Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic; 1988. p. xviii. 284 p.
Fleming ST. Primary care, avoidable hospitalization, and outcomes of care: a literature review and methodological approach. Med Care Res Rev. 1995;52(1):88–108.
Reschovsky JD, et al. Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries. Health Serv Res. 2011;46(4):997–1021.
CARDI: Centre for Ageing Research and Development in Ireland. Stocktake of Ageing Public Policy Initiatives in Ireland, North and South. 2008. Cited 12/9/11.
Moloney ED, Bennett K, Silke B. Factors influencing the costs of emergency medical admissions to an Irish teaching hospital. Eur J Health Econ. 2006;7(2):123–8.
Crimmins EM, Hayward MD, Saito Y. Changing mortality and morbidity rates and the health status and life expectancy of the older population. Demography. 1994;31(1):159–76.
Royal College of Physicians of Ireland, et al. Community medical services for the older person. In: Report of the National Acute Medicine Programme; 2011.
U.S. Agency for Healthcare Research and Quality. AHRQ quality indicators – guide to prevention quality indicators: hospital admissions for ambulatory care sensitive conditions. 2007.
Vest J, et al. Determinants of preventable readmissions in the United States: a systematic review. Implement Sci. 2010;5(1):88.
Agency for Healthcare Research and Quality. Chronic care and disease management improves health, reduces costs for patients with multiple chronic conditions in an integrated health system. Department of Health and Human Services, Editor 2009: United States. http://innovations.ahrq.gov/content.aspx?id=1696.
Jimenez-Puente A, et al. Readmission rate as an indicator of hospital performance: the case of Spain. Int J Technol Assess Health Care. 2004;20(3):385–91.
van Walraven C, et al. Proportion of hospital readmissions deemed avoidable: a systematic review. Can Med Assoc J. 2011;183(7):E391–402.
Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1–4.
Condelius A, Hallberg I, Jakobsson U. Hospital and outpatient clinic utilization among older people in the 3-5 years following the initiation of continuing care: a longitudinal cohort study. BMC Health Serv Res. 2011;11(1):136.
Martin M, Hin PY, O’Neill D. Acute medical take or subacute-on-chronic medical take? Ir Med J. 2004; 97(7):212–4.
Baer RB, Pasternack JS, Zwemer Jr FL. Recently discharged inpatients as a source of emergency department overcrowding. Acad Emerg Med. 2001;8(11):1091–4.
Pines JM, et al. Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. Ann Emerg Med. 2010;56(3):253–7.
Brunjes GB. The search for meaning in the face of death. J Health Care Chaplain. 1987;1(1):63–9.
Barnard A, Hollingum C, Hartfiel B. Going on a journey: understanding palliative care nursing. Int J Palliat Nurs. 2006;12(1):6–12.
Allaudeen N, et al. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011; 6(2):54–60.
Wallmann R, et al. Prediction of 30-day cardiac-related-emergency-readmissions using simple administrative hospital data. Int J Cardiol. 20 July 2011 (10.1016/j.ijcard.2011.06.119).
Courtney MD, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34.
Parry C, et al. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q. 2009;28(2–3):84–99.
Bittencourt RJ, Hortale VA. Interventions to solve overcrowding in hospital emergency services: a systematic review. Cad Saude Publica. 2009;25(7):1439–54.
Purdy S. Avoiding hospital admissions.What does the research evidence say? London: The King’s Fund; 2010.
Crane S, et al. Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index. BMC Health Serv Res. 2010;10(1):338.
Spencer J, et al. Functional outcomes and daily life activities of African-American elders after hospitalization. Am J Occup Ther. 2002;56(2):149–59.
Rea H, et al. Integrated systems to improve care for very high intensity users of hospital emergency department and for long-term conditions in the community. N Z Med J. 2010;123(1320):76–85.
Armstrong CD, et al. Home-based intermediate care program vs hospitalization: cost comparison study. Can Fam Physician. 2008;54(1):66–73.
Basu A, Brinson D. The effectiveness of interventions for reducing ambulatory sensitive hospitalisations: a systematic review. In: Health Services Advisory Committee Technical Report, Canterbury, New Zealand; 2008. p. 245.
Kronman AC, et al. Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life? J Gen Intern Med. 2008;23(9): 1330–5.
Linertová R, et al. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract. 2011;17(6): 1167–75.
Jordon M, et al. Implications of complex adaptive systems theory for interpreting research about health care organizations. Forum Syst Complex Health Care J Eval Clin Pract. 2010;16(1):228–31.
van Kerkhoff L, Szlezak NA. Knowledge Systems for Sustainable Development Special Feature Sackler Colloquium: The role of innovative global institutions in linking knowledge and action. Proc Natl Acad Sci USA. 2010. Epub 2010/03/03.
Glass DJ, Arnold SE. Some evolutionary perspectives on Alzheimer’s disease pathogenesis and pathology. Alzheimers Dement. 2012;8(4):343–51.
Gluckman PD, Hanson MA. Living with the past: evolution, development, and patterns of disease. Science. 2004;305(5691):1733–6.
Weber BH. Extending and expanding the Darwinian synthesis: the role of complex systems dynamics. Stud Hist Philos Sci C Stud Hist Philos Biol Biomed Sci. 2011;42(1):75–81.
Shanahan MJ, Hofer SM. Molecular genetics, aging, and well-being: sensitive period, accumulation, and pathway models. In: Binstock RH, George LK, editors. Handbook of aging and the social sciences. 7th ed. San Diego, CA: Academic; 2011. p. 135–47.
Khushf G. Health as intra-systemic integrity: rethinking the foundations of systems biology and nanomedicine. Perspect Biol Med. 2008;51(3):432–49.
Van Wave TW, Scutchfield FD, Honore PA. Recent advances in public health systems research in the United States. Annu Rev Public Health. 2010;31: 283–95.
Lunney J, et al. Patterns of functional decline at the end of life. J Am Med Assoc. 2003;289:2387–92.
Gill TM, et al. Trajectories of disability in the last year of life. N Engl J Med. 2010;362(13):1173–80.
Goldberger AL, et al. Fractal dynamics in physiology: alterations with disease and aging. Proc Natl Acad Sci USA. 2002;99 Suppl 1:2466–72.
Eisenberg DTA. An evolutionary review of human telomere biology: the thrifty telomere hypothesis and notes on potential adaptive paternal effects. Am J Hum Biol. 2011;23(2):149–67.
Zhu H, Belcher M, van der Harst P. Healthy aging and disease: role for telomere biology? Clin Sci. 2011;120(10):427–40.
Glover J, et al. Atlas of avoidable hospitalisations in Australia: ambulatory care-sensitive conditions. Canberra: AIHW; 2007.
Glouberman S. The grey zones of birth and death. J Eval Clin Pract. 2011;17(2):394–9.
Cole A. Proportion of people dying in hospital is falling. BMJ 2010;341:c4722.
Gruneir A, et al. Where people die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007;64(4):351–78.
Kardamanidis K, et al. Hospital costs of older people in New South Wales in the last year of life. Med J Aust. 2007;187(7):383–6.
Ahearn DJ, et al. Improving end of life care for nursing home residents: an analysis of hospital mortality and readmission rates. Postgrad Med J. 2010;86(1013):131–5.
Murtagh FEM, et al. End of life trajectories across conditions. BMJ. 2011;342:397–8.
Zaninotto P, Falaschetti E, Sacker A. Age trajectories of quality of life among older adults: results from the English Longitudinal Study of Ageing. Qual Life Res. 2009;18(10):1301–9.
Visser G, et al. The end of life: informal care for dying older people and its relationship to place of death. Palliat Med. 2004;18(5):468–77.
Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010;38(10 Suppl):S518–22.
Wilson DM, et al. Age-based differences in care setting transitions over the last year of life. Curr Gerontol Geriatr Res. 2011;2011:101276.
Martin CM. Distortions, belief and sense making in complex adaptive systems for health. J Eval Clin Pract. 2011;17(2):387–8.
Yam CH, et al. Avoidable readmission in Hong Kong – system, clinician, patient or social factor? BMC Health Serv Res. 2010;10:311.
Walsh B, Roberts H, Nicholls P. Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: retrospective analysis of hospital admissions data in England. BMC Geriatr. 2011;11(1):62.
Condelius A, et al. Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Arch Gerontol Geriatr. 2008;46(1):41–55.
Asarnow JR, Jaycox LH, Anderson M. Depression among youth in primary care models for delivering mental health services. Child Adolesc Psychiatr Clin N Am. 2002;11(3):477–97, viii.
Laniece I, et al. Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units. Age Ageing. 2008;37(4):416–22.
Bayliss EA, Ellis JL, Steiner JF. Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol. 2009;62(5):550–7.e1.
Martin CM, Vogel C, Grady D, Zarabzadeh A, Hederman L, Kellett J, et al. Implementation of complex adaptive chronic care: the Patient Journey Record system (PaJR). J Eval Clin Pract. 2012. Epub 2012/07/24.
Norman CD. Health promotion as a systems science and practice. J Eval Clin Pract. 2009;15(5):868–72.
Watt G, O’Donnell C, Sridharan S. Building on Julian Tudor Hart’s example of anticipatory care. Prim Health Care Res Dev. 2011;12(1):3–10.
Kellett J. Hospital medicine (Part 2): what would improve acute hospital care? Eur J Intern Med. 2009;20(5):465–9.
Naylor MD, et al. Translating research into practice: transitional care for older adults. J Eval Clin Pract. 2009;15(6):1164–70.
Clarke M, Shah A, Sharma U. Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis. J Telemed Telecare. 2011;17(1):7–14.
McLean S, et al. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;(7):CD007718.
Tan HM, et al. GP and nurses’ perceptions of how after hours care for people receiving palliative care at home could be improved: a mixed methods study. BMC Palliat Care. 2009;8:13.
McEvoy P, Escott D, Bee P. Case management for high-intensity service users: towards a relational approach to care co-ordination. Health Soc Care Community. 2011;19(1):60–9.
Lunney JR, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387–92.
Jylha M, Volpato S, Guralnik J. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol. 2006;59:465–71.
Nielsen AB, et al. The impact of changes in self-rated general health on 28-year mortality among middle-aged Danes. Scand J Prim Health Care. 2009;27(3):160–6. 1 p following 166.
DeSalvo KB, et al. Health care expenditure prediction with a single item, self-rated health measure. Med Care. 2009;47(4):440–7.
Lawton J. Lay experiences of health and illness: past research and future agendas. Sociol Health Illn. 2003;25(3):23–40.
Rockwood K. What would make a definition of frailty successful? Age Ageing. 2005;34(5):432–4.
Nesse RE, et al. Framing change for high-value healthcare systems. J Healthc Qual. 2010;32(1):23–8.
Hammond RA. Complex systems modeling for obesity research. Prev Chronic Dis. 2009;6(3):A97.
Beautement P, Broenner C. Complexity demystified: a guide for practitioners. Axminster, Devon: Triarchy; 2011. p. 268 p.
Harquail CV, Wilcox King A. Construing organizational identity: the role of embodied cognition. Organ Stud. 2010;31(12):1619–48.
Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293–9.
Zoloth-Dorfman L, Rubin S. The patient as commodity: managed care and the question of ethics. J Clin Ethics. 1995;6(4):339–57.
Kurtz C, Snowden D. The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J. 2003;42(3):462–83.
Silva SA, Charon R, Wyer PC. The marriage of evidence and narrative: scientific nurturance within clinical practice. J Eval Clin Pract. 2011;17(4):585–93.
Lakoff G, Johnson M. Philosophy in the flesh: the embodied mind and its challenge to Western thought. New York: Basic; 1999. p. xiv. 624 p.
Nelson B. A field guide to embodied cognition. 2008. http://corporature.wordpress.com/2008/12/28/a-field-guide-to-embodied-cognition/. Cited 12 Jan 2012.
King’s Fund. Predictive Risk Project: Literature review. NHS Modernisation Agency, New York University, Health Dialog. 2005. http://www.kingsfund.org.uk/current_projects/predicting_and_reducing_readmission_to_hospital/#context. Cited 2 Sept 2011.
Boult C, Pacala JT, Boult LB. Targeting elders for geriatric evaluation and management: reliability, validity, and practicality of a questionnaire. Aging (Milano). 1995;7(3):159–64.
Lyon D, et al. Predicting the likelihood of emergency admission to hospital of older people: development and validation of the Emergency Admission Risk Likelihood Index (EARLI). Fam Pract. 2007;24(2):158–67.
Lindquist LA, Baker DW. Understanding preventable hospital readmissions: masqueraders, markers, and true causal factors. J Hosp Med. 2011;6(2):51–3.
Roland M, et al. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ. 2005;330:289–92.
Sidorov J, Shull R. “My patients are sicker:” using the Pra risk survey for case finding and examining primary care site utilization patterns in a medicare-risk MCO. Am J Manag Care. 2002;8(6):569–75.
Martin C. Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract. 2011;17(3):1–5.
Murphy SME, Castro HK, Sylvia M. Predictive modeling in practice: improving the participant identification process for care management programs using condition-specific cut points. Popul Health Manag. 2011;14(4):205–10.
Obenshain MK. Application of data mining techniques to healthcare data. Infect Control Hosp Epidemiol. 2004;25(8):690–5.
Diehr P, et al. Patterns of self-rated health in older adults before and after sentinel health events. J Am Geriatr Soc. 2001;49(1):36–44.
Gravelle H, et al. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007;334:31–4.
Snowden DJ, Boone ME. A leader’s framework for decision making. A leader’s framework for decision making. Harv Bus Rev. 2007;85(11):68–76, 149.
Biddiss E, Brownsell S, Hawley MS. Predicting need for intervention in individuals with congestive heart failure using a home-based telecare system. J Telemed Telecare. 2009;15(5):226–31.
Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011;68(2):131–55.
Martin CM, Grady D, Deaconking S, McMahon C, Zarabzadeh A, O’Shea B. Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract. 2011;17(3):520–4.
Huang T, et al. A systems-oriented multilevel framework for addressing obesity in the 21st century. Prev Chronic Dis. 2009;6(3):A82.
Horvitz E. From data to predictions and decisions: enabling evidence-based healthcare. Series on data analytics 1. Computing Community Consortium; 2010.
Bayati M, et al. Predictive models and policies for minimizing rehospitalizations for congestive heart failure. 2010. in press.
Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69(3):307–16.
Lewis S. Seeking a new biomedical model. How evolutionary biology may contribute. J Eval Clin Pract. 2009;15(4):745–8.
Sturmberg J, Martin C, Moes M. Health at the centre of health systems reform – how philosophy can inform policy. Perspect Biol Med. 2010;53(3):341–56.
Quinlan JR. C4.5: Programs for machine learning. Burlington, MA: Morgan Kaufmann, Elsevier; 1993.
Kerr WT, Lau EP et al. The future of medical diagnostics: large digitized databases. Yale J Biol Med. 2012;85(3):363–377.
Sheskin D. Handbook of Parametric and Nonparametric Statistical Procedures. 3 ed. Baton Rouge, Florida: CRC Press; 2004.
Vapnik VN. Statistical Learning Theory. New York: John Wiley and Sons, Inc; 1998.
Manning C, Raghavan P, Schütze H. Introduction to Information Retrieval. Cambridge: Cambridge University Press; 2008.
Mitchell T. Machine Learning. Liu C, editor. USA: McGraw Hill; 1997.
Jain A, Murty M, Flynn P. Data Clustering. A Review. http://eprints.iisc.ernet.in/273/1/p264-jain.pdf1997. (Accessed 7/10/12).
Duntemann G. Principal Components Analysis. Newbury Park, California: Sage Publications Inc; 1989.
Cryer J, Chan K. Time Series Analysis with Applications in R New York: Springer 2008.
Witten I, Frank E, Hall M. Data mining: practical machine learning tools and techniques, The Morgan Kaufmann series in data management systems. 3rd ed. Burlington, MA: Morgan Kaufmann, Elsevier; 2011.
Cheshire J, Ziebland S. Narrative as a resource in accounts of the experience of illness. In: Thornborrow J, Coates J, editors. The sociolinguistics of narrative. Amsterdam: John Benjamins; 2005.
Martin CM, et al. Patient Journey Record Systems (PaJR): the development of a conceptual framework for a patient journey system. In: Biswas R, Martin CM, editors. User-driven healthcare and narrative medicine: utilizing collaborative social networks and technologies. Hershey, PA: IGI; 2010. p. 75–92.
Boyd CM, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47(5):697–704.
Murray SA, et al. Archetypal trajectories of social, psychological, and spiritual wellbeing and distress in family care givers of patients with lung cancer: secondary analysis of serial qualitative interviews. BMJ. 2010;340:c2581.