A Pharmacist-Led, Patient-Centered Program Incorporating Motivational Interviewing for Behavior Change to Improve Adherence Rates and Star Ratings in a Medicare Plan.

INTRODUCTION:The Medicare 5-star quality rating system was designed to drive improvements in Medicare quality and to increase accountability among Medicare plans. Medicare star ratings provide significant bonuses for plans that improve medication adherence. Envolve's pharmacy division, Envolve Pharmacy Solutions, which provides services for Medicare Advantage Prescription Drug plans, developed an in-house medication therapy management (MTM) program to improve adherence rates and subsequent star ratings. As part of this program, Envolve invested in motivational interviewing (MI) as a means to improve adherence to antihypertensives, antihyperlipidemics, and antidiabetics but recognized the need for additional staff training to ensure pharmacist success with MI techniques. Thus, Envolve engaged a consultant to help train pharmacists and evaluate the program. This best practices article describes the implementation of an MI program and subsequent changes in patient adherence and star ratings. PROGRAM DESCRIPTION:A pharmacist-led, patient-centered adherence program incorporating MI for behavior change was developed and implemented at Envolve. The program used didactic learning, coaching and skills assessments, and a train-the-trainer (TtT) intervention. This approach resulted in improved adherence rates in all 3 therapeutic classes immediately. In addition, a quality improvement process was incorporated to evaluate the improvements in adherence with this new program over 24 months. OBSERVATIONS:Key findings of the program are as follows: (a) the program increased adherence rates 5-9 percentage points (chi-square tests for all plans and drug classes measured, P < 0.05) over 5 years and improved Medicare star ratings by 1-2 stars; (b) there is a need for support of pharmacy MTM managers to ensure continued success of the program; and (c) there is value in a TtT program for managers that allows them to provide continuous evaluation and feedback to staff for improvement. IMPLICATIONS:Each year, as the Medicare star ratings system matures and plans are held more accountable for improving adherence measures, high star ratings become more difficult to attain. This MI TtT program for pharmacists allows for rapid cycle change in response to these challenges. DISCLOSURES:Funding was provided by Envolve Pharmacy Solutions, which contracted with the University of California, San Francisco (UCSF), School of Pharmacy for the development and implementation of the motivational interviewing and train-the-trainer programs described in this best practices article. Spears, Erkens, and Misquitta are employees of Envolve Pharmacy Solutions. Stebbins and Cutler are faculty in the Department of Clinical Pharmacy at the UCSF School of Pharmacy, who were contracted through Envolve Pharmacy Solutions to provide consulting services for this best practice

Expression of inflammation-related genes is associated with adipose tissue location in horses

Background : In humans, adipose tissue (AT) originating from different depots shows varying gene expression profiles. In horses, the risk of certain metabolic disorders may also be influenced by the impact of specific AT depots. Macrophage infiltration in human and rat AT is considered to be a source of inflammatory changes. In horses, this relationship has not been extensively studied yet. Reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR), a useful method to evaluate differences in mRNA expression across different tissues, can be used to evaluate differences between equine AT depots. For a correct interpretation of the RT-qPCR results, expression data have to be normalized by the use of validated reference genes. The main objectives of this study were to compare mRNA expression of inflammation-related genes, as well as adipocyte morphology and number between different equine AT depots; and in addition, to investigate the presence of antigen presenting cells in equine AT and any potential relationship with adipokine mRNA expression. Results : In this study, the mRNA expression of inflammation-related genes (leptin, chemokine ligand 5, interleukin 1β, interleukin 6, interleukin 10, adiponectin, matrix metalloproteinase 2, and superoxide dismutase 2) and candidate reference gene stability was investigated in 8 different AT depots collected from the nuchal, abdominal (mesenteric, retroperitoneal, and peri-renal) and subcutaneous (tail head and loin) AT region. By using GeNorm analysis, HPRT1, RPL32, and GAPDH were found to be the most stable genes in equine AT. The mRNA expression of leptin, chemokine ligand 5, interleukin 10, interleukin 1β, adiponectin, and matrix metalloproteinase 2 significantly differed across AT depots (P 0.05). Adipocyte area and number of antigen presenting cells per adipocyte significantly differed between AT depots (P < 0.05). Conclusions : Adipose tissue location was associated with differences in mRNA expression of inflammation-related genes. This depot-specific difference in mRNA expression suggests that the overall inflammatory status of horses could be partially determined by the relative proportion of the different AT depots

Presence of the ABCB1 (MDR1) deletion mutation causing ivermectin hypersensitivity in certain dog breeds in Belgium

Hypersensitivity to ivermectin and certain other drugs in Collies and related breeds is caused by a 4-base pair deletion mutation in the ABCB1 gene, better known as the MDR1 gene, encoding P-glycoprotein. There is no information available, however, regarding the presence of this mutation in dogs in Belgium. In this study, the ABCB1 genotype was assessed in 92 dogs of breeds suspected to possess the deletion mutation. The results indicated that the mutation was present in the Australian Shepherd, Collie, Shetland Sheepdog and Swiss White Shepherd, but was not detected in the Bearded Collies, Border Collies and German Shepherds of this study, which is in accordance with the findings in similar breed populations of other countries. In Belgium it is therefore important to take the ABCB1 genotype of the breeds involved into account, in order to use drugs in a safe and efficient manner and to improve the selection procedure in dog breeding

Development of a new set of reference genes for normalization of real-time RT-PCR data of porcine backfat and longissimus dorsi muscle, and evaluation with PPARGC1A

BACKGROUND: An essential part of using real-time RT-PCR is that expression results have to be normalized before any conclusions can be drawn. This can be done by using one or multiple, validated reference genes, depending on the desired accuracy of the results. In the pig however, very little information is available on the expression stability of reference genes. The aim of this study was therefore to develop a new set of reference genes which can be used for normalization of mRNA expression data of genes expressed in porcine backfat and longissimus dorsi muscle, both representing an economically important part of a pig's carcass. Because of its multiple functions in fat metabolism and muscle fibre type composition, peroxisome proliferative activated receptor γ coactivator 1α (PPARGC1A) is a very interesting candidate gene for meat quality, and was an ideal gene to evaluate our developed set of reference genes for normalization of mRNA expression data of both tissue types. RESULTS: The mRNA expression stability of 10 reference genes was determined. The expression of RPL13A and SDHA appeared to be highly unstable. After normalization to the geometric mean of the three most stably expressed reference genes (ACTB, TBP and TOP2B), the results not only showed that the mRNA expression of PPARGC1A was significantly higher in each of the longissimus dorsi muscle samples than in backfat (P < 0.05), but also that the expression was significantly higher in the most cranial of the three muscle samples (P < 0.05). CONCLUSION: This study provides a new set of reference genes (ACTB, TBP and TOP2B) suitable for normalization of real-time RT-PCR data of backfat and longissimus dorsi muscle in the pig. The obtained PPARGC1A expression results, after application of this set of reference genes, are a first step in unravelling the PPARGC1A expression pattern in the pig and provide a basis for possible selection towards improved meat quality while maintaining a lean carcass

Molecular cloning and characterization of the porcine prostaglandin transporter (SLCO2A1): evaluation of its role in F4 mediated neonatal diarrhoea

<p>Abstract</p> <p>Background</p> <p>Because prostaglandins are involved in many (patho)physiological processes, <it>SLCO2A1 </it>was already characterized in several species in an attempt to unravel specific processes/deficiencies. Here, we describe the molecular cloning and characterization of the porcine ortholog in order to evaluate its possible involvement in F4 enterotoxigenic <it>E. coli </it>mediated neonatal diarrhoea, based on a positional candidate gene approach study.</p> <p>Results</p> <p>Porcine <it>SLCO2A1 </it>is organized in 14 exons, containing an open reading frame of 1935 bp, encoding a 12-transmembrane organic anion cell surface transporter of 644 aa. The -388 to -5 upstream region comprises a (CpG)₄₈island containing a number of conserved promoter elements, including a TATA box. A potential alternative promoter region was found in the conserved -973 to -700 upstream region. No consensus polyadenylation signal was discovered in the 3' UTR. Repeat sequences were found in 15% of all the non coding sequences.</p> <p>As expected for a multifunctional protein, a wide tissue distribution was observed. mRNA expression was found in the adrenal gland, bladder, caecum, colon (centripetal coil/centrifugal coil), diaphragm, duodenum, gallbladder, heart, ileum, jejunum, kidney, liver, longissimus dorsi muscle, lung, lymph node, mesenterium, rectum, spleen, stomach, tongue and ureter, but not in the aorta, oesophagus and pancreas.</p> <p>The promoter region and the exons (including the splice sites) of <it>SLCO2A1 </it>were resequenced in 5 F4ab/ac receptor positive and 5 F4ab/ac receptor negative pigs. Two silent and 2 missense (both S → L at position 360 and 633) mutations were found, but none was associated with the F4ab/ac receptor phenotype. In addition, no phenotype associated differential mRNA expression or alternative/abberant splicing/polyadenylation was found in the jejunum.</p> <p>Conclusion</p> <p>The molecular cloning and characterization of porcine <it>SLCO2A1 </it>not only contributes to the already existing knowledge about the transporter in general, but enables studies on porcine prostaglandin related processes/deficiencies as patient and/or model. Here we examined its possible involvement as receptor in F4 enterotoxigenic <it>E. coli </it>mediated neonatal diarrhoea. Because no phenotype associated differences could be found in the gene sequence nor in its jejunal transcription profile of F4ab/ac receptor positive/negative pigs, SLCO2A1 can most likely be excluded as receptor for F4 bacteria.</p

Correlation between porcine PPARGC1A mRNA expression and its downstream target genes in backfat and longissimus dorsi muscle

Knowledge of in vivo relationship between the coactivator PPARGC1A and its target genes is very limited, especially in the pig. In this study, a real-time PCR experiment was performed on longissimus dorsi muscle (MLD) and backfat with 10 presumed PPARGC1A downstream target genes, involved in energy and fat metabolism, to identify possible relationships with PPARGC1A mRNA expression in vivo in the pig (n = 20). Except for UCP3 and LPL, a very significant difference in expression was found between MLD and backfat for all genes (P < 0.01). Hierarchical cluster analysis and the significant pairing of mRNA expression data between sampling locations suggested a genetic regulation of the expression of several target genes. A positive correlation with PPARGC1A was found for CPT1B, GLUT4, PDK4, and TFAM (P < 0.0001). A negative correlation was found for UCP2, FABP4, LEP (P < 0.0001), and TNT (P = 0.0071). No significant correlation was detected for UCP3 and LPL. This study provides evidence for a clear difference in mRNA expression of crucial genes in fat and energy metabolism between 2 important tissues. Our data suggest a clear impact of PPARGC1A on energy and lipid metabolism in vivo in the pig, through several of these downstream target genes