Instrumental variable methods to assess quality of care the marginal effects of process-of-care on blood pressure change and treatment costs

Background: Hypertension is poorly controlled. Team-based care and changes in the process of care have been proposed to address these quality problems. However, assessing care processes is difficult because they are often confounded even in randomized behavioral studies by unmeasured confounders based on discretion of health care providers. Objective: To evaluate the effects of process measures including number of counseling sessions about lifestyle modification and number of antihypertensive medications on blood pressure change and payer-perspective treatment costs. Methods: Data were obtained from two prospective, cluster randomized controlled clinical trials (Trial A and B) implementing physician-pharmacist collaborative interventions compared with usual care over six months in community-based medical offices in the Midwest. Multivariate linear regression models with both instrumental variable methods and as-treated methods were utilized. Instruments were indicators for trial and study arms. Models of blood pressure change and costs included both process measures, demographic variables, and clinical variables. Results: The analysis included 496 subjects. As-treated methods showed no significant associations between process and outcomes. The instruments used in the study were insufficient to simultaneously identify distinct process effects. However, the post-hoc instrumental variable models including one process measure at a time while controlling for the other process demonstrated significant associations between the processes and outcomes with estimates considerably larger than as-treated estimates. Conclusions: Instrumental variable methods with combined randomized behavioral studies may be useful to evaluate the effects of different care processes. However, substantial distinct process variation across studies is needed to fully capitalize on this approach. Instrumental variable methods focusing on individual processes provided larger and stronger outcome relationships than those found using as-treated methods which are subject to confounding

MPA 260, Capstone, Fall 2014

69 pagesProfessor Allen Zagoren DO, MP

Systems Level Metabolic Phenotype of Methotrexate Administration in the Context of Non-alcoholic Steatohepatitis in the Rat.

Adverse drug reactions (ADRs) represent a significant clinical challenge with respect to patient morbidity and mortality. We investigated the hepatotoxicity and systems level metabolic phenotype of methotrexate (MTX) in the context of a prevalent liver disease; non-alcoholic steatohepatitis (NASH). A nuclear magnetic resonance spectroscopic-based metabonomic approach was employed to analyze the metabolic consequences of MTX (0, 10, 40, and 100 mg/kg) in the urine and liver of healthy rats (control diet) and in a model of NASH (methionine-choline deficient diet). Histopathological analysis confirmed baseline (0 mg/kg) liver necrosis, liver inflammation, and lipid accumulation in the NASH model. Administration of MTX (40 and 100 mg/kg) led to liver necrosis in the control cohort, whereas the NASH cohort also displayed biliary hyperplasia and liver fibrosis (100 mg/kg), providing evidence of the synergistic effect of MTX and NASH. The complementary hepatic and urinary metabolic phenotypes of the NASH model, at baseline, revealed perturbation of multiple metabolites associated with oxidative and energetic stress, and folate homeostasis. Administration of MTX in both diet cohorts showed dose-dependent metabolic consequences affecting gut microbial, energy, nucleobase, nucleoside, and folate metabolism. Furthermore, a unique panel of metabolic changes reflective of the synergistic effect of MTX and NASH was identified, including the elevation of hepatic phenylalanine, urocanate, acetate, and both urinary and hepatic formiminoglutamic acid. This systems level metabonomic analysis of the hepatotoxicity of MTX in the context of NASH provided novel mechanistic insight of potential wider clinical relevance for further understanding the role of liver pathology as a risk factor for ADRs

Platinum(II) and palladium(II) metallomacrocycles derived from cationic 4,4 '-bipyridinium, 3-aminopyrazinium and 2-aminopyrimidinium ligands

A series of cationic, ditopic N-donor ligands based on 4,4-bipyridine (4,4-bipy), 3-aminopyrazine (apyz) and 2-aminopyrimidine (apym), each incorporating two positively-charged N-heterocycles linked by a conformationally-flexible spacer unit, have been synthesised and treated with palladium(II) or platinum(II) precursors [M(2,2-bipy)(NO3)2] (M = Pd(II) or Pt(II)) to form highly cationic metallocyclic species. Treatment of 1,6-bis(4,4-bipyridinium)hexane nitrate with [M(2,2-bipy)(NO3)2] in aqueous solution, followed by the addition of KPF6, resulted in the formation of the [2+2] species [M2(2,2-bipy)2{4,4-bipy(CH2)64,4-bipy}2](PF6)8. Treatment of [Pd(PhCN)2Cl2] with 1,3-bis(4,4-bipyridinium)propane hexafluorophosphate in MeCN afforded [Pd2Cl4{4,4-bipy(CH2)34,4-bipy}2](PF6)4. When the cationic apyz or apym ligands were used in aqueous solution, the analogous metallomacrocycles did not form. Instead, deprotonation of the exocyclic amino group occurred upon coordination of the ligand to afford a tetranuclear [4+2] species in the case of platinum(II), with Pt(II)Pt(II) bonding supported by strong UV-vis absorption at = 428 nm which was assigned to a metal-metal-to-ligand charge transfer (MMLCT) band. Thus, treatment of 1,6-bis(3-aminopyrazinium)hexane nitrate with [Pt(2,2-bipy)(NO3)2], followed by the addition of KPF6, led to the formation of the red species [Pt4(2,2-bipy)4{apyz(CH2)6apyz–2H}2](PF6)8. No related products could be identified with palladium(II), consistent with the low propensity for this metal ion to form strong Pd(II)Pd(II) bonding interaction

Challenges of Corn Stover Transportation

Stover has the potential to be a very useful byproduct of corn. Corn stover uses: Feedstock for cellulosic ethanol; Fuel source for power plants; Animal bedding. Benefits of corn stover: Inexpensive; Readily available in Iowa. Who can stover benefit? Farmers who can make money by selling stover; Buyers have access to cheap, eco-friendly material

Presidential Agenda Rhetoric in the State of the Union Address: Obama and Trump

Previous research has illustrated that presidents will make many promises along the campaign trail and those promises are what build their agenda and hopefully get them elected. Once elected their agenda continues to be built through speeches. Researchers have compiled the campaign promises of previous administrations and tracked the completion of those promises. They have both tracked the completion of promises and good faith attempts at completing promises. In this paper, I analyze good faith attempts at keeping the promise on their agenda through presidential rhetoric in State of the Union Addresses. Presidents speak to Congress and the public on many occasions, most notably in their annual required State of the Union Address. The State of the Union Address signals to Congress what the president’s goals and expectations are for the year to come, as well as bragging about their accomplishments and making promises to the public. Studies have shown that when presidents speak on issues of salience and complexity, they have more legislative success in those policy areas

What I believe about leadership and education : a reflective essay

An effective leader for educational change must recognize that change is a process, not a destination, and be able to instill continuing leadership in others. The leader must first be able to develop a leadership team through which responsibilities can be distributed. Second, the leader must recognize what type of change is necessary. With those factors identified, it is the leader\u27s responsibility to identify the magnitude of the work to be accomplished, what level of change must occur, and to then adjust their management style accordingly. Throughout the process, the leader must work to develop the leadership abilities of those on the team. In the end, the measure of a leader is not what they can personally accomplish; rather, the extent to which those involved can carry on leadership roles to impact change that will continue to increase student achievement in the future