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1.  Comparative Effectiveness of Antihypertensive Therapeutic Classes and Treatment Strategies In Initiation of Therapy In Primary Care Patients: A Distributed Ambulatory Research in Therapeutics Network (DARTNet) Study 
Few comparative effectiveness studies of treatment strategies of the use of antihypertensive therapeutic classes in hypertension control have been assessed in a primary care environment.
1) To compare the effectiveness of common antihypertensive therapeutic classes initiated as monotherapy in control of hypertension; and 2) To compare the effectiveness of fixed-dose combinations (FDC), free-equivalent combinations (FEC) and monotherapy on hypertension control.
Observational comparative effectiveness analyses of data electronically extracted from the electronic health records.
The study population consisted of 8,676 patients with an incident prescription for an antihypertensive agent out of 79,176 patients receiving antihypertensive therapy under care in 33 geographically diverse primary care clinics.
Main Measures
Reductions in systolic (SBP) and diastolic (DBP) blood pressure and rates of JNC7 goal attainment.
Key Results
There were small, clinically insignificant differences in BP reductions between the monotherapy classes. Higher rates of BP control were obtained when patients were initiated on an angiotensin-converting-enzyme inhibitor than a thiazide or thiazide-like diuretic (47.8% vs. 39.9%) or a beta-blocker versus a thiazide (45.9% vs. 39.9%). Patients initiated on FDCs had significantly larger reductions in BP than patients initiated on FECs (−17.3 vs. −12.0 mm Hg SBP; −10.1 vs. −6.0 mm Hg DBP) or monotherapy (−17.3 vs. −13.6 mm Hg SBP; −10.1 vs. −7.9 mm Hg DBP). Rates of JNC7 goal attainment also were better for FDCs than FECs (57.2% vs. 42.5%) and for FDCs versus monotherapy (57.2% vs. 44.9%).
Patients initiated on ACEIs and Beta-blockers had slightly higher rates of BP control. The use of FDCs as initial therapy is more effective in the control of hypertension than monotherapy or FECs.
PMCID: PMC3918237  PMID: 24004705
2.  Circulating adiponectin levels are lower in Latino versus non-Latino white patients at risk for cardiovascular disease, independent of adiposity measures 
Latinos in the United States have a higher prevalence of type 2 diabetes than non-Latino whites, even after controlling for adiposity. Decreased adiponectin is associated with insulin resistance and predicts T2DM, and therefore may mediate this ethnic difference. We compared total and high-molecular-weight (HMW) adiponectin in Latino versus white individuals, identified factors associated with adiponectin in each ethnic group, and measured the contribution of adiponectin to ethnic differences in insulin resistance.
We utilized cross-sectional data from subjects in the Latinos Using Cardio Health Actions to reduce Risk study. Participants were Latino (n = 119) and non-Latino white (n = 60) men and women with hypertension and at least one other risk factor for CVD (age 61 ± 10 yrs, 49% with T2DM), seen at an integrated community health and hospital system in Denver, Colorado. Total and HMW adiponectin was measured by RIA and ELISA respectively. Fasting glucose and insulin were used to calculate the homeostasis model insulin resistance index (HOMA-IR). Variables independently associated with adiponectin levels were identified by linear regression analyses. Adiponectin's contribution to ethnic differences in insulin resistance was assessed in multivariate linear regression models of Latino ethnicity, with logHOMA-IR as a dependent variable, adjusting for possible confounders including age, gender, adiposity, and renal function.
Mean adiponectin levels were lower in Latino than white patients (beta estimates: -4.5 (-6.4, -2.5), p < 0.001 and -1.6 (-2.7, -0.5), p < 0.005 for total and HMW adiponectin), independent of age, gender, BMI/waist circumference, thiazolidinedione use, diabetes status, and renal function. An expected negative association between adiponectin and waist circumference was seen among women and non-Latino white men, but no relationship between these two variables was observed among Latino men. Ethnic differences in logHOMA-IR were no longer observed after controlling for adiponectin levels.
Among patients with CVD risk, total and HMW adiponectin is lower in Latinos, independent of adiposity and other known regulators of adiponectin. Ethnic differences in adiponectin regulation may exist and future research in this area is warranted. Adiponectin levels accounted for the observed variability in insulin resistance, suggesting a contribution of decreased adiponectin to insulin resistance in Latino populations.
PMCID: PMC3141565  PMID: 21736747
3.  Pulse wave velocity and carotid atherosclerosis in White and Latino patients with hypertension 
Preventive cardiology has expanded beyond coronary heart disease towards prevention of a broader spectrum of cardiovascular diseases. Ethnic minorities are at proportionately greater risk for developing extracoronary vascular disease including heart failure and cerebrovascular disease.
We performed a cross sectional study of Latino and White hypertension patients in a safety-net healthcare system. Framingham risk factors, markers of inflammation (hsCRP, LPpLA2), arterial stiffness (Pulse wave velocity, augmentation index, and central aortic pressure), and endothelial function (brachial artery flow-mediated dilatation) were measured. Univariate and multivariable associations between these parameters and an index of extracoronary atherosclerosis (carotid intima media thickness) was performed.
Among 177 subjects, mean age was 62 years, 67% were female, and 67% were Latino. In univariate analysis, markers associated with carotid intima media thickness (IMT) at p < 0.25 included pulse wave velocity (PWV), augmentation index (AIx), central aortic pressure (cAP), and LpPLA2 activity rank. However, AIx, cAP, and LpPLA2 activity were not significantly associated with carotid IMT after adjusting for Framingham risk factors (all p > .10). Only PWV retained a significant association with carotid IMT independent of the Framingham general risk profile parameters (p = .016). No statistically significant interactions between Framingham and other independent variables with ethnicity (all p > .05) were observed.
In this safety net cohort, PWV is a potentially useful adjunctive atherosclerotic risk marker independent of traditional risk factors and irrespective of ethnicity.
PMCID: PMC3080337  PMID: 21481252
Pulse wave velocity; hypertension; atherosclerosis; carotid intima media thickness; Latino; inflammatory markers; augmentation index; central aortic pressure; C-reactive protein
4.  Validation of a Patient-Level Medication Regimen Complexity Index as a Possible Tool to Identify Patients for Medication Therapy Management Intervention 
Pharmacotherapy  2014;34(8):826-835.
The Medication Regimen Complexity Index (MRCI) is a 65-item instrument that can be used to quantify medication regimen complexity at the patient level, capturing all prescribed and over-the-counter medications. Although the MRCI has been used in several studies, the narrow scope of the initial validation limits application at a population or clinical practice level.
To conduct a MRCI validation pertinent to the desired clinical use to identify patients for medication therapy management interventions.
An expert panel of clinical pharmacists ranked medication regimen complexity for two samples of cases: a single-disease cohort (diabetes mellitus) and a multiple-disease cohort (diabetes mellitus, hypertension, human immunodeficiency virus infection, geriatric depression). Cases for expert panel review were selected from 400 ambulatory clinic patients, and each case description included data that were available via claims or electronic medical records (EMRs). Construct validity was assessed using patient-level MRCI scores, medication count, and additional patient data. Concordance was evaluated using weighted κ agreement statistic, and correlations were determined using Spearman rank-order correlation coefficient (ρ) or Kendall τ.
Moderate to good concordance between patient-level MRCI scores and expert medication regimen complexity ranking was observed (claims data, consensus ranking: single-disease cohort 0.55, multiple disease cohort 0.63). In contrast, only fair to moderate concordance was observed for medication count (single-disease cohort 0.33, multiple-disease cohort 0.48). Adding more-detailed administration directions from EMR data did not improve concordance. MRCI convergent validity was supported by strong correlations with medication count (all cohorts 0.90) and moderate correlations with morbidity measures (e.g., all cohorts; number of comorbidities 0.46, Chronic Disease Score 0.46). Nonsignificant correlation of MRCI scores with age and gender (all cohorts 0.08 and 0.06, respectively) supported MRCI divergent validity.
This study used cross-sectional, retrospective patient data for a small number of patients and clinical pharmacists from only two universities; therefore, results may have limited generalizability.
The patient-level MRCI is a valid tool for assessing medication regimen complexity that can be applied by using data commonly found in claims and EMR databases and could be useful to identify patients who may benefit from medication therapy management.
PMCID: PMC4260116  PMID: 24947636
medication regimen complexity; MRCI; complexity; medication therapy management; MTM; geriatrics; hypertension; diabetes; human immunodeficiency virus; HIV; chronic disease

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