text:
Hospital quality improvement in Ethiopia: a partnership–mentoring model
Background and Objective Quality improvement efforts are increasingly common in the United States; however, their use in developing countries is limited. We sought to evaluate the impact of a large-scale intervention on several key management indicators through hospital quality improvement efforts.
Design Pre–post-descriptive study of 14 hospitals in Ethiopia.
Setting Six regions and two city administrations in Ethiopia.
Participants Hospital leaders and management mentors in participating hospitals.
Intervention In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills.
Main Outcome Measure(s) Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors.
Results In pre–post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged.
Conclusions Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.
- Ethiopia
- quality improvement
- hospital management
- Africa
Quality improvement efforts to promote greater management effectiveness within hospitals are increasingly common in the USA [1–3]; however, use of quality improvement effort in developing countries is modest. Recent 'World Health Reports' published by the World Health Organization have called for health system strengthening as paramount to the goal of improving health outcomes [4, 5], noting the critical role that hospitals play in efforts to strengthen health systems. Despite the potential role of quality improvement in health system strengthening [6–9], we have only limited evidence about its implementation and effectiveness in developing countries.
Studies of healthcare quality improvement in developing countries suggest its positive impact on quality-related outcomes, although the scope of the studies is narrow [10–15]. Three studies have been conducted in single hospital settings [10, 12, 13], and two additional studies [11, 15] have been conducted in primarily health center settings. Using pre–post observational designs, the studies uniformly report improvements in care as measured by specific indicators such as availability and cleanliness of latrines, use of stock cards for pharmacies, improved floor washing and availability of adequate equipment [11, 14], and in perceptions of more positive organizational culture and overall enhanced quality of service [10, 12, 13, 15]. Despite the consistency of these findings, however, the evidence about the impact of quality improvement efforts in developing countries remains limited because studies typically include one or a handful of sites with little quantitative data to evaluate the impact of the interventions on targeted outcomes.
In this study, we sought to examine the impact of a large-scale intervention, the Ethiopia Hospital Management Initiative (EHMI), to improve hospital management through the use of quality improvement methods in hospitals. As has been previously described [16], the EHMI employs a partnership–mentoring model, which incorporates the principles and tools of quality improvement including participatory approaches to organizational change. Under the direction of the Ethiopian Minister of Health, EHMI was launched in January 2005 in partnership with the Clinton Foundation HIV/AIDS Initiative (CHAI) and the Yale School of Public Health. During 2005–06, EHMI was piloted in 14 government hospitals across Ethiopia with the goal of replicating successes from the pilot efforts in a broader set of hospitals throughout the country. Understanding the impact of this large-scale intervention can help further assess the potential of quality improvement in strengthening health systems in developing countries.
Since 1994, Ethiopia has been managing a decentralized health system across nine regional states and two city administrations (Addis Ababa and Dire Dawa). The Federal Ministry of Health (FMOH) develops policy and technical guidelines, which are managed by Regional or City Administration Health Bureaus (RHB). Hospitals remain a primary point of access for healthcare services within the Ethiopian health system. Although there has been a significant increase in the number of private healthcare facilities in largely urban centers throughout the country, the majority of the population depends on government hospitals for their health care.
In this study, we implemented pilot quality improvement projects in 14 government hospitals within six regions and two city administrations. Three of the hospitals were located in rural settings, four were located in semi-urban settings and seven were located in Addis Ababa. The 14 hospitals included one teaching hospital and a mix of specialized, referral and district hospitals with number of beds ranging from 74 to 560, with a mean of 240 beds. The general manager at each hospital was a medical director (always a physician). With the exception of a financial administrator, all members of the management team were clinicians (e.g., doctors, nurses and pharmacists). At baseline, the primary challenges in these hospitals included low staff morale; shortage of financial resources, medical equipment, drugs and other supplies; limited opportunities for staff training; poor infection control and a lack of community participation in hospital governance [16].
Study design
We conducted a pre–post study of the 14 hospitals that participated in the EHMI, under the leadership of the Minister of Health and in partnership with CHAI. A detailed description of the partnership–mentoring model used in each hospital is elaborated elsewhere [16] and described briefly here. The Yale University team recruited 24 Senior Yale–Clinton Foundation Fellows and Post-Graduate Yale–Clinton Foundation Fellows with experience in hospital administration and/or management to serve for 1 year as management mentors for the medical director and hospital management teams in the 14 hospitals. The Yale–Clinton Foundation Fellows were assigned in teams, with a full-time Post-graduate Fellow assigned to each of the 14 hospitals and Senior Fellows splitting their time between two hospitals. The Fellows worked on a daily basis in the hospitals as management mentors and lived for 12 months in the area in which the hospitals were located. During the year, the Ethiopian hospital management team members also participated in a professional development course offered by Yale Faculty on site. Course content included scientific problem-solving methods, problem identification and prioritization (e.g. use of flow charts, decision matrices and fishbone diagrams), project planning and evaluation, human resource management and leadership skills, working with governing boards and budgeting. At the end of the course, participants received the Yale Certificate in International Health Care Management. In collaboration, the Fellows, together with each hospital management team and in some cases with the help of RHB representatives, conducted a baseline needs assessment for the hospital, completed a problem identification and prioritization exercise and collectively identified an implementation plan and evaluation measures for completing at least one management project within their respective hospital.
We measured the change in the presence of 75 key management indicators from the time of baseline needs assessment (August 2006) to the follow-up 10 months later (May 2007). For each management indicator, the hospital reported it as 'present' (item = 1) or 'absent' (item = 0). Improvement was characterized as the hospitals having rated the indicators as '0' at baseline and '1' at follow-up. The key management indicator checklist was designed collaboratively by Yale University, the CHAI Fellows and the Federal Ministry of Health and, subsequently, formed the basis of the 'Blueprint for Hospital Management in Ethiopia' [17]. The checklist included a total of 75 indicators in the following domains: human resources, quality management, medical records and patient flow, nursing standards and practices, infection prevention and control and financial management.
In addition, we compared the Fellows' written reports of their perception of the skills and confidence of the medical directors and other hospital management staff at the 14 hospitals near baseline (September 2006) and follow-up (June 2007). Similarly, we compared the medical directors, and key managers' reports regarding the skills and contributions of the Fellows to the hospital environment and the overall program near baseline (September 2006) and follow-up (June 2007). Survey instruments employed a set of closed-ended Likert scale items and indicated perceptions of management skills and contributions. Instruments are available from the authors upon request.
Data analysis
We used descriptive statistics to summarize the percentage of hospitals with each management indicator present in August 2006 compared with May 2007. In addition, we summarized the surveys of Fellows and Ethiopian management teams using frequency analysis of the 4-point Likert scale responses and grouped responses into a binary variable (i.e. combining the two positive and two negative responses), with the data from baseline and from follow-up for each survey. We did not conduct statistical testing of changes in the prevalence of indicators as this was an exploratory study, and we lacked adequate statistical power given the limited sample size of the 14 hospitals. Qualitative comments recorded in the surveys were content analyzed and sorted by topic area.
Hospital sample
Half of the hospitals (n = 7/14) were located in the capital of Ethiopia, Addis Ababa. The remainder was split quite evenly between other urban (21.4%) or smaller city areas (28.6%). The mean number of beds was 240 per hospital, although the number ranged substantially from 74 beds in one hospital to >500 beds in another hospital. Overall, the average occupancy rate was 83%.
Hospital management indicators
We found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007 (Table 1). Improvements were apparent in multiple domains including human resources, medical records and patient flow, nursing standards and practice, infection prevention and control, quality management and financial management. The areas in which performance had been particularly low had the greatest improvement including conducting employee training, implementing nurse assessments upon admission and creating infection prevention manuals, committees and policies. Also, substantial increases were seen in the prevalence of quality improvement coordinators/teams, use of channels in the hospitals to report quality problems and employee participation in quality projects. The change in the percentage of hospitals from August 2006 to May 2007 that had the management indicator present reflected a total of 105 improvements across all 14 hospitals, which is a per-hospital mean of 7.5 (105/14) improvements, with SD equal to 5.9 improvements. Three hospitals (one in Addis and two in the rural areas) had at least 15 improvements, whereas four hospitals (two in Addis Ababa, one in the semi-urban areas and one in the rural areas) had fewer than five improvements.
|% (Aug 2006)
|% (May 2007)
|Human resources
|Hospital has a human resource department
|Hospital performs employee training
|Hospital uses performance evaluation system
|Medical records and patient flow
|Hospital has patient master index record numbers
|Medical record contains
|Front sheet (e.g. patient name, contacts, etc.)
|Doctor's order sheet
|Progress notes for all disciplines
|Laboratory results
|Radiology reports
|Consultation summaries
|Discharge sheet
|Patient flow has been mapped for
|Transport from home to hospital
|Medication ordering, administering and documenting
|Laboratory test ordering
|Radiology test ordering
|Referrals to and from other providers
|Nursing standards and practices
|Nurses perform the following
|Patient assessment upon admission
|Draw blood samples
|Document route, time and dose of medication
|Teach patient/family about diagnosis and treatment
|Hospital has standard for nurses' checks of patient status
|Hospital has nurse-to-nurse reports at end of shifts
|Nurses are licensed
|Infection prevention and control
|Hospital has infection prevention manual
|Hospital has infection prevention committee
|Hospital has infection prevention practitioner
|Hospital has department-specific policies
|Hospital follows standard (universal) precautions
|Hospital uses cleaning process to minimize contamination
|Clean and dirty items are stored separately
|Hospital uses disinfectants
|Hospital monitors hospital-acquired infections
|Quality management
|Hospital has mission statement
|Hospital has continuing education for physicians
|Hospital has implemented quality improvement programs
|Hospital has quality improvement coordinator/team
|Most employees are aware of quality improvement program
|Hospital has set goals for quality
|Most employees know hospital quality goals
|Hospital has channels to report quality problems
|Employees participate in quality projects
|Hospital uses data feedback processes for quality
|Financial management
|Hospital has yearly budget plan
|Hospice has income statement
|Hospital has statement of cash flow
A total of 30 of the 75 (40.0%) management indicators surveyed did not increase or were reportedly lower in May 2007 (Table 2). In almost all of these areas in which no improvement was apparent, the baseline prevalence of the indicators was relatively higher (i.e. there was less opportunity for improvement than for the set of indicators where improvement was apparent).
|% (Aug 2006)
|% (May 2007)
|Human resources
|Hospital has organizational chart
|Hospital has job descriptions
|Hospital has compensation program describing salary/benefits
|Medical records and patient flow
|Medical record contains
|Medication administration record
|Case management notes
|Patient flow has been mapped for
|Patient admission/transfer
|Medical record number assignment
|Patient discharge
|Patient billing
|Nursing standards and practices
|Nurses perform the following
|Insert intravenous catheters
|Insert Foley catheters
|Administer medications
|Document clinical findings
|Assist in ambulating/dressing/bathing patient
|Document medical order carried out
|Nurses report significant findings to physician
|Nurses report to physician if medical order not effective
|Infection prevention and control
|Hospital has liquid soap available
|Hospital has clean towels for drying hands
|Hospital has alcohol rub available
|Hospital has sinks with running water in all clinical areas
|Quality management
|Physicians are licensed
|Hospital tracks quality or volume by department
|Hospital has continuing education for nurses
|Financial management
|Hospital conducts budget variance analysis
|Hospice tracks overall volume over time
|Hospital record revenue sources for organization
|Hospital has balance sheet
|Hospital reports volume data to Ministry of Regional Bureau
|Hospital reports financial data to Ministry of Regional Bureau
The May 2007 data highlight key areas in which performance remains quite low, with fewer than 20% of hospitals having the relevant management indicators in place. These include employee knowledge of the quality goals of the hospital, surveillance on hospital-acquired infections and availability of liquid soap and clean towels in patient-care areas.
Fellows' perceptions of changes in management skills of hospital leaders
We found that the management skills of the medical directors as perceived by the Yale–Clinton Foundation Fellows improved from August 2006 to May 2007 in several management domains, although their level of confidence in their management skills did not increase generally (Table 3). Importantly, the relationships between medical directors and several key constituent groups (i.e. RHB and hospital administrative staff) were perceived to have improved for several hospitals.
|% (Aug 2006)
|% (May 2007)
|Skills are excellent/good in
|Human resources
|Hospital operations
|Nursing management
|Infection prevention and control
|Quality improvement
|Budgeting and finance
|Leaders' confidence level is excellent/good in
|Human resources
|Hospital operations
|Nursing management
|Infection prevention and control
|Quality improvement
|Budgeting and finance
|Leaders' relationship is excellent/good with
|Regional health bureau
|Hospital clinical staff
|Hospital administrative staff
aCalculated from number of surveys completed, which varied by item from 10–14.
Ethiopian hospital leaders' perceptions of Fellows' mentorship skills
In general, the Ethiopian hospital leaders, which included medical directors, matrons and administrators, perceived the Fellows' mentorship and interpersonal skills (e.g. listening, teaching and coaching) positively. These generally positive perceptions did not change appreciably from the beginning to the end of the program (Table 4). In data not shown, >90% of the hospital leaders reported themselves to be 'very satisfied' with the quality improvement projects in their hospitals; additionally, >90% of these leaders reported feeling 'excellent' or 'good' about the Hospital Management Initiative and believed the program would positively benefit other Ethiopian government hospitals.
|Mentoring skill area
|% (Aug 2006)
|% (May 2007)
|Listening skills
|Teaching and coaching skills
|Ability to understand local context
|Establishing trust
|Showing courtesy and respect
|Interpersonal skills
aCalculated from number of surveys completed, which varied by item from 10–14.
We found marked changes in several management indicators over 10 months of intervention using a partnership–mentoring model, EHMI, in Ethiopian hospitals. About 60% of the management indicators surveyed showed some improvement in the domains of human resources, medical records, nursing standards and practice, infection prevention and control, quality management and financial management. Although improvements were not uniform across all hospitals and across all indicators, the EHMI training and mentoring in quality improvement seemed to have a positive overall effect in key areas. This finding is consistent with other research showing that quality improvement efforts can be effective in lower-resource countries [7, 10–15], although such work has not been previously conducted in Ethiopia, and in such a wide geography as six regions and two city administrations of the country.
An important aspect of successful healthcare management is the ability of leaders to work collaboratively and effectively with other groups in the system. In the hospital setting, such groups include the RHB or city health bureau and the hospital clinical and administrative staff. Our data suggest that the hospital leaders participating in this intervention were able to improve their relationships with these key constituent groups. These relationships may foster longer-term improvements in the management and integration of the hospital with its regional or city healthcare system.
Several aspects of this program are noteworthy. First, the program was conceived of, established by and supported by the Minister of Health, who attended training sessions and met regularly with the EHMI team to support their work. This support from the governmental and regulating body for hospitals was critical to facilitating changes. The Ministry provided substantial leadership in retaining focus on hospitals' efforts, motivating RHB to engage in hospital improvement activities and to create supporting regulation to enable hospitals to facilitate the recommended management actions. Without such in-country engagement, quality improvement efforts alone are less likely to be effective in strengthening health systems.
Second, the program provided more than technical support for the hospital leaders; it provided day-to-day mentorship with a committed international team of mentors who were selected to coach hospital leaders in management and quality improvement skills. In large part, this is because management is a process that is learned over time through trial and error, rather than a specific technical expertise that can be taught didactically. The management skills included learning to define a problem, set priorities, identify root causes, delegate to others, develop common goals, utilize flow chart processes and provide corrective feedback as needed. The success of this type of coaching requires strong and trusting relationships that are best developed over time and through regular face-to-face contact. Thus, the intervention demonstrates that the partnership–mentoring model can be an effective approach to management improvement efforts.
Third, the program reflected a partnership in its own governance, with strong involvement of a non-governmental organization and a university. Together, these partners provided the experience and expertise as well as the academic perspective to extract general lessons from specific projects in order to replicate these in other hospitals and contexts. For instance, the successful quality improvement projects contributed to a Blueprint for Hospital Management in Ethiopia [17], which characterizes eight key domains of 'best practice' in hospital management in resource-limited settings. This resource allows the lessons learned in a single quality improvement project to be translated into projects in other settings where senior hospital and governmental leaders foster replication. In addition, the partnership has led to the development of a new Master of Hospital Administration degree through a partnership with Jimma University and Yale University, as a way to professionalize the role of hospital management in the country. Such an educational track in the country can lead to sustained improvement in management, as a new cadre of hospital leaders are trained to strengthen this critical aspect of the healthcare system.
Our findings reflect the first study known to us that documents a countrywide effort in quality improvement focused on hospital management in Africa. Although the data suggest important improvements, they should be interpreted in the light of several limitations. First, the sample sizes for all analyses were limited. The study is therefore exploratory and descriptive without adequate statistical power to test the statistical significance of changes over time or between regions or hospitals. In addition, ratings of medical directors' and Fellows' skills were based on respondent perceptions. Nevertheless, the study does provide some initial information in an area that has not been previously evaluated and, therefore, is useful as an alternative model to help health systems gain greater attention. Second, turnover among hospital leaders during the year was unavoidable. As a result, the changes in hospital leaders' management skills reflect two cross-sections of leaders rather than a single cohort over time. Nevertheless, the quality improvement efforts resulted in positive changes despite such management turnover, which can slow processes of quality improvement. Third, it might be possible that data were misrepresented by hospitals in their evaluations; however, these evaluations were conducted collectively by the Yale–Clinton Foundation Fellows, the management teams, and in some cases, RHB representatives. Therefore, it would be difficult to misrepresent data markedly. Fourth, the study was conducted in Ethiopia, and results may differ in other countries. However, we did include hospitals from a range of urban and less urban settings suggesting that the approach can be effective in diverse settings. Last, while we experienced improvements in the first year of the program, sustained improvements will require additional strategies in future years of the program.
Sustaining the improvements in hospital management and further scaling-up the efforts are critical goals in the future years of the EHMI. Therefore in the second and third years of EHMI, additional cohorts of Ethiopian hospital leaders, who are appointed as Chief Executive Officers of the hospital, are enrolled in a Master of Hospital and Healthcare Administration (MHA) degree program, which requires for graduation a masters' thesis on quality improvement efforts in the hospital. At the same time, EHMI will seek greater alignment of RHB and FMOH goals regarding hospital improvement. To foster this, the partnership–mentoring model will be applied in the next 2 years at the RHB level, as it was applied at the hospital level during the first year of the program. Although external technical support to hospitals will still be needed, building leadership capacity in-country and government-hospital alignment are central to scaling up the improvements experienced in the first year of EHMI.
Our study, with existing evidence from other countries, contributes to growing research literature indicating that quality improvement efforts can be effective in making positive management changes in developing regions of the world. Nevertheless, experience even in higher-income countries in Europe [18–20] and in the USA [21–23] indicates that progress in quality improvement can be slow and its success depends on the commitment of senior organizational leaders to sustain improvement efforts. Although the program is implementing strategies to foster such senior leadership, longer term follow-up is needed to evaluate the replication and sustaining of these early accomplishments.
Patrick and Catherine Weldon Donaghue Medical Research Foundation Donaghue Investigator Award and the Clinton HIV/AIDS Initiative.
The authors are grateful to the committed efforts of the 2006–07 Yale-Clinton Foundation Fellows: Jennet Arcara, Elizabeth Arend, Charles Borden, Jaweer Brown, Lisa Browne, Rebecca Zewdie, Saran Ellis, Salem Fisseha, David Gervilla, David Hartley, Temi Ifafore, Mike Ikpe, Chris Kenyhercz, Mariama Samba-Koroma, Mary Anne Lally-Graves, Turkan Nabi, Steven Neri, Jackie Omotalade, Corrie Paeglow, David Ranney, Wendy Schwartz, Tara Thomas, Andre Villanueva, Zeleka Yeraswork and the CHAI team in Ethiopia, and Peter Huffman, who provided support for this project. The paper has benefited from thorough editing by Avital Havusha.
- © The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved


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What a greedy bunch of turds this thing has been a great dividend paying stock for the last 2 years why offer more shares? Is this secondary going to kill this thing?
Is anyone concerned about the "team"? In the priv equity biz it's all about the "team". Lately they've been running key people out the door, usually an indicator of some sort of disfunction. Or did your broker mention that?
In this closed-end thing, valuation is really fuzzy but currently there's a lot romance about because of all the $$ the mega-firms have made.
This outfit has only been around since 04 and is up 68% since then, did your broker tell you that?
Just how much lipstick have they put on this pig?????
Probably not! It will allow them to do more, bigger, and more profitable deals. They have shown they can manage money; they will more of it to manage; your earnings should get better. If the market takes it down it becomes a buying opportunity.
ACAS, AINV, etc. --periodically have secondaries--like clock work the price of the stock goes down temporarily and then always comes back higher to date. All they have to do is invest the new money in profit making ventures (that is where you are counting on smart people running the companies) and you end up with a higher dividend and an appreciation in capital.
It is called a buying opportunity if past history is any indicator of the future.
Greedy bunch of turds ?
If you want to find one of them, look in the mirror.
Heck yeah I wouldn't be in the game if I wasn't greedy. The buying op this creates means I can add some more to my position. The dividend is just too ripe not to put some more in my coffers. Not a growth plat by any means it is a great value play
You shouldn't own a BDC if you are unwilling to live with the results of periodic secondary offerings.
Of course AINV will deploy the money over time in a manner that becomes accretive. But for the time being the raising of monies is treated as dilutive.
ACAS is doing a secondary too. ACAS stock is down too.
A BDC that stops raising money is a dead BDC that would reach a theoretical limit on the amount of annual dividend income they could pay.
AINV is 1/5 the size of ACAS. AINV needs to grow itself and the only way is to raise proceeds from secondaries AND deploy the money accretively so that dividends can go higher.
Certainly you will be somewhat diluted, but think of it this way. The more capital they raise, the more they can put to work. In the end, that means better earnings, albeit spread across a greater number of shares. Keep in mind, that these secondary offerings are an expected dynamic of this business model and in the long run, should enhance shareholder value. This is not a pump and dump kind of stock. Hold for the long term and you may be well rewarded. Relax.
Depends on what they do with the proceeds. Assuming they have good investments to fund that return profits greater than the dividend currently being paid you should see a NAV and dividend increase as a result. Secondaries are accretive if issued at a price greater than NAV although your percentage interest in the company has been diluted. Since they have to pay out 90% of net income or 98% of net income and capital gains according to law the only way a BDC can grow is to raise additional capital through secondaries. No different than a REIT.
They are increasing the shares outstanding by approximately 19.5%. 16,000,000/82,000,000 currently outstanding. So your ownership interest in the company will decline by approximately 20%. To maintain your interest you will need to buy 20% more shares and any percent over that will increase your ownership interest. Weakness in the price is usually a good time to do it. As Jay Gould said, Money is made by sitting. Not by thinking.

subset: commoncrawl


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1 Buckstone Pl, Asheville, NC, 28805, United States of America, 855-239-9399
Courtyard by Marriott Asheville - Asheville
Lowest price$143
available on 10/30/16
Searching for 3-star Asheville hotels? Consider Courtyard by Marriott Asheville located in Downtown Asheville, 0.3 mi (0.5 km) from Asheville Mall and 2.6 mi (4.1 km) from Biltmore Estate. You'll also be a short walk from Innsbruck Mall and within 2 mi (3 km) of Pack Square.
Your hotel has a restaurant where you'll find a selection of items to try for breakfast. Relax in the indoor pool during your stay. Guests wishing to enjoy a drink will surely want to visit the bar/lounge.
Your hotel has a restaurant where you'll find a selection of items to try for breakfast. Relax in the indoor pool during your stay. Guests wishing to enjoy a drink will surely want to visit the bar/lounge.
Leisure facilities on offer include the fitness center and spa tub. Guests can make use of the free WiFi.
See all 96 Venere.com reviews
Fantastic service
Good internet service
Value for money
Value for money could be better
TripAdvisor Traveller Rating: 4
From 214 reviews
Courtyard by Marriott Asheville - Asheville
Hotel Info: 855-239-9399from $143
- Standard Room, 1 King Bed
- Standard Double Room, 2 Double Beds
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel has 78 rooms
- This hotel is arranged over 3 floors
- Check-in time starts at 3 PM
- Check-out time is noon
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets not allowed
Extra people
- Roll-away beds available, charges may apply*
- Free WiFi in public areas
- Free WiFi and wired Internet access in rooms
- Free self parking
Other information
- Smoke-free property
In the hotel
Food and drink
- Full breakfast (surcharge)
- Restaurant
- Bar/lounge
- Coffee shop/café
- Coffee/tea in a common area
Things to do
- Indoor pool
- Fitness facilities
- Spa tub
- Golfing nearby
- Hiking/biking trails nearby
- Kayaking nearby
- Mountain biking nearby
- Rafting nearby
- Billiards or pool table
Working away
- Business center
- Conference space
- Meeting rooms
- Conference space size (feet) - 650
- Conference space size (meters) - 60
- 24-hour front desk
- Dry cleaning/laundry service
- Laundry facilities
- Free newspapers in lobby
- Luggage storage
- Number of buildings/towers - 1
- Year Built 1996
- Elevator/lift
- Safe-deposit box at front desk
- Fireplace in lobby
- In-room accessibility
In the room
Home comforts
- In-room climate control (air conditioning)
- Air conditioning
- Coffee/tea maker
- Iron/ironing board
Freshen up
- Private bathroom
- Shower/tub combination
- Free toiletries
- Hair dryer
Be entertained
- Premium TV channels
Stay connected
- Desk
- Free newspaper
- Free WiFi
- Phone
Food and drink
- Refrigerator (on request)
- Microwave
- Daily housekeeping
Courtyard by Marriott Asheville - Asheville's small print
Also known as
- Asheville Courtyard
- Asheville Courtyard Marriott
- Courtyard Asheville
- Courtyard Asheville Marriott
- Courtyard Marriott Asheville
- Courtyard Marriott Hotel Asheville
- Courtyard Asheville Hotel Asheville
- Courtyard Marriott Asheville Hotel
Optional extras
Full breakfast is offered for an extra charge of USD 10.95 per person (approximately)
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.


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B&B Il Poggiolo delle Rose, Impruneta
- Free breakfast, free WiFi, and free parking
Main amenities
- 6 guestrooms
- Rooftop terrace
- Room service
- Airport shuttle
- Air conditioning
- Daily housekeeping
- Garden
- Self-serve laundry
- Meeting room
- Multilingual staff
- Concierge services
- Luggage storage
Feel at home
- Free cribs/infant beds
- Rollaway/extra beds (surcharge)
- Private bathroom
- Separate bedroom
- Free toiletries
- Hydromassage showerhead
What's around
- Boboli Gardens (3.1 mi / 4.9 km)
- Florence Charterhouse (1 mi / 1.5 km)
- Piazza Niccolo Acciaioli (1 mi / 1.7 km)
- Florence American Cemetery and Memorial (2.4 mi / 3.8 km)
- Villa del Poggio Imperiale (2.8 mi / 4.6 km)
B&B Il Poggiolo delle Rose, Imprunetafrom NZ$99
- Comfort Apartment, 2 Bedrooms
- Family Room, 2 Bedrooms
- Comfort Double Room, 1 Bedroom
- Comfort Double Room Single Use
- Superior Triple Room, 2 Bedrooms, Garden Area
- Comfort Apartment, 2 Bedrooms, 2 Bathrooms
Recommended hotels
At a glance
Key facts
Hotel size
- This hotel has 6 rooms
- Check-in time 11:30 AM-1 AM
- Check-out time is 11 AM
- Express check-in/out
Airport shuttle service is available on request. Contact the property in advance to make arrangements.
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Children (3 years old and younger) stay free when occupying the parent or guardian's room, using existing bedding
- Pets not allowed
- Free WiFi and wired Internet access in public areas
- Free WiFi and wired Internet access in rooms
- Airport shuttle (available on request) *
- Train station pickup *
- Free extended parking
- Free RV/bus/truck parking
- Area shuttle *
In the hotel
- Free breakfast
- Room service (during limited hours)
- One meeting room
- Concierge services
- Tours/ticket assistance
- Laundry facilities
- Luggage storage
- Multilingual staff
- Rooftop terrace
- Garden
In the room
- In-room climate control (air conditioning)
- Air conditioning
- Minibar
- Iron/ironing board (on request)
- Down comforter
- Blackout drapes/curtains
- Soundproofed rooms
- Yard
- Individually decorated
- Private bathroom
- Shower only
- Bidet
- Free toiletries
- Hair dryer
- 20-inch LCD TV
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- Desk
- Free WiFi
- Phone
- Daily housekeeping
- In-room safe
B&B Il Poggiolo delle Rose, Impruneta's small print
Also known as
- B&B Il Poggiolo delle Rose
- B&B Il Poggiolo delle Rose Impruneta
- Il Poggiolo delle Rose Impruneta
All guests, including children, must be present at check-in and show their government-issued photo ID card or passport.
Cash transactions at this property cannot exceed EUR 2999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation.
For transfers, guests must contact the property before arrival at the number on the booking confirmation.
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
A tax is imposed by the city and collected at the property. The tax does not apply from November 1st to February 28th. Please note that further exemptions may apply. For further details, please contact the property using the information contained in the confirmation received after booking.
- A tax is imposed by the city: EUR 1 per person, per night, up to 4 nights. This tax does not apply to children under 15 years of age.
Optional extras
Rollaway beds are available for EUR 25 per night
Airport shuttle service is offered for an extra charge of EUR 15 per person (roundtrip)
WiFi is available in public areas for EUR 1 per hour (rates may vary)
High-speed Internet access (wired) is available in public areas for an extra charge
Train station pick-up service is offered for an extra charge
Area shuttle service is offered for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
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Soy caramel macc***** is the devil. Healing hands and a prayer cloth needed now!!
My fellow Bougie ladies and gentlemen I need some healing hands and a prayer cloth right now… My name is Bougie and I am a
Via Jeddah Mind Trick: Burnt Skin (A post on racism overseas)
BBG – Angelica is an African American woman from Detroit (the "D") but an Arizona exile who writes about her experiences of living in Saudi Arabia. Angelica
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Jesus Save My Baby Hairs: A Natural Hair Rant
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The Sexting Judge and the Bailiff
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We are all Black but you as a light skin person are benefiting from light skin privilege.
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Political Powerhouses, Black Women First and much more
From the Archives: Political Powerhouses in Vogue Three black women, the U.S. Ambassador to the United Nations Susan Rice, First Lady Michelle Obama and Former Secretary


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9 search results for The Hobbit production video
Watch: New 12-minute 'Hobbit' production video takes you to Hobbiton
Type: Article | Date: Tuesday, Dec 27, 2011Peter Jackson highlights the creation of the Hobbit village in new behind-the-scenes clip
Peter Jackson says 'The Hobbit' won't panel at Comic-Con 2013
Type: Article | Date: Tuesday, Jul 2, 2013Shooting schedule just won't allow it
Watch: Latest 'Hobbit' video diary offers a sneak peek at CG goblins and trolls
Type: Article | Date: Sunday, Nov 25, 2012Peter Jackson gives fans an inside look at the post-production process
Movie Power Rankings: Peter Jackson's 'The Hobbit' journeys to No. 1
Type: Article | Date: Thursday, Dec 29, 2011Where do 'Dark Knight Rises,' 'Thor 2' and 'Prometheus' end up?
Watch: New 'Hobbit' video diary has barrel-riding, mini Orlando Bloom
Type: Article | Date: Wednesday, Jun 6, 2012Peter Jackson gives fans a behind-the-scenes look at the massive production
'Boxtrolls,' 'How to Train Your Dragon 2' lead Annie Awards Nominations
Type: Post | Date: Monday, Dec 1, 2014'Book of Life,' 'Song of the Sea' Disney's 'Big Hero 6' all major contenders
A big morning for WETA: 'Hobbit' diary and 'Apes' trailer
Type: Post | Date: Thursday, Apr 14, 2011Nostalgia and the cutting edge collide in behind the scenes and trailer debuts
A Return To Middle-Earth, Part I: Liveblogging the 'Lord Of The Rings' on Blu-ray
Type: Post | Date: Tuesday, Dec 27, 2011Why are we heading back now, and what will we find when we get there?
Report: Peter Jackson and "New Moon" confirmed for Comic-Con
Type: Article | Date: Saturday, Jun 6, 2009NYT also says Warner Bros. to present 10 films, hints at 'Avatar'


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• Cast Aluminum
• Interior Dimensions: 12 1/4 Cup
• Exterior Dimensions: 14.13"L x 9.56"W x 1.19"H
• Product Weight: 2lbs
• 10-Year Warranty
• Made in the USA
Use and Care Instructions
1. Before initial use and after subsequent uses, hand wash with hot soapy water.
2. Before each use, brush with solid vegetable shortening and dust with flour or spray with unsalted vegetable shortening with flour in the spray.
3. Mixes and recipes may vary. Fill the pan no more than 3/4 full to avoid overflow.
4. Metal utensils, scouring pads and abrasive cleaners should not be used on nonstick


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Director Anthony D'Souza's remake of Malayalam blockbuster Pokkiri Raja has a purposefully illogical but interesting story — well, somewhat interesting until the interval.
We are passionate about Media and Bollywood. And we love our India and its rich and ancient culture. Welcome to our site, do contact us if you have any questions!
© 2014 Bollywood.com. All Rights Reserved. Powered by Sakshay Web Technologies Pvt. Ltd.


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YOUR HOME'S VALUE... get three estimates and compare.
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One of the few C2 lots left on Broadway corridor. This corner lot is approximately 30,500 square feet with Broadway St. frontage, completely fenced with 2 rolling gates. The sale includes parcel 113-55-074B.


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Wagons rollingãÎ new innovation in CSP
Well they might not be wagons, but solar receivers that will be rolling at the Advanced Technology Centre for Renewable Energiesã test facility in the Tabernas Desert (Almeria, Spain). The research centre has developed what it describes as a ãVariable Geometry Central Receiver Test and Research facilityã, which it recently presented at the SolarPaces World Conference. According to its developers the new facility could be 17% more efficient than conventional solar fields.
The research facility of the Advanced Technology Centre for Renewable Energies (CTAER), located in the Tabernas Desert (Almeria, Spain) is currently in its last stage of the construction phase and will be operational during the first term of 2013.The facility was presented last week at the SolarPaces 2012 International Congress by Prof. Dr. Valeriano Ruiz Hernandez and Dr. Manuel Silva Perez.
CTAER describes the innovation as ãthe first solar concentrating system based on the concept of variable geometryã and estimates it may achieve around 17% more efficiency than current plants. The facility is located within the CTAER premises in Tabernas next to the PSA-CIEMAT Almeria Solar Platform.
One of the most characteristic elements of this new concept is the ãheliomobileã, the first one of its kind in the history of these technologies. This video shows how the heliomobiles move across the concentric rails to the tower in order to reflect the highest possible direct solar radiation.
Prof. Dr. Valeriano Ruiz HernûÀndez, Chair at University of Seville and President of CTAER, and creator of the project describes the new research facility: ãFrom the Earthãs perspective, the Sun is in constant movement, a fact that we should not forget. This is the reason why I have designed a central receiver test facility, currently in its last phase of construction, which contains a field of mobile heliostats and a receiver mounted on a rotating platform. We have named this concept ãvariable geometryãã.
ãIn this new concept of heliostats field, the heliostats (from now on ãheliomobilesã), during the morning are positioned on the west side of the field; at midday their position moves toward the north of the tower, and in the afternoon they are positioned on the eastside. Throughout the whole day, they adopt different positions in order to redirect the direct solar radiation and to achieve the least geometric loss possible; that is, keeping the cosine of the angle of incidence (the angle between the solar ray and the normal to the reflecting surface of the heliomobile) as close to 1 as possible at each moment.ã
17% more efficient
According to simulations carried out with the NSPOC programme a field of heliomobiles could achieve improvements in the cosine factor, enabling a significant increase of the efficiency of a present plant (see graph). The results, show that during the sunlight hours of a day, the variable geometry plant increases in average its efficiency around 17% per year. During the sunniest months, improved efficiencies of up to 30% can be achieved.
The variable geometry solar facility is a project designed and developed by CTAER,a private foundation based in AndalucûÙa (Spain) and constituted by a board with public and private participation. The projectãs budget during its first phase is ã˜5 million, and it is jointly financed by the Department of Economy, Innovation, Science and Employment of the Andalusia Regional Government (Junta de AndalucûÙa), through an agreement with the Ministry of Economy and Competitiveness of the Spanish Central Government and the European RegionalDevelopment Fund.
This facility is part of CTAERãs more comprehensive plan for developing research infrastructures aimed at offering solutions for improvements in the performance of solar thermoelectric plants of different technologies. The next facility already awarded is a test bench for parabolic trough, which will begin construction in the near future, followed by test benches for the Stirling dish and Fresnel technologies.
For additional information:
Innovative Solutions to Offset Development Dilemmas


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Emergency Closing Information
In the event that weather or other emergency conditions warrant the early closing, all-day closing or delayed opening of Towson University, an announcement will be made through the following communication channels:
- Campus-wide email
- TU Emergency Text Message Alert (register here)
- University Facebook page
- University Twitter feed
- Local radio and television stations
- Towson University homepage
Such schedule adjustments will also be available on the Towson University Information Line: 410-704-2000. Please DO NOT call the University Police Department with university closing-related questions. The university will not post an announcement that the university is open. No announcement means "business as usual."
Main Campus Closure
When the main campus is closed, all events (including those sponsored by off-campus organizations) are canceled. Communications and Media Relations will not make announcements about individual department or program activities.
Towson University announcements of delayed opening or closure apply to the main campus, as well as Towson City Center, 7400 York Road and Terracedale.
Cook Library — Cook Library will close when the campus is closed.
Burdick Hall — When the campus has a delayed opening, Burdick Hall gym will open one hour after school opens.
Dining Closure Information
If TU is closed:
- Newell and Glen dining: 9 a.m.–7 p.m.
- Einstein Bros. Bagels: 10 a.m.–4:30 p.m.
- PAWS: 10 a.m.–11 p.m.
- West Village dining hall: 11a.m.–9 p.m.
- West Village Outtakes and Glen Micromart: Noon–8 p.m.
- Newell Den and Roadside BBQ (West Village): 4:30 p.m.–11 p.m.
- All other locations closed
- Tapingo offline
For a 10 a.m. opening:
- West Village, Newell and Glen dining halls: soft opening at 9 a.m. with limited service, full service ASAP
- Paws, Newell Den: soft opening at 9 a.m., full service ASAP
- All other locations: 10 a.m.
- Tapingo online at 10 a.m.
For a noon opening:
- West Village, Newell and Glen dining halls: soft opening at 9 a.m., full service ASAP
- Newell Den: 9 a.m. soft opening with full service by noon
- Einstein Bros. Bagel: 10 a.m.
- All other locations: 11 a.m. soft opening with full service by noon
- Tapingo online at noon
Off-campus Closure
Off-campus programs and courses — TU in Northeastern Maryland (TUNE), for example — adhere to the announcement of the off-campus facility.
Vehicles may not be parked in closed off areas.
- You must move off of garage roofs
- If space is available in a covered resident area, park in those areas first
- If no space is available in covered resident areas, you may park in Overflow and Commuter spaces during the inclement weather time. Residents will not be ticketed in the other areas during an inclement weather period.
- Vehicles must be moved back to their regular assigned areas within 24 hours of the official re-opening of campus.
- No shuttles, including ParaTransit and SafeRide will operate when the campus is closed.
- Riders should expect delays in service and plan accordingly.
- Notices will be posted on the Nextbus web site.
- If the campus opens late, shuttles will begin running 1 hour prior to the planned delayed opening time, as long as it is safe to operate.
- If the campus closes early, shuttles will run for 1 hour after the official closure time, as long as it is safe to continue operating.
For inclement weather days when we are running, the following stops will be re-located as indicated:
The Kenilworth Route
- Stop #19 Kenilworth At Charles Apts. pick up and drop off will be on Kenilworth Ave. at the east end of Donnington Circle.
- Stop #48- Kenilworth at the Colony. In the event that the parking lot at the Colony is inaccessible, pick up and drop off will be on Kenilworth Ave. curbside.
The Goucher Route
- Stops #63, 24, 25 Fairways Apts. Pickups and drop offs will be on Goucher Blvd at Colbury Rd.
- Stop #37 Towson Crossings Apts. Pickups and drop offs will be on Deanwood Road at the west end of Dowling Circle.
The Rodgers Forge Route
- Stop #55 Walker Apts. Pickups and drop offs will be at Stop #56 Drumcastle Apts, Holly Lane at Castle Drive
Frequently Asked Questions (FAQs) About Closing
Q. Who decides to close the campus or to cancel or delay classes?
A. Between 5 and 5:30 a.m., our vice president for Administration and Finance consults with the associate vice president for Public Safety and chief of police, as well as the associate vice president of Facilities Management. At that time, they discuss the forecast, the condition of the campus and the known road conditions from Baltimore County and surrounding police jurisdictions. They deliberate with the information they have available and then make a decision, generally before 6 a.m., about campus closing, opening late, or remaining open without delay. If the decision is to close or delay, Communications and Media Relations then posts the news on the TU homepage, notifies the media, and records announcements on TU's 410-704-2000 and 410-704-NEWS phone lines. The TU Police Department will send a campus-wide email announcement and text-message alerts to those who have signed up to receive them.
Q: If classes are not cancelled, but I feel it's unsafe for me to travel, will my
instructors excuse my absence?
A: The university has no official policy on attendance if classes are not cancelled. The decision in whether to travel is always yours. Many instructors will be flexible. It's best to ask your instructor for his/her approach so you're aware of it before a storm hits.
Q. Does TU ever issue announcements that the campus is open?
A. No. Announcements are issued only when normal operations must be disrupted or suspended. If you don't hear an announcement, it's safe to assume the campus is open.
Q. What if an emergency occurs during the day?
A. The same notification process is executed as with overnight emergencies.
Q. Will scheduled events take place if TU is closed?
A. NCAA athletic events may proceed as scheduled, provided the university can ensure a safe environment for players and spectators. (Announcements regarding NCAA events are distributed through the same channels as other TU closing advisories.) All other events, regardless of sponsor, are canceled.
Q. Will TU issue announcements about individual department or program activities?
A. No. Departments should set up their own systems of communication, either through recorded announcements or telephone calls.
Q. Is there a telephone number I can call for the latest information?
A. Call 410-704-2000 or 410-704-NEWS for recorded updates. Please DO NOT call the University Police.
Q. Which radio and TV stations will air emergency closing-related news?
A. In the Baltimore area: WTMD (89.7 FM), WYPR (88.1 FM), WHFS (97.5 FM), WWMX (106.5 FM), WLIF (101.9 FM), WJFK (1300 AM), WBAL Radio 11 (1090 AM), WJZ (105.7 FM), WQRS 102.7, WBAL-TV (11), WJZ-TV (13) and WMAR-TV (2). In the Washington, D.C., area: WTOP (820 AM/103.5 FM), WRC-TV (4), WUSA-TV (9), WJLA-TV (7) and Newschannel 8.
Q. What about text alerts?
A. You are encouraged to register to receive text messages. This is the safest way to ensure that you receive critical TU notifications on safety issues, school closings and weather alerts. Get more information about Towson University's emergency notification system.
Q. What if I work or take classes at an off-campus facility that is affiliated with
A. Off-campus programs and courses (at TU in Northeastern Maryland (TUNE), for example) adhere to the announcements of the off-campus facility. TU's announcements apply only to the main campus, including Towson City Center, 7400 York Road and Terracedale.
Q. What is the difference between liberal leave and administrative leave for employees?
A. Liberal Leave: authorization for staff to use earned leave for lateness or absence because of an emergency. Note: If you have been identified as a sustainable operations employee, you should talk to your supervisor about whether you should report to work during liberal leave scenarios. Administrative Leave: granted to staff only when TU is closed. Only emergency essential personnel should report to work when administrative leave is in effect.
Q. Should some employees report to work when TU is closed?
A. Emergency essential personnel should report to work. Talk to your supervisor to see if this policy affects you.
Information for Faculty and Staff
In the event of campus closure, non-essential personnel should not report to work without the approval of their vice president. Supervisors/managers of employees who still report to work have the authority to tell the employee to go home.
Regardless of campus closure, emergency essential personnel are required to report for work. Emergency essential personnel are vital to the operation of the facility, whose absence from duty could endanger the safety and well-being of the campus population and/or physical plant.
Employees identified as sustainable operations personnel must also report to work as directed by their supervisors/managers. Sustainable operations personnel are designated as vital to the operations of their division/department. The functions and level of operations to be sustained are determined by department heads.
An announcement of liberal leave means staff may use their earned leave for lateness or absence because of an emergency.
For information about leave, please contact the Office of Human Resources at 410-704-2162.


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In 2005, it was estimated that more than 20 million people in the United States had diabetes. Approximately 30% of these people had undiagnosed cases. Increased risk for diabetes is primarily associated with age, ethnicity, family history of diabetes, smoking, obesity, and physical inactivity. Diabetes-related complications—including cardiovascular disease, kidney disease, neuropathy, blindness, and lower-extremity amputation—are a significant cause of increased morbidity and mortality among people with diabetes, and result in a heavy economic burden on the US health care system. With advances in treatment for diabetes and its associated complications, people with diabetes are living longer with their condition. This longer life span will contribute to further increases in the morbidity associated with diabetes, primarily in elderly people and in minority racial or ethnic groups. In 2050, the number of people in the United States with diagnosed diabetes is estimated to grow to 48.3 million. Results from randomized controlled trials provide evidence that intensive lifestyle interventions can prevent or delay the onset of diabetes in high-risk individuals. In addition, adequate and sustained control of blood sugar levels, blood pressure, and blood lipid levels can prevent or delay the onset of diabetes-related complications in people with diabetes. Effective interventions, at both the individual and population levels, are desperately needed to slow the diabetes epidemic and reduce diabetes-related complications in the United States. This report describes the current diabetes epidemic and the health and economic impact of diabetes complications on individuals and on the health care system. The report also provides suggestions by which the epidemic can be curbed.
Diabetes and its complications are a major cause of morbidity and mortality in the United States and contribute substantially to health care costs. Although we have already seen an epidemic of diabetes in the United States over the past 2 decades, we can expect a continued rise in the incidence of diabetes as the population ages, a continued increase in adult obesity rates, and an increase in the population of minority groups that are at high risk for diabetes. In addition, rising childhood obesity rates and the increasing diagnosis of type 2 (formerly "adult-onset" diabetes) among children and young adults have become an increasingly serious health crisis, which will result in more people having and managing diabetes for most of their lives.
Although 90% to 95% of the diabetes burden in the United States is due to type 2 diabetes, an understanding of the different types of diabetes and their impact on health is warranted. This article reviews the literature on the epidemiology of diabetes in the United States and provides background on the complications associated with diabetes, especially those complications most frequently seen by physical therapists.
Pathophysiology of Diabetes
Diabetes mellitus is a group of chronic metabolic conditions, all of which are characterized by elevated blood glucose levels resulting from the body's inability to produce insulin or resistance to insulin action, or both.1 This group of conditions can be subdivided into 4 clinically distinct types:
type 1, which results from autoimmune beta-cell destruction in the pancreas and is characterized by a complete lack of insulin production;
type 2, which develops when there is an abnormal increased resistance to the action of insulin and the body cannot produce enough insulin to overcome the resistance;
gestational diabetes, which is a form of glucose intolerance that affects some women during pregnancy; and
a group of other types of diabetes caused by specific genetic defects of beta-cell function or insulin action, diseases of the pancreas, or drugs or chemicals.1
Type 1 diabetes accounts for 5% to 10% of all cases of diabetes. Its risk factors include autoimmune, genetic, and environmental factors. To date, there are no known ways to prevent type 1 diabetes. Type 2 diabetes accounts for 90% to 95% of all diagnosed diabetes cases. This form of diabetes generally begins as insulin resistance and, because the body is unable to produce enough insulin to address the resistance, the pancreas may reduce the production of insulin or eventually stop producing it. Minority women, women who are obese, women with a family history of diabetes, and women who have had gestational diabetes in a previous pregnancy are at higher risk than other women for developing gestational diabetes. Strict glycemic control and management of women with gestational diabetes is necessary to prevent birth complications in the developing infant. Women who have had gestational diabetes have a 20% to 50% increased risk for developing type 2 diabetes later in life.2
Prediabetes is a precursor condition to diabetes in which a person has elevated blood glucose levels but does not meet diagnostic criteria for diabetes. People with prediabetes can have impaired fasting glucose or impaired glucose tolerance, or both. From 1988 to 1994, approximately 25% of a cross-sectional sample of US adults 40 to 74 years of age were classified as having prediabetes.3 For the year 2000, this would mean that 12 million people in the United States had prediabetes. This finding clearly indicates that there is a large population that is at risk for developing diabetes within a relatively short time frame.
Incidence and Prevalence
In 2005, an estimated 1.5 million new cases of diabetes were diagnosed.2 Although the incidence (or new cases of diabetes) describes increases in the number of people affected by the disease, the prevalence (or existing cases of diabetes) describes the overall burden of the disease in the population. Two population-based sources of data on diabetes, the National Health Interview Survey (NHIS)4 and the Behavioral Risk Factor Surveillance System (BRFSS),5 provide data on the prevalence of diabetes in the United States. Although these sources provide accurate self-reported data about diabetes for the United States, they have been limited to reporting the prevalence of diagnosed diabetes because they assess whether a person has been told by a physician or health care professional that he or she has diabetes. This limitation, then, does not allow for measurement of undiagnosed diabetes (ie, those people who have diabetes but have not yet been diagnosed by a physician).
The National Health and Nutrition Examination Surveys (NHANES) are the only nationally representative surveys that have taken blood samples in addition to survey questions and, therefore, can estimate both diagnosed and undiagnosed diabetes.6 Based on prevalence estimates from NHANES for 2005, the total prevalence of diabetes (both diagnosed and undiagnosed) was estimated at 20.8 million or 7.0% of the US population. Of these, 14.6 million were diagnosed and 6.2 million—almost 30% of all diabetes cases—were undiagnosed.
Trends Over Time
Diabetes mellitus is now approaching epidemic proportions.7 In the United States, the prevalence and incidence of diabetes have increased dramatically during the past 2 decades.7 According to data from the NHIS for the period from 1980 to 2005, the age-adjusted prevalence of diagnosed diabetes was fairly stable at about 3.0% from 1980 to 1990 and then began to increase. In 1990, the age-adjusted prevalence rate was 2.9%.8 It increased to 4.5% in 2000 and to 5.3% in 2005. The overall prevalence of diagnosed diabetes increases with age and the rate of increase over time has been largest in people over 65 years of age.8 The prevalence of self-reported diagnosed diabetes has increased over time from 1997 to 2005 in all age groups (Fig. 1).9 Data from the 1997–2005 NHIS indicate that older adults have consistently borne a greater burden of diabetes.9
Age-adjusted prevalence rates for diagnosed diabetes have consistently been higher among African Americans and Hispanics compared with whites. African-American women have the highest prevalence of diabetes compared with other racial or ethnic and gender groups. In 2005, the age-adjusted prevalence rate for diagnosed diabetes was 8.3% in African-American women compared with 8.0% in African-American men, 7.5% in Hispanic women, 7.1% in Hispanic men, 4.7% in white women, and 5.4% in white men.9 The number of individuals with diagnosed diabetes is estimated to triple by the year 2050.10 Estimates show that 3.2 million African Americans currently have diabetes.2 The number of African Americans with diabetes is projected to triple by the year 2050, but the number of whites with diabetes is estimated to only double.7
Risk Factors
Although the pathogenesis of diabetes is complex, a number of factors that increase the risk for the disease have been identified. Risk factors for type 1 diabetes include family history, race (with whites at higher risk than other racial or ethnic groups), and certain viral infections during childhood. Risk factors for type 2 diabetes are more diverse; some are modifiable, and others are not.
Nonmodifiable risk factors for type 2 diabetes include age, race or ethnicity, family history (genetic predisposition), history of gestational diabetes, and low birth weight. Diabetes incidence and prevalence increases with age. In 2005, the Centers for Disease Control and Prevention reported that the prevalence of diabetes among people aged 20 years or older was 20.6 million (9.6% of the people in that age group), and the prevalence of diabetes increased with age (10.3 million people aged 60 years or older, or 20.9% of those in that age group, had diabetes).2
African Americans are more likely to develop diabetes than whites.11 In addition, for Native Americans, the rates of diagnosed diabetes range from 5% to 50% in different tribes and population groups. Little difference exists by sex. Genetic factors also play a role, but nongenetic or lifestyle risk factors (such as diet and physical activity) appear to be the primary culprits.12
Modifiable or lifestyle risk factors include increased body mass index (BMI), physical inactivity, poor nutrition, hypertension, smoking, and alcohol use, among others.7,11 Increased BMI is consistently shown to be one of the strongest risk factors for development of diabetes.13 In addition, distribution of body fat,14 and specifically an increased waist-to-hip ratio, increase a person's risk for diabetes.15
Consistent findings from various studies show that lower levels of physical activity increase a person's risk for diabetes. A recent review of 10 prospective cohort studies investigating moderate-intensity physical activity and diabetes provides evidence that people who achieve recommended levels of even moderate activity are about 30% less likely to develop diabetes than their inactive counterparts.16
Total caloric intake, as well as specific components of diet such as refined carbohydrates and fats, have been linked to diabetes development. Moderate alcohol use may reduce the risk for developing diabetes,10 but smoking has been shown to be an independent risk factor for diabetes.17
Psychosocial factors such as depression, increased stress, lower social support, and poor mental health status also are associated with an increased risk for the development of diabetes.18–22 Recently, adverse housing conditions were found to be independently associated with the development of self-reported diabetes, although the mechanism by which housing conditions exert their risk is still unknown.23 (Also see the article in this issue by Kirkness et al24 documenting the number of risk factors for diabetes in a large sample of patients seen by physical therapists.)
In 2002, diabetes was the sixth leading cause of death,2 with 73,249 death certificates listing diabetes as the underlying cause of death and an additional 224,092 death certificates listing diabetes as a contributing cause of death. Diabetes is likely to be underreported as a cause of death due to the many complications associated with diabetes that ultimately cause death. Overall, the risk of death among people with diabetes is almost twice that of people of similar age who do not have diabetes.2 Duration of diabetes also is an important determinant of mortality; younger age-of-onset groups (<45 years of age) have an increased risk of premature death. From death certificate data, it appears that age-adjusted death rates for African Americans and Hispanic Americans are similar to the rates of whites.25,26 An increased mortality rate in North American Native Americans with type 2 diabetes also is apparent.
There is general agreement about the distribution of causes of death in type 2 diabetes.27 Two thirds of people with diabetes die of heart disease and stroke. The risk for cardiovascular disease mortality is 2 to 4 times higher in people with diabetes than in people who do not have diabetes.
There are several risk factors that increase the risk for dying in people with diabetes. In a large intervention trial, men with diabetes were more likely to die as a result of cardiovascular disease when they had the conventional risk factors of elevated serum cholesterol, elevated systolic blood pressure, and cigarette smoking.28 In recent studies, "tight control" of elevated blood pressure in type 2 diabetes reduced deaths related to diabetes by 32% compared with less tight control.29
Diabetes can affect many different organ systems in the body and, over time, can lead to serious complications. Complications from diabetes can be classified as microvascular or macrovascular. Microvascular complications include nervous system damage (neuropathy), renal system damage (nephropathy) and eye damage (retinopathy).1 Macrovascular complications include cardiovascular disease, stroke, and peripheral vascular disease. Peripheral vascular disease may lead to bruises or injuries that do not heal, gangrene, and, ultimately, amputation.
Figure 2 shows the prevalence of the most common diabetes complications among people with type 2 diabetes. Data from the 1999–2004 NHANES indicate that the prevalence of microvascular complications—chronic kidney disease (defined as microalbuminuria), foot problems (defined as foot/toe amputation, foot lesion, or numbness), and eye damage (defined as being told that diabetes had affected the eyes or had retinopathy)—are much higher than the prevalence of macrovascular complications (heart attack, chest pain, coronary heart disease, congestive heart failure, and stroke).30 Complications can be either episodic (eg, foot ulcers or infections) that can be treated and recur numerous times or progressive (eg, nephropathy), which usually begin relatively mildly, but over time result in further damage to the organ and greater loss of functionality that is generally irreversible.
Other complications include dental disease, reduced resistance to infections such as influenza and pneumonia, and macrosomia and other birth complications among pregnant women with diabetes. Although the types of complications are similar for type 1 and type 2 diabetes patients, the frequency or timing of occurrence can vary. The types and prevalence of the most common diabetes complications are discussed further in more detail with specific attention to differences between complications of type 1 versus type 2 diabetes.
Heart Disease and Stroke
Cardiovascular disease causes up to 65% of all deaths in people with diabetes.31 Ischemic heart disease and stroke account for the greatest proportion of morbidity associated with diabetes. In addition, as described above, mortality rates due to heart disease are 2 to 4 times higher among people with diabetes compared with those without diabetes. People with diabetes also are 2 to 4 times more likely to develop stroke than people without diabetes. More than 70% of people with diabetes have high blood pressure or are being treated with medications for hypertension. The role of hyperglycemia in cardiovascular complications among persons with diabetes is not clear.
Risk factors for cardiovascular disease among people with diabetes are similar to those for people without diabetes and include hypertension, hypercholesterolemia, and smoking. It appears, however, that the presence of even one of these risk factors leads to poorer outcomes among people with diabetes compared with those without diabetes.28 Data on trends in cardiovascular disease complications associated with diabetes are available from the 1950s to 2003 for different populations, and overall these data indicate that there have been large and significant decreases in the incidence of cardiovascular complications among people with diabetes over time.32,33 The greatest decreases appear to have occurred during the 1980s and 1990s and coincide with significant advances in medicines to control glycemic levels as well as medicines to control blood pressure and blood cholesterol levels. It appears, however, that these decreases have slowed since the late 1990s.9 (Also see the article in this issue by Cade34 for a detailed perspective on microvascular and macrovascular disease in people with diabetes.)
Peripheral Arterial Disease
Peripheral arterial disease (PAD, also referred to as peripheral vascular disease [PVD]), is caused by the narrowing of blood vessels that carry blood to the arms, legs, stomach, and kidneys. In people with diabetes, the risk for PAD is increased by age, duration of diabetes, and presence of neuropathy. Other factors associated with cardiovascular disease, such as C-reactive protein levels and homocysteine levels, also are associated with an increased risk for PAD.35 Peripheral arterial disease is characterized by 2 types of symptoms: intermittent claudication (or the intermittent pain, ache, or discomfort that may occur during exercise or walking but resolves with rest) and pain at rest (which is caused by ischemia in the limb, indicating inadequate blood flow to the affected limb).35 Peripheral arterial disease is a major risk factor for lower-extremity amputation.
Data on PAD trends come from hospital discharge data from the National Center for Health Statistics and indicate that the hospital discharge rates for PAD as the primary diagnosis have decreased steadily since 1996. The age-adjusted hospital discharge rate for PAD peaked at 7.8 per 1,000 people with diabetes in 1996 and was down to 3.3 per 1,000 people with diabetes in 2003. In addition, discharge rates for PAD were higher in men than in women and increased with increasing age.9
Retinopathy (Blindness)
Diabetic retinopathy is the most common microvascular complication among people with diabetes and results in more than 10,000 new cases of blindness per year. In addition, retinopathy is associated with prolonged hyperglycemia, it is slow to develop, and there is some evidence that it can begin to develop as early as 7 years before clinical diagnosis of type 2 diabetes.36 The age-adjusted prevalence of visual impairment decreased from 23.7 per 100 people with diabetes in 1997 to approximately 17.7 per 100 people with diabetes in 2005.9 The prevalence of visual impairment among people with diabetes increases with age. In 2005, 27% of adults with diabetes who were 75 years of age or older reported some degree of visual impairment compared with 15% of adults with diabetes who were between 18 and 44 years of age.9 Throughout the period of 1997–2005, women with diabetes were more likely than men with diabetes to have visual impairment. Prevalence rates in women with diabetes have been falling throughout this time period, whereas rates in men with diabetes have stayed fairly constant since 2001. There appears to be no difference between racial groups in the prevalence of visual impairment during the period 1997–2005. Duration of diabetes is the most significant predictor of visual impairment among people with type 2 diabetes. As much as 90% of blindness due to retinopathy among people with diabetes may be preventable if detected and treated early. Annual dilated eye examinations are recommended for all patients with diabetes.37
Nephropathy (Renal Disease)
Diabetic nephropathy is defined as persistent proteinuria (more than 500 mg of protein or 300 mg of albumin per 24 hours) in patients without urinary tract infection or other diseases causing the proteinuria. In patients with type 1 diabetes, development of clinical nephropathy is a relatively late event; however, in patients with type 2 diabetes, diabetic proteinuria may be present at diagnosis.
The incidence of diabetic nephropathy in patients with type 2 diabetes is low during the first 10 to 15 years of diabetes duration, after which it increases rapidly to a maximum at about 18 years of duration, and then declines.38–40 The actual onset of type 2 diabetes may precede its clinical diagnosis by many years,41,42 which may explain the high prevalence of nephropathy at diabetes diagnosis. In 2002, diabetes-related nephropathy accounted for 44% of new cases of end-stage renal disease (ERSD), and 153,730 people with ESRD due to diabetes had either received a kidney transplant or were on chronic dialysis treatment.2
The etiology of diabetic nephropathy is poorly understood. Several risk factors are involved, some of which are modifiable and others are not. Metabolic regulation is one of the key modifiable risk factors for development of diabetic nephropathy. In people with either type 1 or type 2 diabetes, strict metabolic control leads to a significant reduction in the risk of developing microalbinuria and the risk of progression to persistent proteinuria.43–45 The impact of strict metabolic control on prognosis is most pronounced in patients with normal levels of albumin in the urine and patients with microalbuminuria. Increasing blood pressure and hypertension also are associated with an increased risk of progression of diabetic renal disease.46 However, it is still unclear whether blood pressure at diabetic onset predicts later development of diabetic nephropathy. Other risk factors, including cigarette smoking, obesity, anemia, and genetic factors, also have been suggested.47
People with type 2 diabetes and diabetic nephropathy are at increased risk for developing many other diabetic complications. The renal-retinal syndrome has been known for years and refers to the presence of both types of diseases at the same time. People with diabetes and nephropathy also are more likely to develop coronary heart disease and stroke compared with patients with diabetes without nephropathy. People with diabetes and nephropathy also are more likely to die from macrovascular disease, as described above.
Overall, the incidence of nephropathy has declined in recent decades, due to improvements in the management of people with diabetes to promote tight control of glycemia as well as improved control of hypertension. For example, comparison of 4 cohorts of patients with type 1 diabetes whose disease was diagnosed between 1965 and 1984 showed that the cumulative incidence of diabetic nephropathy over the following 20 years were lowest in the most recently diagnosed cohorts.48,49
Peripheral Neuropathy
Diabetic peripheral neuropathy (DPN) is a common complication estimated to affect 30% to 50% of individuals with diabetes.50–53 The primary risk factor for DPN is hyperglycemia.52,54 Other independent risk factors include age, duration of disease, cigarette smoking, hypertension, elevated triglycerides, higher BMI, alcohol consumption, and taller height.53–56
Chronic sensorimotor distal symmetric polyneuropthy is the most common form of DPN.57 Polyneuropathy can lead to sensory loss, muscle weakness, and pain. The typical presentation of polyneuropathy is a gradual onset of sensory impairment, including burning and numbness in the feet. The onset is so gradual that the disease may go undetected for years. Neuropathic pain may be severe when present; however, it is reported to occur in only 11% to 32% of individuals with polyneuropathy.58–60
Diabetic peripheral neuropathy leads to a number of impairments and functional limitations. Individuals with DPN are at high risk for foot ulceration and subsequent lower-extremity amputation.61–63 In individuals with diabetes, the presence of DPN is associated with a greater number of health care visits per year and an inability to work due to physical limitations.50 Other potential complications of DPN, such as falls, are less clearly attributable to the illness; however, they can result in significant functional limitations. (Also see the articles in this issue by Mueller et al,64 Sinacore et al,65 and Hilton et al66 about neuropathic skin, bone, and muscle in people with diabetes mellitus.)
Data from the National Center for Health Statistics indicate that the hospital discharge rates for DPN have steadily increased from 1996 to 2003. The age-adjusted hospital discharge rate for DPN increased from 4.7 per 1,000 people with diabetes in 1996 to 6.8 per 1,000 people with diabetes in 2003. Discharge rates were higher in men than in women and higher for people younger than 45 years of age compared with those who were 45 years of age and older.9
Lower-Extremity Amputations
Nontraumatic lower-extremity amputations (LEAs) are a devastating complication of diabetes. As many as 15% of people with diabetes will have such amputations during their lifetime. People with diabetes are 10 to 20 times more likely to have LEAs than those without diabetes. People 65 years of age and older account for about 55% of patients with diabetes who had nontraumatic LEAs.67
The annual number of diabetes-related hospital discharges with LEA increased from about 33,000 in 1980 to 84,000 in 1997.9 Although large increases in the number of LEA discharges occurred in the early 1990s, the number of discharges for LEAs leveled off afterward. In 2003, there were about 75,000 diabetes-related hospital discharges with LEAs.9 The age-adjusted rate of hospital discharges for LEAs per 10,000 population increased after the 1983 implementation of the prospective reimbursement system by the Center for Medicare and Medicaid Services, leveled off starting in the mid-1980s, and then began increasing in the early 1990s. After reaching a peak in 1996, LEA rates decreased slightly. In 2003, the age-adjusted LEA rate was 4.4 per 1,000 people with diabetes.9
There are several risk factors for LEA, including increasing age, being male, being African American, having peripheral neuropathy, and having chronic ulcers. About 85% of all LEAs occurring in people who had diabetes for more than 30 months were preceded by a chronic, nonhealing foot ulcer.62,68 Diabetic foot ulcers are common and are estimated to affect about 15% of all individuals with diabetes during their lifetimes.69 Peripheral vascular disease contributes to about half of all amputations in people with diabetes.62 Many foot ulcers might be prevented by regular foot inspections, access to foot care, and adequate footwear.70,71 However, the majority of individuals with diabetes do not get regular inspections of their feet, adequate shoes, or proper foot care.72 (Also see the article in this issue by Mueller et al64 about physical stresses contributing to skin breakdown in people with diabetes mellitus.)
There is still controversy concerning the benefit of primary minor amputation versus primary major amputation. The advantage of primary minor amputation is that there is a lower risk for new major amputation and better rehabilitation potential.73 However, in a prospective study of 189 patients with diabetes, there was no difference in the rate of new amputations between people with index minor amputations and people with index major amputations, and those with index minor amputations had longer healing times.74 People with diabetes who had an index major amputation had a higher mortality rate, an equal rate of new amputations regardless of level, an increased rate of major amputations, and lower rehabilitation potential compared with patients with an index minor amputation.74 Disability as a result of an LEA is quite common.
Control of Risk Factors to Reduce Complications
Across all of the diabetes-related complications described above, the 3 most significant risk factors are hyperglycemia, high blood pressure, and hypercholesterolemia. It has been suggested that improvements in glycemic control, blood pressure, and cholesterol level can reduce a person's risk for complications.2 For example, in a person with diabetes, each percentage point reduction in glycosylated hemoglobin (Hb A1c) level can reduce that person's risk for microvascular complications by 40%; a 10 mm Hg decrease in blood pressure can reduce that person's risk for any diabetic complication by up to 12%; and control of serum lipids can reduce that person's risk for cardiovascular complications by 20% to 50%.2 Clearly, better control of these risk factors in people with diabetes can lead to more favorable outcomes.
Burden to the Health Care System
According to the American Diabetes Association, the estimated costs associated with diabetes in the United States in 2002 totaled $132 billion, with direct medical costs of $92 billion and indirect costs (disability, loss in work productivity and premature mortality) of $40 billion.75 Given no additional increase in the prevalence of diabetes in the United States, these expenditures would be expected to reach approximately $192 billion by 2020.75 Of the $92 billion in direct costs for 2002, $23 billion was due to health care events with a primary diagnosis of uncomplicated diabetes and an additional $25 billion was for treatment of diabetes-related cardiovascular disease.75 (Also see the perspective article in this issue by Cohn76 about the economic realities for the care of people with diabetes mellitus.)
Approximately 40% of the total cost of diabetes in the United States is due directly to inpatient care for treatment of diabetes complications.77 Several studies have estimated annual and cumulative economic costs of diabetes complications over time.78,79 These studies found that macrovascular disease (mainly cardiovascular events and stroke) accounted for as much as 85% of the costs of complications associated with diabetes and that these conditions are a significant determinant of costs at an earlier time during the course of the disease than microvascular complications.78 It is important to note, however, that relatively mild microvascular complications can become more serious over time and contribute significantly to morbidity and related costs in later years.
In addition, a key factor in the development of diabetes complications is glycemic level, both at diagnosis and an "upward drift" in glycemic level over time. People with higher initial Hb A1c levels had higher cumulative costs than people with lower levels, and people who experienced higher annual drift in Hb A1c levels had even further increased costs.78 These economic estimates suggest that improving glycemic control and other known risk factors for diabetes, particularly those for cardiovascular disease among people with diabetes, will significantly affect long-term costs.78,79 Although the evidence is strong that Hb A1c control and reduction can reduce a patient's risk for microvascular complications, the evidence is not so strong that glycemic control greatly reduces a person's risk for cardiovascular complications. Clearly, a combined effort to control blood glucose, blood pressure, and blood lipids will have the greatest effect on reducing a person's risk for diabetes-related complications and, ultimately, will have a favorable impact on the economic costs associated with diabetes.80–82 (Also see the articles in this issue by Turcotte and Fisher83 and Gulve84 on the effects of exercise in managing these risk factors in people with diabetes mellitus).
Early projections for the number of people with diagnosed diabetes in the United States in 2050 were calculated to be around 39 million.85,86 Since those calculations were done, however, the national incidence of diabetes has continued to increase from 2000 to 2004, and the mortality rate among people with diabetes has declined. Therefore, new projections for the diabetes burden in 2050 were published in 2006.10 The number of people with diagnosed diabetes in the United States is expected to increase from 16.2 million in 2005 to 48.3 million in 2050. These new estimates clearly depend on a stable incidence rate for diabetes over time; even incremental increases in incidence will have a significant effect on the expected number of people with diagnosed diabetes in the future. In addition, these estimates assume no advances in prevention, treatments, or control of risk factors; no increases in life expectancy; and no discovery of a cure. Changes in any of these factors could substantially alter the projections for 2050.
It is clear that there is a growing epidemic of diabetes in the United States. An increasing prevalence of diabetes risk factors will only exacerbate the problem; therefore, population-based efforts that affect the modifiable diabetes risk factors, particularly obesity and physical inactivity, are needed to reduce the burden of diabetes. In addition, among people with diabetes, the rate of complications is high. These complications not only significantly affect the morbidity and mortality associated with diabetes, but also contribute to the ever-growing costs related to diabetes. Adoption of appropriate diet and exercise behaviors and adherence to medication regimens will result in tighter glycemic control that, along with controlled blood pressure and blood lipids, will greatly reduce the burden of diabetes complications in the United States.
Dr Deshpande and Dr Schootman provided concept/idea/project design. All authors provided writing. Dr Harris-Hayes provided consultation (including review of manuscript before submission).
- Received January 16, 2008.
- Accepted May 16, 2008.
- American Physical Therapy Association


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Danny Gottlieb: Morello Paradiddle Triplets
Morello Paradiddle Triplets
By Danny Gottlieb Originally Published In DRUM! Magazine's October 2009 Issue
One of my favorite rudimental variations for jazz is playing a paradiddle as a triplet. I first discovered this in Joe Morello's long out-of-print masterpiece, Rudimental Jazz (which I hope he will revise and reissue in the near future!) Ex. 1 shows the paradiddle as a triplet, with standard paradiddle sticking. A fun coordination variation, shown to me by the brilliant Dutch percussionist Martin Verdonk, is illustrated in Ex. 2, which adds the clave pattern under the paradiddle, which is played by the bass drum (Martin plays this on congas, with the left foot playing the clave on a cow bell with a pedal).
Another jazz hero, Jack DeJohnette often plays paradiddle as triplet variations as well, and the following are two of my exercises inspired by Jack. Ex. 3 illustrates the same paradiddle, but with the bass drum playing the accents, and the snare sticking for the other notes remaining the same. In Ex. 4 we keep the same pattern, but move the hands between the toms. These fun examples can be used for both soloing and comping, and I hope you will use them as a basis for your own creative experimentation.


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HIXENBAUGH, Sean Allen
HIXENBAUGH, Sean Allen, 43, of Rescare's Pineview Group Home in Belmont, OH, died Sunday, February 24, 2013.
He was born March 13, 1969, in Wheeling, WV.
Surviving are his parents, Bud and Sue Corbett of Bridgeport; brothers and sisters, Wayne (Cheryl) Hixenbaugh of Bridgeport, Brenda (Carl) Moore of Bethesda, Stephanie Travis of Bridgeport, Keith (Maria Clayton) Corbett of Bridgeport, and Chad (Kim Barton) Hixenbaugh of Valley Grove; 10 nieces and nephews; three great- nieces and nephews.
Friends will be received at Toothman Funeral Home in St. Clairsville on Tuesday from 6-8 p.m. and on Wednesday from 11:30 a.m. until time of service at 12:30 p.m. with Rev. Laurie Armstrong officiating.
Sean will be sadly missed by all of his family including his many aunts, uncles, and cousins.


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