The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Holiday sales continue to soar on Cyber Monday

Web shopping soared on Cyber Monday, continuing a strong start to the holiday season.

Online sales were up 26.6 percent from last year by Monday evening, according to IBM Digital Analytics Benchmark, which tracks data from 500 retail sites. ComScore meanwhile, expected online sales to hit a record of about $1.5 billion by day's end.

Cyber Monday has become the biggest online shopping day in recent years as employees head back to the office but continue to cybershop for holiday gifts. The growth of smartphones and tablets has only increased that ability, an opportunity Web retailers have been eager to exploit.

This year, retailers aggressively pushed "Pre-Black Friday" promotions and flooded consumers with emails touting good deals in the days before Thanksgiving. As a result, the big shopping days of Thanksgiving, Black Friday and Cyber Monday have blurred into a sale-laden week.

Some retail analysts had worried that strong online sales growth on Thanksgiving Day and Black Friday would entice shoppers to buy earlier, threatening revenue later in the season.

"So far, that is not the case," said Jay Henderson, the strategy director for IBM Smarter Commerce. "Extending the shopping season has really just fueled additional online spending rather than cannibalizing days later in the season."

Sales across Amazon.com, the largest online retailer, had risen 52 percent from the previous year by midmorning Monday, according to ChannelAdvisor, which offers services to third-party sellers on e-commerce sites. Meanwhile, eBay sales volume increased 57 percent, the firm said.

The average online order size on Cyber Monday was $130.30. That was down from almost $200 during the whole of Cyber Monday last year, according to IBM.

But Monday's discounts on the websites of bricks -and-mortar retailers weren't necessarily as broad or as deep as consumers could find if they shopped in the days before, according to Michael Brim, founder of deal site BFAds.net. "We're not seeing across the board the lowest prices like we do on Black Friday or Thanksgiving," he said. "It's better than the average weekly sales, but it's not on the level of Black Friday … yet," he said.

Most retailers — about 97 percent — were expected to offer Cyber Monday deals this year, up from 90 percent last year, according to the National Retail Federation. That means good deals were there for the finding on sites that might not normally have sales, Brim said.

Laptops and apparel at specialty sites were popular items Monday, Brim said.

Amazon offered $30 off its 7-inch Kindle Fire tablet, which usually sells for $159. The deal was available only on Cyber Monday.

Hoffman Estates-based retailer Sears said it found that a number of its shoppers opted to buy online and pick up merchandise in the store, according to spokesman Tom Aiello, who declined to say whether online traffic increased Monday. Shoppers want "to save on shipping, or they want to touch it — and get it the same day and make sure they've got that gift in their hands," he said.

Tribune news services contributed.

crshropshire@tribune.com

Twitter @corilyns

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Pfleger points police to suspect in fatal stabbing

During an argument with his wife Wednesday, Demetrius Jackson allegedly stabbed to death a 55-year-old man who intervened, then called St. Sabina Catholic Church to pray with the Rev. Michael Pfleger.

Shortly after a Cook County judge ordered Jackson, 32, held without bond on Sunday on a charge of first-degree murder, Pfleger, reached by phone, recounted the conversation he had with Jackson on Friday, a day before he turned himself in.

"He told me the guy who he allegedly stabbed is his best friend," Pfleger said. "He said (the victim) punched him in the face. He told me he just reacted. He asked me to pray with him, and I prayed with him."

Jackson, who lives in Chicago's Roseland neighborhood, hung his head in Cook County Bond Court as a judge said he faced a murder charge in the death of William Terry of the 10300 block of South Forest Avenue.

Jackson and his wife were arguing in their home, also in the 10300 block of South Forest, Wednesday night when he allegedly grabbed a knife and threatened to kill her, prosecutors said. The wife fled to Terry's home and called 911, prosecutors said.

Before police arrived, Jackson's wife and Terry decided to walk back to Jackson's home. Still holding a knife, Jackson confronted the two outside and continued to berate his wife, authorities said. Terry stepped between them, "trying to calm" the defendant, Assistant State's Attorney Brad Dickey said. Terry fell to the ground, and Jackson leapt on top of him, stabbing him multiple times in front of several witnesses, authorities said.

"Terry was able to stagger to his home," Dickey said. Gasping for breath, he collapsed on his front porch. He was taken to Advocate Christ Medical Center in Oak Lawn shortly after 8 p.m. and pronounced dead, according to police. Other county officials said Terry lived in Riverdale.

Jackson, who appears to have no criminal record, worked with St. Sabina on the Safe Passage project, public defender Stephen Herczeg said. A Chicago Public Schools program, Safe Passage employs community members to help improve safety by standing guard along the routes children travel to schools.

When the two spoke, Pfleger encouraged Jackson to turn himself in to police.

"I told him, 'I'm not a court or a lawyer or a judge,'" Pfleger said. "I told him I wouldn't judge him. I just encouraged him to turn himself in and not run. A lot of times, people are afraid to go to the police directly. I said I would try to set it up."

When Jackson agreed, Pfleger said he called police at the Gresham District, telling them of Jackson's intentions.

As promised, Jackson showed up at a police station Friday morning and gave a video-taped confession, according to court documents.

"Thank God it worked," said Pfleger. "It's very sad. I feel bad about the man who got killed, too. It's a loss of two lives."

efmeyer@tribune.com

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Dog bite sidelines ‘Dirty Dozen’ trumpeter Towns

NEW ORLEANS (AP) — Dirty Dozen Brass Band trumpeter Efrem Towns is recovering at home in New Orleans from a vicious attack by a Rottweiler at an Atlanta motel.

He missed performances in Colorado and New Orleans after the attack on Nov. 18, and doesn’t know if he’ll make the band’s next scheduled gig on Dec. 28, The Times-Picayune (http://bit.ly/XOJoNr) reported.

He and baritone sax player Roger Lewis said the dog surged from an open motel room door after Towns knocked on the door of Lewis’ room.

“I didn’t know if it was a dog, wolverine, bear, mongoose or what. I just knew something had me,” Towns said.

He said the dog‘s owner came out of the next room, and they were able to subdue it.

At Atlanta’s Grady Hospital, he received 30 stitches in his groin. Towns, who has health insurance through his wife, Tracie, said he will be seeing a urologist this week.

The Dirty Dozen Brass Band formed in 1977, and is credited with creating the contemporary, funk-infused brass band sound. It’s been featured on albums with David Bowie, Elvis Costello and the Black Crowes.

Towns said he probably could practice while convalescing. “But I’m very uncomfortable right now,” he said Friday evening. “I’m basically immobilized — it’s hard getting around. I’m kind of miserable.”

The experience hasn’t soured Towns on dogs. He and his wife own three miniature schnauzers, a standard schnauzer and a mixed breed. On Friday, his daughter’s dachshund was visiting.

“I’m a dog person,” he said. “And even though I got bit, I hope they don’t put that dog to sleep.”

___

Information from: The Times-Picayune, http://www.nola.com

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Agency Investigates Deaths and Injuries Associated With Bed Rails

Thomas Patterson for The New York Times

Gloria Black’s mother died in her bed at a care facility.

In November 2006, when Clara Marshall began suffering from the effects of dementia, her family moved her into the Waterford at Fairway Village, an assisted living home in Vancouver, Wash. The facility offered round-the-clock care for Ms. Marshall, who had wandered away from home several times. Her husband Dan, 80 years old at the time, felt he could no longer care for her alone.

Thomas Patterson for The New York Times

Gloria Black, visiting her mother’s grave in Portland, Ore. She has documented hundreds of deaths associated with bed rails and said families should be informed of their possible risks.

But just five months into her stay, Ms. Marshall, 81, was found dead in her room apparently strangled after getting her neck caught in side rails used to prevent her from rolling out of bed.

After Ms. Marshall’s death, her daughter Gloria Black, who lives in Portland, Ore., began writing to the Consumer Product Safety Commission and the Food and Drug Administration. What she discovered was that both agencies had known for more than a decade about deaths from bed rails but had done little to crack down on the companies that make them. Ms. Black conducted her own research and exchanged letters with local and state officials. Finally, a letter she wrote in 2010 to the federal consumer safety commission helped prompt a review of bed rail deaths.

Ms. Black applauds the decision to study the issue. “But I wish it was done years ago,” she said. “Maybe my mother would still be alive.” Now the government is studying a problem it has known about for years.

Data compiled by the consumer agency from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults — about 4,000 a year — were treated in emergency rooms with bed rail injuries. Officials at the F.D.A. and the commission said the data probably understated the problem since bed rails are not always listed as a cause of death by nursing homes and coroners, or as a cause of injury by emergency room doctors.

Experts who have studied the deaths say they are avoidable. While the F.D.A. issued safety warnings about the devices in 1995, it shied away from requiring manufacturers to put safety labels on them because of industry resistance and because the mood in Congress then was for less regulation. Instead only “voluntary guidelines” were adopted in 2006.

More warnings are needed, experts say, but there is a technical question over which regulator is responsible for some bed rails. Are they medical devices under the purview of the F.D.A., or are they consumer products regulated by the commission?

“This is an entirely preventable problem,” said Dr. Steven Miles, a professor at the Center for Bioethics at the University of Minnesota, who first alerted federal regulators to deaths involving bed rails in 1995. The government at the time declined to recall any bed rails and opted instead for a safety alert to nursing homes and home health care agencies.

Forcing the industry to improve designs and replace older models could have potentially cost bed rail makers and health care facilities hundreds of million of dollars, said Larry Kessler, a former F.D.A. official who headed its medical device office. “Quite frankly, none of the bed rails in use at that time would have passed the suggested design standards in the guidelines if we had made them mandatory,” he said. No analysis has been done to determine how much it would cost the manufacturers to reduce the hazards.

Bed rails are metal bars used on hospital beds and in home care to assist patients in pulling themselves up or helping them out of bed. They can also prevent people from rolling out of bed. But sometimes patients — particularly those suffering from Alzheimer’s — can get confused and trapped between a bed rail and a mattress, which can lead to serious injury or even death.

While the use of the devices by hospitals and nursing homes has declined as professional caregivers have grown aware of the dangers, experts say dozens of older adults continue to die each year as more rails are used in home care and many health care facilities continue to use older rail models.

Since those first warnings in 1995, about 550 bed rail-related deaths have occurred, a review by The New York Times of F.D.A. data, lawsuits, state nursing home inspection reports and interviews, found. Last year alone, the F.D.A. data shows, 27 people died.

As deaths continued after the F.D.A. warning, a working group put together in 1999 and made up of medical device makers, researchers, patient advocates and F.D.A. officials considered requiring bed rail makers to add warning labels.

But the F.D.A. decided against it after manufacturers resisted, citing legal issues. The agency said added cost to small manufacturers and difficulties of getting regulations through layers of government approval, were factors against tougher standards, according to a meeting log of the group in 2000 and interviews.

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Black Friday sales online top $1 billion for first time

SAN FRANCISCO (Reuters) - Black Friday retail sales online this year topped $1 billion for the first time ever as more consumers used the Internet do their early holiday shopping, comScore Inc said on Sunday.

Online sales jumped 26 percent on Black Friday to $1.04 billion from sales of $816 million on the corresponding day last year, according to comScore data.

Amazon.com was the most-visited retail website on Black Friday, and it also posted the highest year-over-year visitor growth rate among the top five retailers. Wal-Mart Stores Inc's website was second, followed by sites run by Best Buy Co., Target Corp. and Apple Inc, comScore noted.

Digital content and subscriptions, including e-books, digital music and video, was the fastest-growing retail category online, with sales up 29 percent versus Black Friday last year, according to comScore data.

E-commerce accounts for less than 10 percent of consumer spending in the United States. However, it is growing much faster than bricks-and-mortar retail as shoppers are lured by low prices, convenience, faster shipping and wide selection.

ShopperTrak, which counts foot traffic in physical retail stores, estimated Black Friday sales at $11.2 billion, down 1.8 percent from the same day last year.

"Online has been around 9 percent of total holiday sales, but it could breach 10 percent for the first time this season," said Scot Wingo, chief executive of ChannelAdvisor, which helps merchants sell more on websites, including Amazon.com and eBay.com.

ComScore expects online retail spending to rise 17 percent to $43.4 billion through the whole holiday season. That is above the 15 percent increase last season and ahead of the retail industry's expectation for a 4.1 percent increase in overall spending this holiday.

CYBER MONDAY OUTLOOK

It's not clear yet whether strong Black Friday sales online will weaken growth on Cyber Monday, which has been the biggest e-commerce day in the United States in recent years.

"Cyber Monday will be a big day, but not as much of a big day as it has been in the past," said Mia Shernoff, executive vice president for Chase Paymentech, a payment-processing unit of J.P. Morgan Chase & Co.. "Faster broadband Internet connections in the office used to drive this. But now many consumers have faster connections at home and smart phones and tablets - they don't have to wait."

ComScore Chairman Gian Fulgoni said Cyber Monday online sales may reach $1.5 billion this year. That would be up 20 percent from the corresponding day last year - slower year-over-year growth than Thanksgiving and Black Friday.

More than 129 million Americans plan to shop online on Cyber Monday, up from almost 123 million on the same day last year, according to a survey conducted in recent days for the National Retail Federation.

The group also expects 85 percent of retailers to have a special promotion for Cyber Monday.

Amazon, the world's largest Internet retailer, will launch Cyber Monday deals at midnight on Sunday. The company is planning a limited time Cyber Monday promotion for its 7 inch Kindle Fire tablet, offering it at $129 instead of the regular $159, a spokesman said on Sunday.

MOBILE SHOPPING GROWTH

A big source of online shopping growth this holiday season has come from increased use of smart phones, which let people buy online even when they are in physical stores, and by tablet computers, which have spurred more online shopping in the evenings, Wingo and others said.

Mobile devices accounted for 26 percent of visits to retail websites and 16 percent of purchases on Black Friday. That was up from 18.1 percent and 10.3 percent, respectively, on the same day last year, according to International Business Machines, which analyzes online traffic and transactions from 500 U.S. retailers.

More than 20 million shoppers plan to use mobile devices on Cyber Monday, up from 17.8 million a year ago, the NRF said.

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Hard-fought victory assures Irish spot in national title game

LOS ANGELES — Deliverance arrived on a crisp southern California night, welcomed in a frenzy of leaps and hugs and arms wind-milling helmets and cathartic screams. Notre Dame waited decades for this, all right, the end to the interminable search for its long-lost promise. It just needed to climb to the top of college football to find it.

The Irish will play for a national championship in January, inextricably No. 1 and 12-0 after a 22-13 victory over USC before 93,607 witnesses Saturday night at Los Angeles Memorial Coliseum, a sparkling moment of rapture in the City of Angels. Whether Notre Dame is back maybe isn't the point right now. It's that the Irish have arrived.

"We had a dream," linebacker Manti Te'o said, "and we put in the work to make sure that dream came true."

It was a grinding, imperfect but relentless effort Saturday to get there, and maybe there couldn't be any other way. Everett Golson, the redshirt freshman quarterback, cramped up but cut loose for 217 yards passing and was mistake-free. Theo Riddick, the senior tailback who was a slot receiver at this time last year, stampeded to 146 yards and a score.

And the Heisman hopeful, Te'o, picked off another pass and helped spearhead another adrenalized, fourth-quarter goal-line stand that stomped out USC's last hope and created a save-the-date for Jan. 7. There Notre Dame will play in the BCS title game, almost assuredly against the winner of the SEC, becoming the most galvanizing foil yet to that league's dominance.

"The way it's set up, only two teams can play for a national championship," Irish coach Brian Kelly said. "It feels great that you have that opportunity."

One game now, to look upon everyone else from the summit for the first time since 1988.

"Ecstatic," Irish safety Zeke Motta said. "There's no other feeling like it that I could have ever imagined. You think about the hard work and the competing that we did in the offseason, and to witness it pay off, and to be in this position we're in right now, there's no other feeling like it."

There were other, substantially less exultant feelings swirling in the same stadium tunnel a scant four years ago. Athletic director Jack Swarbrick could laugh about that Saturday night: About being pinned against a wall to discuss the downward spiral of the Charlie Weis era then, and being cornered to talk about a head-spinning revival now.

A year after that utter demolition by USC in 2008, Swarbrick made his coaching change and brought in Kelly. He brought in his program-builder. He thought it was the perfect fit. He also thought it would take longer than this.

"I gotta tell you, I always thought it was next year," Swarbrick said. "From Day 1, I thought it was next year. So it's cool. It's cool to be ahead of schedule."

In fact, maybe the only guy not taken aback was the guy responsible for it all.

"You get this far into it, and now you start to look up and go, oh, we're 11-0 — you want to finish it off," Kelly said.

"It's easy to say well, yeah, I'm surprised. But when you go in that locker room and you're around the guys I'm around, you're not surprised. What they've done, the commitment they've made, they've done everything I've asked them to do. Everything. So it doesn't surprise me anymore."

Notre Dame had USC where it wanted the Trojans early, on-heels and tested, on the spot to demonstrate any mettle or desire at the end of a season gone wrong and going nowhere. The Irish thundered to a 10-0 first-quarter lead, first scoring on a Kyle Brindza 27-yard field goal and then a Riddick 9-yard score.

If this was the last hurdle to the BCS title game, it appeared knee-high. But USC showed it could be resolute, swiftly moving to an 11-yard Robert Woods touchdown reception to reignite some drama. From there, it was field goal after field goal after field goal for both sides, a constant thrust and parry, all the way to a Brindza 33-yarder that made it a 19-10 lead entering the fourth quarter.

"We understood that it was going to be a dogfight, and that's what it was," Te'o said.

Then Notre Dame watched in glee as USC coach Lane Kiffin began exacting self-torture. First came the pre-snap timeout that might have wiped out a touchdown catch, only to watch the ensuing pass sail out of the end zone.

And after the fifth Brindza field goal created a two-score cushion with six minutes left, the pain became excruciating. A 53-yard Marqise Lee reception after a long kickoff return set up a goal-to-go situation for the Trojans. Two pass interference penalties put them on the 1-yard line. They ran once. They ran again. They ran again. Then they threw an incomplete pass.

Notre Dame had made its stand, everyone exploding off the sideline and into celebration.

"If you have followed us all year, that's how we play," Kelly said. "We come up big defensively at some time during the game. We did that again."

All that remained were 21/2 minutes to burn. Irish fans in attendance counted down the Coliseum clock, as if it was New Year's Eve.

And then the celebration began, wild and joyous, for a date decades in the making. Players bobbed and chanted in front of the fans. Te'o grabbed Kelly in the tunnel in a spontaneous embrace, telling his coach he loved him.

Notre Dame will play for a national title. A moment so many waited for, and never saw coming.

"I haven't really grasped the whole situation," Riddick said, sitting on a table in a Coliseum tunnel. "What can I say? We're going to Miami."

bchamilton@tribune.com

Twitter @ChiTribHamilton

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‘Gangnam Style’ most watched YouTube video ever

SEOUL, South Korea (AP) — South Korean rapper PSY‘s “Gangnam Style” has become YouTube’s most viewed video of all time.

YouTube says in a posting on its Trends blog that “Gangnam Style” had been viewed 805 million times as of Saturday afternoon, surpassing Justin Bieber‘s “Baby,” which has had 803 million views.

The blog says the “velocity of popularity for PSY’s outlandish video is unprecedented.”

PSY’s video featuring his horse-riding dance was posted on YouTube in July, while “Baby” was uploaded in February 2010.

PSY’s video has become a global sensation, with many people around the world mimicking his “Gangnam Style” dance. In their October meeting, U.N. Secretary-General Ban Ki-moon, a South Korean, joked that he had to relinquish his title as “the most famous Korean,” and tried a few of PSY’s dance moves.

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Rosenthal: Big Ten getting too big for its own good?

There's a lesson the empire builders at Big Ten Conference headquarters in Park Ridge would do well to heed if they can be convinced to stop peering out to the distant horizon:

Growth through acquisition is fraught with peril.

"In the business world you acquire new companies and you have to deal with different corporate cultures, different priorities and so forth," Robert Arnott, chairman of Research Affiliates LLC, an investment firm, said in an interview. "Merging them is often very messy and often fails. Here you're merging two teams into an existing conference and it creates risks. … Even college football teams have different cultures, different ways of thinking about how to win and different standards."

There undoubtedly was a logic behind each acquisition as the old Sears sought to expand and diversify its corporate profile. By the time the Chicago-area company's portfolio grew to include Allstate insurance, Coldwell Banker real estate and Dean Witter Reynolds stock brokerage, it was clear the increase in size was in no way matched by an increase in strength.

Rather than an all-powerful Colossus astride many sectors at once, it was reduced to an unfocused blob, bereft of identity, covering plenty of ground but hardly standing tall. Years after shedding its far-flung holdings, Sears has yet to regain its muscle, mojo or market share.

"It's hard to find a better example of a company that lost its mission and focus in the quest for growth," Arnott said.

"(Growth) may be partly a defensive move. It may be ego driven. In the corporate arena, you certainly see that in spades," he said. "When growth is through acquisition, you have to figure out what the real motivation is. Is it synergy, the most overused word in the finance community, or is it ego?"

Adding the University of Maryland and New Jersey's Rutgers University in 2014 will push the Big Ten to 14 schools and far beyond the Midwestern territory for which it's known. But doing so may not achieve what its backers envision.

Rather than spread the conference's brand, it may merely dilute it. The fit may be corrosive, not cohesive.

There is a school of thought that this is but the latest evidence that the Big Ten is not about athletics, academics or even the Midwest. Instead, it is just a television network, the schools content providers and student-athletes talent.

As it is, the overall TV payout is said to give each of the 12 current Big Ten schools about $21 million per year. They point to the Big Ten's lucrative deals with ESPN and its own eponymous cable network, a partnership with News Corp. They note that public schools Rutgers and Maryland are near enough to New York, Baltimore and Washington, D.C., to drive a better bargain with cable carriers.

To Big Ten Commissioner Jim Delany, a New Jersey native, the addition is more the result of a paradigm shift that has redrawn the college sports map over the past decade. Some conferences splinter. Others seize new turf. The result: Idaho's Boise State football team is poised to join the Big East Conference next year.

"Institutions that get together for academics or athletics have got to be cognizant that they are competing for students, they are competing for student athletes, they are competing for research dollars," Delany told reporters.

"When you see a Southern conference in the Midwest or you see a Southern conference in the Plains states or whether you see other conferences in the Midwest or Northeast, it impacts your recruitment. ... It impacts everything you do," he said. "At a certain point you get to a tipping point. The paradigm has shifted, and you decide on a strategy to basically position yourself for the next decade or half-century."

Big has always meant more than 10 in the Big Ten, an intercollegiate entity formed by seven Midwestern universities that now boasts 12 with the bookends of Penn State and Nebraska added in 1990 and last year, respectively. Last week's announcement of adding schools 13 and 14 was just a reminder that the conference has only had 10 member schools for 70 of its 116 years and won't again for the foreseeable future.

Rutgers President Robert Barchi said his school looked "forward as much to the collaboration and interaction we're going to have as institutions as we do to what I know will be really outstanding competition on our field of play."

But make no mistake, the Big Ten was born out of sports, specifically football. A seven-school 1896 meeting at Chicago's Palmer House had Northwestern among those still stinging from a scathing Harper's Weekly critique of college sports abuses, the Tribune reported at the time.

A prohibition on allowing scholarship and fellowship students to compete was shot down. But "a move towards the coordination of Faculty committees" in terms of standards and enforcement passed and the precursor to the Big Ten was born.

Along the way, the conference has added member schools and come to recognize that the Big Ten's image has much to say about how those institutions are perceived. Scandals already are no stranger to the Big Ten. But whether you play in a stadium or on Wall Street, the bigger one gets, the bigger target one becomes.

"Whoever's biggest draws scrutiny," said Arnott, co-author of a research paper, "The Winners Curse: Too Big to Succeed." "That means politicians, regulators, the general public generally don't root for the biggest. They look to take them down a notch, so it's harder to succeed as the largest. It's also harder to move the dial and move from success to success as you get really big."

Everyone talks about becoming too big to fail, but there's also too big to scale, companies that are unable to capitalize on the efficiencies of their increased size ostensibly because they are so big that they cannot be managed adequately.

"People talk about economies of scale. There are also vast diseconomies of scale, mostly in bureaucracies," Arnott said. "The more people you have involved, the more people you have who feel they have to have their views reflected in whatever's done. So you wind up with innovation by committee."

That's deadly. That's why companies break up, citing the need to get smaller so they can grow.

"If you break up companies into operating entities that are more nimble," Arnott said, "the opportunities to grow are no longer hamstrung by centralized bureaucracies that have to pursue synergies that don't exist."

Size matters in all fields of play. Sometimes smaller is better.

philrosenthal@tribune.com

Twitter @phil_rosenthal

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Larry Hagman dies at 81; TV's J.R. Ewing

Fervor for the television show “Dallas” was intense in 1980, when the Queen Mother met actor Larry Hagman and joined the worldwide chorus asking: “Who shot J.R.?”

“Not even for you, ma’am,” replied Hagman, who portrayed villainous oil baron J.R. Ewing at the center of the popular prime-time soap from 1978 until 1991.

An estimated 300 million viewers in 57 countries had seen J.R. get shot by an unseen assailant, a season-ending plot twist that is credited with popularizing the cliffhanger in television series.

Hagman, who became a television star in the 1960s starring in the sitcom “I Dream of Jeannie,” died Friday at a Dallas hospital, said a spokesman for actress Linda Gray, his longtime co-star on “Dallas.” He was 81.

A year ago, Hagman announced his second bout with cancer. He had spoken candidly about decades of drinking that led to cirrhosis of the liver and, in 1995, a life-saving liver transplant.

“He was the pied piper of life and brought joy to everyone he knew,” Gray said in a statement. “He was creative, generous, funny, loving and talented.... an original and lived life to the full.”

For years, he was considered the unofficial mayor of Malibu, where he lived for decades in an oceanfront home. He often led impromptu ragtag parades on the sand while wearing outlandish costumes and flew a flag from his deck that declared “Vita Celebratio Est” — “Life is a celebration.”

As an actor, Hagman came with a serious pedigree. He was the son of Mary Martin, a legendary star of Broadway musicals best known for originating the role of Peter Pan in the 1950s.

On “Dallas,” Hagman's J.R. Ewing was “the man viewers loved to hate,” according to critics, a scheming Texan in a land of plenty. Much of the show's run paralleled the nation's fascination with big money and big business in the 1980s, and the role made him an international star.

“Here is a man born to play villainy,” former Times TV critic Howard Rosenberg wrote soon after the show's debut. “His performance on ‘Dallas’ is a salute to slime.”

A Texas native, Hagman often said he played the character as a composite of “all those good old boys” he had known growing up, “who caught more flies with honey instead of vinegar.”

He approached the role as “a cartoon,” Hagman once said of the role that earned him two Emmy nominations. “It was outrageous comedy to me.”

By his own admission, Hagman drank his way through “Dallas.” Champagne was “his poison” — he would uncork a bottle by 9 a.m. and keep the bubbly flowing all day. He once poured bourbon on his cornflakes.

“The drinking sometimes made it harder to remember lines, but I liked that constant feeling of being mildly loaded,” Hagman said in 1995 in People magazine.

Diagnosed with cirrhosis of the liver during a checkup in 1992, Hagman said he became an instant teetotaler. After developing a cancerous tumor on his liver, he underwent a liver transplant three years later.

“I'm often asked how my liver transplant operation changed my life. Aside from saving it, nothing changed,” he wrote in his 2001 autobiography, “Hello Darlin’.” “It confirmed what I've always tried to do — live my life as fully as possible before the clock runs out.”

When Hagman arrived in Hollywood in the 1960s, he had already appeared in a half-dozen Broadway plays and spent two years on the daytime television soap opera “The Edge of Night.”

From five television pilots, Hagman chose to read for the part of astronaut Tony Nelson on “I Dream of Jeannie.” Created by Sidney Sheldon, the show plugged into the nation’s space mania and owed a creative debt to another hit series, “Bewitched.”

Jeannie was played by Barbara Eden, who complicates the life of uptight Nelson after he aborts a mission on a desert island and unleashes her character — a magical and alluring genie — from a bottle.

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