Not examined
Bellón et al. [71]
Spain (Andalousia)
208 hu age ≥ 15 in one health center
Not examined
Not examined
Not examined
ED/OPD-contacts excluded; no further specification of contact type
hu cut-off: 14.7 for females, 13.8 for men
Luciano al. [72]
Spain (Catalonia)
GP sample age ≥ 65 with ≥ 3 chronic conditions
Not examined
23,1 (age ≥ 65: 22.4)
Not examined
Not examined
ED/OPD-contacts excluded; no further specification of contact type
hu:10 % highest users = consultation frequency > 12
Bergh et al. [73]
1 health center sample age ≥ 65
Not examined
GP-contacts: 1.2–1.4
(hu: 5, nhu: 1)
Not examined
Not examined
hu: 10 % highest users
Moth et al. [74]
Primary care sample age ≥ 40
(>2/3 of contacts <15 min
Not examined
Not examined
Not examined
Contacts = face-to-face, phone, email and home visits (telephone + mail-contacts 39.1 %); high use not examined
Drees [75]
(PCP 15 min, NPCP 15–30 min)
Not examined
Not examined
Not examined
Practice consultations and home visits, no ED/OPD contacts; high use not examined
Health Insurance Authority [76]
"Care intensive" patients (cip); no age limit
Not examined
All physicians: cip: 39.6, ncip: 7 (PCP: cip: 30, ncip: 5;
NPCP: cip: 9.6, ncip: 2)
Not examined
Not examined
No specification of contact type
cip: numbers of contacts & services + hospital days (=7 % of population)
The top position is also found for the referral rate to secondary ambulatory care by a primary physician (93 % of the elderly at least once in a one-year period) and – inversely – for the length of contact with a physician in minutes.
There is a remarkable correspondence between the two internationally comparative studies on GP workload by patients per week and consultation lengths in minutes (rows 1 and 2) with regard to the ranking of the countries under study. This is the case for the data on Germany, the Netherlands, and the UK. In both studies, German GPs see more patients in shorter consultations, whereas GPs in the UK and the Netherlands see more than one third fewer patients. In the Commonwealth study (row 2), the GPs in the United States have the lowest number of patients per week, combined with relatively long consultations.
Several studies on the number of physicians visited and the number of contacts with them in the USA (rows 3–7) suggest a number around 7 visits per year for the elderly, increasing up to 16 for highly multimorbid elderly. Especially in the case of multimorbidity, contacts with specialists seem to be more frequent than with primary care physicians. Even if this greater number of contacts with specialists compared to primary care physicians seems to be a feature unique to the USA, the absolute number of contacts – both with primary care physicians and specialists – and the number of contacted specialists are by no means striking when compared to other OECD countries (see below).
Some other OECD countries show lower average numbers of contacts with physicians (e.g., the UK [rows 20–21] and Sweden [39]). Others show somewhat higher numbers (e.g., the Netherlands [rows 8–11], Switzerland [rows 17–19], Spain [rows 22–23], and Canada [rows 12–15]). In all studies, contact frequencies are substantially higher in cases of multimorbidity or especially when examining (elderly) high utilizers.
When high utilization is examined, some studies find very high contact rates, such as 40 in Austria (row 27), 44 in Ontario (row 12), and 50 in British Columbia (row 14). In all of these cases, however, the sample consists of the 5–7 % of the highest utilizers. Considering the 19 % of the highest utilizers found in our study despite strict cutoffs (e.g., ≥ 50 contacts per year), many foreign studies use cutoffs for high utilization which could function as cutoffs for low use in German studies.
Even with all of these differences between the studies taken into account, the German figures far surpass those of most other industrialized countries. In this context, it should be kept in mind that the German figures do not include oral health services, most of the complementary medical services not covered by the health insurance, and the visits to emergency departments (currently estimated at 125/1,000 of the total population per year and rapidly increasing). Also, according to the study by Koch et al., no substantial difference between the type of contacts in German GP-practices in comparison to other countries are given, as German GPs declare that 70 % of their contacts with patients are personal contacts, a figure corresponding to a middle ranking (min: 66 %, max: 87 %) among the 11 countries in that study [40].
Further research is needed to explain these exceptional features of the German ambulatory healthcare system. Several reasons may contribute to this phenomenon, probably involving mechanisms on the side of the providers, the patients and the system itself. Among the reasons on the patients' side, possibly greater attention to complaints and diseases, greater health related fears [41], tendencies to delegate responsibility from one self to physicians, and greater beliefs in procedural approaches to diagnosis may play a role. German physicians in ambulatory care may practice contact increasing strategies, e.g., by recall habits, client binding strategies, and competition with specialists. Also, the impact of bureaucratic directives of the insurance system on utilization (e.g., quarterly prescription regulations, remuneration specifics and budget limits, certification requirements for short time sick leave etc.) should be analyzed. Like in the United States, specialists in Germany play an important role in caring for common conditions, independent of the level of comorbidity and of the medical need for highly specialized care [3, 42]. This may be due to the particular "double specialist track" in Germany, a term describing the doubling of hospital based specialists working solely in the hospital (with an actual density of 1 hospital specialist [including resident specialists] to 814 inhabitants) by a supply of specialists working solely in ambulatory care (actual density of 1 specialist to 1,192 inhabitants) [43]. Furthermore, the German ambulatory healthcare system is based solely on the figure of the physician, whereas nurse practitioners and qualified registered nurses hardly play a role in the provision of services in the practices, which leads to a complete lack of alternatives to the physician in health services.
The high number of contacts in Germany is associated with smaller time slots per consultation when compared with the UK and especially with the USA (Table 4: [40, 42, 44, 45]). Other authors forwarded that in gatekeeping countries (with fixed lists of patients) GP consultations are longer, more time is spent talking with patients, especially about psychosocial aspects of their conditions, and the workload of general practitioners is lower [46]. Table 4, however, shows that this is not generally the case.
The main problem of high patient numbers per day and short consultation lengths may be that those patients who need intensive visits may not get them because the waiting room is always full, such as is the case in Germany, where it is not uncommon for GPs to see 70 patients per day. Østbye et al., who calculated the number of hours needed to provide guideline-conform care for the 10 most common chronic diseases in the USA, "provided the disease is stable and in good control", found a requirement of 3.5 h a day. When adding uncontrolled disease, the estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands would increase to 10.6 h a day. The authors concluded that "current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall" [47]. German GPs are aware that their patient load does not allow them to allocate sufficient time per patient, and they consider a reduction of their patient load by around 25 % to be necessary for sufficient care [48].
The other danger of high utilization is that most of the contacts produce diagnoses, suggestions for further diagnostic procedures, referrals, drug prescriptions, physiotherapy prescriptions, and lifestyle recommendations that need to be understood by the patients and integrated into their lives. It is unclear how elderly patients handle this in their daily lives. Barbara Starfield concluded from several studies that "an excessive specialist supply with inappropriate specialist use leads to greater frequency of tests, more false-positive results, and worse outcomes than appropriate specialist use. The more physicians patients see, the greater the likelihood of adverse effects" [42]. As people's use of specialist services is rapidly increasing, at least in the United States [42] and in Germany, the concepts of personal responsibility and self-management by (elderly) patients appear equally as fanciful as those stressing the need for continuity and comprehensiveness in medical care in these countries.
Incentives for change?
In spite of the dissatisfaction on both sides – primary care physicians and patients – professional and/or political initiatives to reduce the utilization rates have not occurred, so far. Politicians might fear that the introduction of visible restrictions to utilization may result in criticism for a presumed cutting the welfare state. The size of high utilization described in this paper is generally considered to be a social achievement rather than a societal problem of medical care. The political and public disinterest in the issue of utilization frequency is also demonstrated by the fact that a reform of the reimbursement system in ambulatory care in 2008 went ahead with a discontinuation of the administrative documentation of utilization rates. Since that year, the responsible institutions – statutory health insurance companies, statutory physicians' associations, and also the government – consciously renounce to document data on contact and referral rates for Germany.
Masking the facts
The exceptional figures for Germany have not been noticed internationally because the OECD publishes mistakable data on the contact rates in German ambulatory care. Under the heading "number of contacts with physicians", OECD does not report the number of contacts (actually estimated at 20 contacts per year [49]) but the number of contacted practices per patient and year (e.g., 8.2 in 2009). By means of this unusual – and misleading – definition of "contact", explained only in a rather cryptic footnote, Germany occupies a prominent but still inconspicuous position in the international rank order of contact numbers [50].
High use or overuse?
Of course, high utilization rates do not mean unjustified and/or dangerous overuse per se. Also, apart from figures on the general population and for the elderly as described in this paper, specific figures for the German working population are lacking. Also, evidence for the motives behind high utilization cannot be found in claims data. As there is no objective criterion for high utilization and, thus, no valid reference for diagnosing overuse, the very high utilization figures in German ambulatory medical care do not allow to use the term overutilization. On the other hand, the far-above-neighbor OECD countries utilization figures do not correspond to German outcome figures [51]. Therefore, questions arise about the relationship between benefit and harm of such high contact rates. As the utilization of inpatient care in Germany is also at the top of the OECD ranking list [18], more research is needed on the reasons and motivations for utilization rates in both healthcare sectors as well as on the interaction between the two [52]. In contrast, older people generally need a comprehensive and coordinated treatment plan, which is difficult to achieve with a two-digit number of contacts with specialists, especially considering the well-known deficits of communication between these specialists [53].
Strengths and weaknesses
This study is based on claims data and therefore shows strengths and weaknesses inevitably related to this database. Apart from age and gender, no further socio-demographic variables were gathered that could be used to explain the differences in prevalence and risk. By including 46 diagnoses, we assume that all common and serious chronic diseases have been investigated. These diagnoses are documented by physicians – GPs and specialists – working in statutory healthcare and thus not by specially trained study personnel. It is known that there are limits to the validity of coded, claims related diagnoses [54, 55]. Validity issues of this nature were also found in the primary data collected via interviews with general practitioners [56, 57]. On the other hand, claims data allow a larger study population, including patients that are hard to reach in field studies, such as nursing home residents, very elderly patients, and severely ill patients. Memory bias regarding utilization and a bias due to socially acceptable answers of patients are excluded. This is the case for provider data as well. Finally, this cross-sectional study can detect associations but not causes.
The claims data stem from one insurance company, which poses the question of representativity. As there was and still is a high number of insurances (some 150 around 2006) some operating at regional and others on a national level, there is no possibility to draw a representative sample of the insured population in the strict sense of the term. The few studies comparing data from several insurers show that both problems of internal and external validity are given. With regard to internal validity, the GEK-Data show a higher proportion of males for historical reasons. As analyzed in a previous study, these gender difference does not have a major impact on utilization figures in the elderly population insured by the GEK [3]. As for external validity, comparisons between insurances are limited to the epidemiology of certain diseases, and studies on utilization data are lacking [58, 59]. Exercising extreme caution we may postulate from other data sources on insurance characteristics that there is no reason to assume that data from GEK-sources are exceptional or extreme.
Germany is likely to be at the top of the rank order of utilization of ambualtory healthcare (at least) among the elderly. Followers are far behind. Reamarkably, a discussion of this phenomenom is absent in Germany.
The high utilization of ambulatory care physicians appears to be a multilayered, complex phenomenon based on many chronic diseases of varying origin. Both serious somatic illnesses and psychological complaints lead to high utilization. Also, health system characteristics and incentives from providers might play an important role. Complex problems require complex solutions. Therefore, an optimization of the utilization of statutory healthcare requires a multidimensional approach that goes beyond financial restrictions alone. Further research is needed both regarding the reasons and the remedies of this very high utilization of ambulatory medical care by the elderly in Germany and, perhaps, also by the working-age population.
The comparison of studies on utilization of physicians suffer from imprecision of definitions of essential terms like contact, visit, consultation etc. This is also the case for consultation length and referral rate. These imprecisions make international comparisons difficult. Hence, OECD – and other insitutions – should point more explicitely at this problem in their publications and untertake steps towards harmonization.
Data availibilty
The data of this study are property of the BARMER GEK Krankenversicherung sited at Wuppertal, Germay. Access to the data will need an application at the insurance headquarter.
This study was sponsored by the German Federal Ministry for Education and Research (registration numbers 01ET0725 and 01ET0731). We thank the BARMER GEK Health Insurance Company for providing the GEK insurance data.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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- Moth G, Vestergaard M, Vedsted P. Chronic care management in Danish general practice - a crosssectional study of workload and multimorbidity. BMC Fam Pract. 2012;13:5.View ArticleGoogle Scholar
- Direction de la recherche, des études, de l'évaluation et des statistiques (Drees). Consulter un spécialiste libéral à son cabinet: premiers résultats d'une enquête nationale. Etudes et résultats l n° 704 - octobre 2009.Google Scholar
- Hauptverband der österreichischen Sozialversicherungsträger (ed). Behandlungsintensive Populationen. Literaturrecherche und empirische Analyse. Vienna 2014. (http://www.hauptverband.at/portal27/portal/hvbportal/content/contentWindow?contentid=10008.605210&action=b&cacheability=PAGE&version=1419250039; Accessed 8 Apr 2016).


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Ok so I'm going through this major transition right now in my life that had me feel much less grounded than I usually am. So this past weekend, I accepted the invitation to a sweat lodge weekend retreat with Big Heart Circle at Ashokan Center in New York. I had never been to anything like this before and I'm SO glad I chose to go.
"What is this major transition," you're probably asking? Well…. I'm leaving my nice cushy stable J.O.B. of 4 years and diving back full force into the freelance/entreprenurial world – with full intent of filling my life with guitar gigs. I have intensified my study and training to prepare for January 1st — which is when my transition is official.
I gained some incredible things out of this weekend. Besides detoxing, I was able to connect with the elements of mother earth in a new way. In remembering that we are all ONE — once we break everything down to molecules and atoms, I bathed my feet in the grass/mud and breathed in the majestic icy air near Winchell's Falls and mentally pictured mother nature flowing up through my fingers when I play guitar. I'll never forget it. Though I didn't play guitar at all during this retreat, when I returned to the city, my playing had noticeably improved because of it.
And during the weekend, I was so thrilled to have met Michelle Christine Garza, who had brought her guitar along and frequents the Big Heart Cirle community. She's the type of person you just fall in love with immediatley. She's so open hearted and talented. She has the voice of a sweet bird and plays a finger style guitar that melts any soul. She writes these spiritual tribute songs to life and nature and really makes a difference wherever she shares her talent. And the extra cool thing is, she writes and sings in quite a few different languages and even if you don't know the language, you still understand. Music truly trancends any language barrier. Here's her link. http://michellechristinegarza.com/. I had brought my djembe drum along for the trip so it was awesome to be able to accompany Michelle on a few songs after the lodge in the Pewter House. Joining with her, I felt like I was traveling to another land in drumming trance. And I knew everything was going to be okay.
Check Michelle on Facebook too!

subset: commoncrawl


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Read: Genesis 6:11-14, 7:17-8:3, 9:8-13
Key Verses: Genesis 9:8-13
When I read about the times of Noah, how the men were corrupt and lived only for themselves and their own pleasure, I think about our world today.
I also think about God being angry. In our world, we seem to think that you can't love someone and be angry with them, but from the very beginning we are shown that God loves people. Yet here in this story He was angry enough to destroy them all. The Bible says that He was sorry that He created us (Gen. 6:8). It doesn't seem to add up, does it?
But there was hope. Even in God's anger with the human race, He loved them enough to preserve them. He found favor in 1 man, Noah.
I wonder what Noah did or how he lived that found favor in the eyes of the Lord. Why out of all the people who covered the earth at that time did Noah find favor?
But he did find favor with the Lord, and God used Noah to preserve man.
And then God made a covenant with Noah and set the rainbow in the sky as a sign of His promise to never destroy the earth by flood.
Instead of destroying man, God made a way for man to be reconciled to Him. He sent His Son.


text: Sign up now for essential seminar on construction marketing strategy Marketing strategy for construction The CIM Construction Industry Group (CIMCIG) is hosting a morning seminar at Bristol Golf Club on 13th September specifically for marketers in the building industry. The two-hour breakfast seminar is sponsored by MRA Marketing, and looks at how to develop and implement a comprehensive marketing strategy in the construction and building materials sectors. Speakers include Lucia Di Stazio of MRA Marketing, Mike Jordan of Bluegg, Bethan Lewis of Brighter Comms and Andy Mudie of Nuaire, who is also Vice Chair of Creative, Services and Events for CIM Wales. Lucia Di Stazio, Managing Director of MRA Marketing, comments: "The overall session will review strategic planning and management best practice, looking at rebranding, breaking into new markets, launching products or company branches and more, with examples of successful, award-winning case studies from previous Construction Marketing Award winners. Marketers in this sector based in the South-West can discover why their PR and digital strategy needs to be aligned, and how to strengthen their product offering through a customer service strategy." The event will benefit anyone with a product, brand, communications or marketing role in a company involved in the construction sector, whether contractor, manufacturer or merchant. This essential seminar is just £30 for members or students and £40 for non-members. The session starts at 9:15am (with registration and buffet at 8.30am) and finishes at 11:30am, with free parking onsite. For further details or to book online go to www.cim.co.uk/event/85393, email firstname.lastname@example.com or call 01628 427340. For more on MRA Marketing visit www.mra-marketing.com or follow @MRAMarketing on Twitter. CIMCIG With 50,000 members in 130 countries, the Chartered Institute of Marketing (CIM) is the largest professional marketing body in the world, and over 100 years old. The CIM's Construction Industry Group (CIMCIG) is one of the organisation's most active industry groups in the UK, and its LinkedIn Group has over 3,000 followers. CIMCIG was set up in 1971 in the UK to specifically support marketers in construction, to raise the status of marketing in the industry and to promote best practice. MRA Marketing: For further information, more news and contact details ...» News title: - Sign up now for essential seminar on construction marketing strategySubmitted by: - MRA Marketing Date published:- 23/08/2017 16:53:52


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Teacher's Diary, Children's Medical Center - Dallas, TX
Day one
These kids may be sick, but if God dances to children's laughter his favorite radio channel is this classroom.
Instead of saying hi or shaking my hand, five-year-old Peter introduced himself by walking into class, putting his index finger firmly on my left middle finger and proclaiming, This is the bad one. And no matter what big kids say, giving the finger is not the same as lending a helping hand.
Day two
This place is tougher than I thought.
Nap time was a disaster. Instead of sleeping, the kids mimicked soldiers by crawling under desks in the dark. Apparently, giggles double as camouflage for five year olds.
Also, Peter's best friend Jason got sick, threw up on his desk and cried. I asked him how old he was (to take his mind off of the embarrassment). He proudly answered, Six, by showing me one whole hand and the middle finger of the other. I see a pattern emerging.
Day six
Sleeping meds alleviated difficulties with nap time.
Day eighteen
Annie ran into class this morning wearing Mrs. Johnson's wig on her head. I never thought a proper, southern lady that old could run so fast. When I accidentally said crap in front of the kids, a couple of them lit up like I had shown them a treasure map. Even Jason brightened for a smile.
Note to self: A chocolate chip cookie and tiny carton of milk put the children to sleep when medication isn't available.
Day twenty-eight
I found Peter and Katie playing, You show me yours. I'll show you mine. I walked up as Peter pointed at her waist, From the crack, it looks like you broke yours off. They tried to convince me it was okay because they were married. I giggled so unexpectedly, I think a miracle came out.
Day forty-two
Jason was absent for the fourth day in a row. Katie hasn't returned for a week and a half. I'm starting to worry.
Day forty-eight
This was the hardest day yet.
The kids found out that Katie isn't coming back to class. Peter acted worse than usual. He even stripped down, stood on top of the middle table in the class and demanded an extra cookie or Stephanie gets the sprinkler treatment.
Day fifty-four
Jason came back from being sick for a week wearing his family's war medals on his shirt. He tells everyone, My grandpa died in Vietnam. And my daddy got a purple heart in Iraq. I don't think my family is very good at war, but I'm fighting hard as I can against cancer.
Brushing away tears is a salute.
This poem originally appeared in Yellow Mama and is included in The Mattress Parlor (Scribble Fire Press, 2011).


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Wednesday, June 19, 2013
Jaemor Farm Market
Recently, I took a quick trip to the Smokey Mountains and went up I-985/441 through north Georgia. Every time I pass by this way I have to stop at Jaemor Farm Market. There are so many reasons, especially during the summer and fall. This place has grown over the years until it has become a real tourist attraction.
In the fall, it is for the apples and the pumpkins plus a corn maze. As we turned off the main road we always pass apple trees that line the entrance to a group of large sheds. The main one, a large open-air market is filled with almost everything you can think of.
At this time of year you can find plants, hanging baskets and lawn ornaments for sale.
There are also beautiful peaches. These are early peaches and are smaller than the ones they have later in the season. Of course we had to buy some of them and we now have a gallon of Ruby Prince peaches ripening in our kitchen. I think peaches are the perfect summer fruit.
There were tons of home-grown strawberries.
There is produce of every kind. Of course it is not all grown on the farm, or even grown locally but there is almost everything you could hope to find.
The baked goods are everywhere. These cakes sure look home-made and delicious.
Strolling through the open-air market is so enjoyable with so much to see.
The only thing I really didn't want were the boiled peanuts. I know most people love them and for anyone who likes them, help yourself and pay for them at the counter. They are a real southern delicacy. For me, they are just way too salty.
At the left side of the shed is my favorite area. Here there is a little seating area where you can sit down with a cup of coffee and a fried pie. They have apple, dried apple, sugar free apple, cherry, strawberry, peach, dried peach, pecan, German chocolate, coconut, sweet potato, lemon, pineapple and plain old chocolate. You can also get apple fritters, cake pops and a few other things I don't remember. They also sell ice cream in this area, though I didn't see any at this visit.
We had a very delicious strawberry fried pie and brought some more home with us to give away. They make great gifts.
As we were leaving, I noticed that the apples were growing nicely and I think they will be something I will go back for later in the year, when I pass through. I will also pick up more peaches and of course, more fried pies.
2 comments:
- AnonymousJune 20, 2013 at 5:37 PM
Hello Deberah - I love your story today, especially the beautiful photos! You're such a great photographer. I'm ready to 'Head North!' Can you say 'Road Trip?' Looks like a great place, thank you so much for sharing, JoanieReplyDelete
I really love this place. It is a nice place to shop but the atmosphere is kind of like an old outdoor market. It is quaint.ReplyDelete
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7 Untapped Keyword Sources
When I first enrolled into the never-ending game of "SEO", I just had one keyword research tool in my armoury — Google Keyword Planner.
It was the only bread and butter for my keyword research program.
Like most of the beginner SEOs, I didn't have much of a clue about the tricks to exploit the keyword research methodology.
I used to sit down for hours trying to find the perfect keyword that would be the glory! (Yes, I'm talking about long-tail keywords with low competition)
Not until I started to look beyond the interface of Keyword Planner. Yes! I still use the Keyword Planner, but I've also leaned the ways to gamble through various methods and tools to find my keyword match.
Luckily, it has paid off!
So without further ado, let jump to my favourite keyword sources that you probably have missed while trying to snatch the low hanging fruit of Keyword Planner.
Use Bing for Related Searches and Auto Suggestions
Whenever, I read blogs or articles about keyword research, I see many SEO experts pointing out on Google's auto suggest box (Instant Predictions) and related searches.
However, they hardly flex a muscle to reach out to other Search Engines like Bing or Yahoo…
I know that Google is the ultimate heavyweight of the search engine share market but there are few other search engines that you should keep your eye-ball on.
Here is how you can use Bing to produce some Gem of Keywords.
Step #1: Go to Bing.com and type in some generic head keyword.
Let's say I typed in a fat keyword "Rock." Let the magic begin!
Step #2: Check for instant predictions and related searches.
And instantly, I found a long tail keyword — Facts about igneous rocks.
Step #3: Drop the keyword to Adwords Keyword Tool and Bingo!
This keyword has 880 average monthly searches… Not bad for a 2 minute search 😀
Step #4: Now it's time to check for the keyword's competition.
You don't want to compete in the jungle of lions, right?
It seems like we have an easy deal. Top 5 spots have some weak authority links.
The number 4 of SERPs has a PA of 1 and DA of 39. This page only provides five facts about igneous rocks. And it has definitely under-utilised the power of longer content.
Imagine if these 5 facts can jump into Top-Five, how much value you can gain with a longer content that states 25 facts on one bounce!
Step #5: You can also pick up keywords from related searches of Google…
It's hard to believe that the related searches provided by Google and Bing are completely different.
As you can see from above screenshot and this one here:
Not even a single keyword of Google's related searches match with Bing. Wow!
I don't know whether it's the animosity between these two search engine giants or the searches are done differently, but it works in our favour. And I simply love it 😀
Utilize Yahoo Ads to Good Effects
Yahoo is a treasure trove of ads that can hook you up with few money keywords. Strangely, Yahoo seems to display ads for every generic head term.
Further, it gives you option to search for ads providing various variations of the head keyword you searched in.
Ads can provide you with rare keywords that your mind mapping tools could not think of, like this one here:
Seriously, I'm a music freak, and I love testing headphones!
But I had literally no clue about PXC 310 BT… These are the kinds of keywords you can miss, if you just hang on Google Keyword Planner for answers.
Let's check if this keyword is worth our time or not?
Looks decent enough to give a try.
Hunt for Keywords in the Jungle of Google Books
Google Books is a service that lets you search keywords in millions of books and magazines that Google has scanned over the span of hundred years.
Here is how you can hunt for your money keyword with Google Books:
Simply log into books.google.com or change the tab from web to books while you are in SERPs…
Choose the one that looks a good fit to you. For this keyword research, I clicked on "Headphones: Buyer's Guide 2015."
Skim through the contents break-down, you will find numerous long tail keywords to work with like these:
Now take one out and drop it to GKP and check the result
One stage clear! Give a pat in your back 😀
How is the competition for this keyword? (Hint: Easy peas for you)
Pro Tip: You can use Google Book's Advance Search mechanism to get deep insights of specific books you are looking for…
These books can also be your resource for next long epic guide or blog ideas…
Amazing, right? Even I thought so.
Use Google's "Never Show Instant Results" for Quick Long-Tail Keywords
Google's instant suggest has always been a famous weapon for many SEOs.
The given image below is the sample of what you see every time you attempt to write something on the search box…
In the above screenshot, there are 4 keywords suggested by Google… How many times have you Pluck out the keywords one by one; dropped it into GKP & saved it in CSV?
I think I have the answer.
But what if I told you that's not it? What if I told you that you can get more rich keywords within Google Suggest just like this?
As you can see that now you have almost triple number of keywords than you had before.
How is it possible? You just need this simple modification & you will have same number of keywords…
Go to search settings by clicking on to the small gear button at top-right corner of your Google's SERPs.
In Google Instant Predictions check on the small box that says never show instant results…
Save it and you are good to go….
Now give a high-five 😀
Explore the Beauty of GKP's Landing Page
Let me tell you the rule most of the SEOs follow –
- Quick brainstorming
- Typing the keywords in GKP's product or service box
- Scrolling the GKP till you find the keyword
- Repeat!
The problem with this method is that Adwords Keyword tool only extracts close variations within the given search term.
So to get extra out of this awesome tool, you need to be a little creative.
The method I'm going to state is one of my all time favorites. And a big shout out to Brain dean for this awesome tip. Yes, he is an absolute genius.
For this trick to work, you need a well-trafficked site that has limitless contents like Scoop it.
Go to the search page of scoop it and type anything…
For this blog, I will simply type in "wedding"
Just grab the URL and paste it in the GKP's Landing Page.
These are the keywords you would not have got if you were stuck inside GKP's Product or Service box.
Bonus Tip: You can also scroll through the suggestions given by scoop it, and note down any relevant keyword from the box…
Designer wedding cards looks good. Noted!
Soovle.com to Dig Deeper into Long Tail Keywords Gold Mine
Soovle.com is a free, easy to use & time-saving tool that shows every suggestion data from Google, Wikipedia, Amazon, Answers.com, YouTube, Bing and Yahoo.
If you like tools like UberSuggest, you will definitely fall in love with Soovle.
First, head over to Soovle & enter a fat keyword of your choice in the search box:
For example, if you were looking for baseball-related keywords, you could use keyword "Baseball"
Soovle will then scrape the suggested results and display it to you:
These are the keywords that your competitors may have overlooked in a quest of running through GKP only.
Hit Keyword Discovery Tool to Reveal More Keywords
Keyword Discovery is another sophisticated keyword research tool that will hook you with ton of keyword ideas.
The good thing about this tool is that it extracts the keyword phrases that drive traffic… It simply means you get keywords that have been searched frequently over the past 12 months.
Here is what you get when you search for a fat term like "Baking."
These are all potential keywords with decent search volume.
Keyword research is the most integral part of SEO & content marketing campaign. The ability to choose right keyword can turn you into winner!
I have used these tools on my websites and my clients…
The question is — when will you?


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Car insurance is one of the most important insurance covers that anybody can take up in life. It s not only mandatory simply because it is a requirement by the law to have one before you drive but because of the possible benefits it has to offer. There is so much that one should put into consideration when shopping for car insurance in Pennsylvania and one of them is the cost. Different firms will charge different charges in order to get insurance for your car. For this article, we will be taking a closer look at what it entails when you are out there shopping for cheap auto insurance in Pennsylvania.
1. Do adequate research first
The first thing that you want to do in order to find the cheapest kind of auto insurance in Pennsylvania is to do adequate and efficient research. This is to mean that you want to research on what the insurance firms that are close to you have to offer and for how much. Do not narrow down your research to only the best firms but include also the upcoming firms. Yes, we do know that the firms that have been there are the best to deal with but with a new and upcoming firm in the market, it means that they have something new to offer and to attract in customers they have to be friendly in their prices.
2. Compare firms
As we have mentioned earlier, Pennsylvania is full of so many different types of insurance firms. Each insurance firm will therefore not be the same like the other in terms of operation and even their charges. Comparing two or more firms allows you to know the strengths and weakness of each insurance firm. Plenty of online sites can do such comparison.
3. Hire a car insurance agent
Most people in Pennsylvania will prefer to hire the services of a car insurance agent within their locality so that they can do the work of finding cheap car insurance in Pennsylvania for them. You want to take full advantage of this simply because the agents have the right kind of skills and expertise when it


text:
The Top Ten Westerns Of All Time
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text:
A few years ago, Americans were asked in a survey how much our government spends on foreign aid as a percentage of the entire federal budget. People typically guessed 20 percent. In reality, the federal government's foreign aid represents less than one percent of the budget. Watchers of the news have seen that the tsunami crisis has brought the United States' generosity into question. The White House and Secretary of State fired back maintaining the US is among of the most giving nations in the world. But what is the bottom line?
Some of the discrepancies in interpretation arise for the difference between the total amount of dollars spent and that amount in relation to national budgets and gross national income. While the United States does indeed lead the world in total amount of dollars pledged, it doesn't come near to the United Nations target of 0.7 percent of GNP and is substantially lower that the average efforts of all Organisation for Economic Co-operation and Development (OCED) nations 0.41 percent.
The figures below are drawn from the Organisation for Economic Co-operation and Development Aid Statistics.


text:
If at first
you don't succeed …
A group of
12 Cuban refugees who turned a truck into a boat and set sail for
Florida has been stymied in their second attempt to make it to the
United States, The Associated Press reported Sept. 30.
Media outlets
across the country reported on the group in late July, when they
took a 1951 Chevy truck, strapped on some air-filled 55-gallon drums,
put a propeller on the driveshaft and set sail for Florida.
the group's low-tech James Bond routine was discovered, and they
were picked up by the Coast Guard 40 miles short of their goal,
having crossed most of the distance between the Communist island
nation and the Florida coast.
Under a policy
established during the Clinton administration, if Cuban refugees
make it to American soil, they are allowed to stay. If caught on
the ocean, they are returned to Cuba.
Having failed
in using a truck to cross the ocean – a predictable result for less
creative people – the group applied for legal visas that would allow
them to emigrate to the United States.
Last week, The AP said, the group began to receive letters denying their
requests for the visas.
"We are
really disappointed," said Eduardo Perez, a truck-boat passenger.
The truck was
doing about 8 mph when it was discovered by airborne officers July
18. It wasn't hard to spot – the truck is bright green, the tarp
covering the bed was bright yellow and the barrels keeping it afloat
were blue.
After the Cubans
were taken off, it was deemed a "hazard to navigation,"
and sank, Reuters news service reported.
Despite the
wide variety of boats used by Cuban emigrants in years past, the
boat still stands out as unique.
"We haven't
come across any vehicles like that before," Coast Guard Petty
Officer Ryan Doss told reporters.


text:
Repair Policy
While each design is expertly constructed, from time to time, it may be necessary have a repair performed on your jewelry.
All requests for repairs must be submitted to Nak Armstrong in writing by the retailer. Please visit our Stockists page or email firstname.lastname@example.com for assistance in contacting your Nak Armstrong retailer.
Unless deemed a manufacturing defect, repairs incur charges based on the necessary materials and labor costs. A repair fee and delivery estimate will be provided either prior to or upon receipt of your item, depending on the nature of the repair. Please note that we are not responsible for your item until it is in our possession.


text:
- Follow Teaching nonmajors biology on WordPress.com
Recent Posts
- "Practice Perfection": It's Not Just for Gymnasts
- The Laptop Ban: New Research
- Moldy bread, experimental design, and you
- Raise Your Hand: How Do You Start the Semester on the Right Foot?
- Another Way to Connect Selection, Phenotype, and Genotype
- So many learning resources … so little time
- Antibiotic resistance in the lab … with actual bacteria!
- Attend the best conference for people who teach biology labs … for free!
- Antibiotic-Resistant Bacteria: A Simple, Realistic Lab Activity
- Selling the laptop ban: An activity
Category cloudAcademic conferences Active learning Assessment Assignments Chemistry Citizen science Collaboration Concept mapping Course design Ecology Engaging students Evolution Experimental design fungi Instructional technology Just for fun Laboratory activities Learning at home Microbiology Podcast Science in art Science news STEM Student writing Study skills Teaching Uncategorized Videos Vine
Tag Archives: video
TED-Ed video: The Cancer Gene We All Have
My friend and colleague Michael Windelspecht recently produced a useful video about cancer. Complete with compelling animations, narration, and analogies, it's a great launching point for in-class group work or for a homework assignment. The video's explanations span from genetics … Continue reading
FOH: Finally, a cure for FMOOWMP
If your students are like mine, no location on campus is scarier than your office. Did you know that their reluctance to come to your office hours actually has a medical cause? I didn't until I saw this funny new … Continue reading
Posted in Just for fun, Teaching, Uncategorized Tagged Arizona State University, commercial, FMOOWMP, FOH, office hours, video Leave a comment
Video recommendation: HHMI's Biology of Skin Color
Over a year ago I mentioned the HHMI Biointeractive site and its excellent videos. I just viewed another one on the same site. This one is called The Biology of Skin Color, and it is another winner. It is narrated by … Continue reading
Posted in Evolution Tagged DNA, HHMI, natural selection, Nina Jablonski, skin color, ultraviolet radiation, video 1 Comment
Stop-motion Biology Definitions: A Survey
Have you heard of Vine? It's a Twitter app that allows users to record 6-second, looping videos and upload them to Vine and other media, like YouTube and Facebook. We are considering building short stop-motion Vine videos to define the glossary … Continue reading
Posted in Engaging students, Instructional technology, Study skills, Teaching, Vine Tagged definition, stop-motion, video, Vine 5 Comments


text:
ComputerTime 1.0
SoftwareTime's ComputerTime 1.0 automates the process of controlling and limiting children's computer use. For each child you can specify a schedule of days and times during which computer use is allowed. You can also set a limit on the total amount of usage in any day, week, or month. And you can specify the maximum amount of computer use at one sitting.


text:
The new Circus in a Suitcase contains everything you need to be a juggling star. Each kit contains 1 Tropic diabolo with Jive sticks and string, 3 beginner juggling balls, 1 spinning plate with stick, and our world famous Juggling 101 DVD. All comes smartly packaged in a busker style suitcase. Everyone is sure to enjoy this creative gift.
Do you own this product? Write a review.


text:
While John was born in Washington D.C, John and his parents, (Both Lawyers), moved to Southern California, where he grew up. In addition to being an outstanding student in High School, John was also the Captain of his High School Water Polo Team for 3 years.
In addition to Water Polo, John is an avid and outstanding long-distance cyclist; Incredibly cycling from Seattle, Washington to Portland, Oregon, a distance of more than 200 miles in just one day. Taking a year off during college, John honed his musical skills as a member of a Rock band, playing gigs throughout Southern California.
John received his Bachelor's Degree from the University of Oregon and his Law Degree from Virginia's University of Richmond, T.C. Williams School of Law, where he was one of the editors of the Richmond Journal of Law in the Public Interest. John is now married, living with his wife and "child" (A Rescue Dog), and is an avid fan of the L.A. Dodgers, L.A Lakers, and the Oregon Ducks.
University of Richmond, T.C. Williams School of Law
University of Oregon
Criminal Law, Criminal Traffic Law and Personal Injury Law
2014, Virginia State Bar
Virginia State Bar


text:
The shopping centre industry is a major contributor to federal, state and local government revenues. The SCCA's objective is to ensure taxation policies, at all levels of government, which boost economic development and productivity and which ensure a fair distribution of the burden of taxation.
Increasingly state and local governments are relying on commercial property as a major source of revenue, particularly through land tax and council rates. Local councils are also actively discriminating against shopping centres through 'minimum rating' measures, which have no relation to land value, and 'differential rating' measures, whereby shopping centres pay higher rates, even though these centres often directly fund many of the services local governments usually provide. Land tax and rate increases are very damaging to the local retail economy since much of the burden is borne, either directly or indirectly, by the retailers who comprise the shopping centre. SCCA advocates for sensible land valuation methodologies and a fairer distribution of the taxation burden.
Recent Submissions
- Submission to Senate Inquiry re Treasury Laws Amendment (GST Low Value Goods), 10 April 2017
- Submission to Department of Infrastructure and Regional Development re value Capture, 31 January 2017
- Submission to Transport for NSW regarding Parking Levy Review, 2 December 2016
- Submission to IPART re Local Government Rating System, 14 October 2016
- Submission to IPART Rate Review, May 2016
- Shopping Centre Council of Australia and Australian Retailers Association Joint Submission to state Treasurers – Retail Sector Tax Policy Position, April 2016
- Submission to Parliamentary Committee on value-capture, 12 February 2016
- Submission to Minister for Territories, Local Government and Major Projects re Value Capture, 1 February 2016
- Joint submission Shopping Centre Council of Australia and Australian Retailers Association to Treasury on Netflix Tax, 20 October 2015
- Joint submission Shopping Centre Council of Australia and Australian Retailers Association – Tax Integrity Exposure Draft Bill, 7 July 2015
- Joint submission Shopping Centre Council of Australia and Australian Retailers Association Re: Think Tax Discussion Paper, 1 June 2015
- Submission to the SA Government on SA Tax Review, 22 April 2015
- Submission to Federal Treasury and Australian Reinsurance Pool Corporation on 'Review of Terrorism Insurance Act', 14 November 2014
- Submission to the NSW Joint Standing Committee on the Office of Valuer-General re Inquiry into the Land Valuation System, 8 March 2013
- Submission to the South Australian Economic and Finance Committee on Taxation Review, 31 January 2013


text:
Q. Where do I return books (DVD, CDs, etc.) that I have checked out?
You may return items to any of our branch libraries. Generally if the library is open, the book drops are closed and you will need to go into the library to drop off your items.
[Please DO NOT RENEW items that show on your record as this will cause fines to appear.]
Returned materials may be separated by type before being checked in, so all your materials may not be cleared at the same time. You are credited with the date of return, so as long as your materials are returned on or before the due date there will be no overdue fines.
If you see that returned materials are still showing as checked out on your record after 5 open business days, please contact the library branch where you returned them for assistance.


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RUMOR - Aliens: Colonial Marines tester says Wii U version is the worst
"Oh wow. Yes okay. I was hoping someone would ask this. I have played the WiiU version. The one that is supposedly the best of all of them? It is not. It is the worst. It is a bit of a joke. The WiiU is basically the same game as the console version but with framerate issues, worse texture loading, and horrendously misguided minigames thrown in. You get a 'scanner' to scan enemies and get bonus points that aid your harming them. When you cut open doors (which happens a lot in the game) you have a game where you have to keep the heat 'optimal'. They just add frustration, and take away even more from the fun. We don't know if it will come out, Sega are conisdering canceling it, but right now its still going." - game tester
Check out his full comments here (thanks DStroke!)