The patient's medication access journey: a conceptual framework focused beyond adherence.

BACKGROUND: It is well known that medication accessibility reduces morbidity and mortality and increases health-related quality of life; however, despite efforts to improve health care access, many Americans still face challenges in accessing medications. Several health care access and utilization conceptual frameworks have been created and used for decades to illustrate key relationships and interdependencies between elements of the system. However, none of these frameworks have focused exclusively on medication access and associated factors. Medication access is a complex, multidimensional issue that must consider not only patient-specific challenges, but also health system limitations, among others. A better understanding of medication access, beyond the proxy marker of adherence, is needed to identify opportunities to improve accessibility. OBJECTIVE: To develop a conceptual framework that defines a patient's medication access journey and characterizes barriers frequently encountered while seeking medication access. METHODS: A multistakeholder roundtable composed of 15 experts from across the health care continuum was convened in 2018 by the Pharmacy Quality Alliance to develop a conceptual framework for medication access. The roundtable participants were convened through in-person and telephonic meetings. To inform their work, 2 literature reviews and an environmental scan were conducted to identify medication access barriers, interventions affecting medication access, and medication access quality measures. RESULTS: The resulting framework included 7 nodes that represent the major access points encountered by patients when attempting to access medications: perceived need, help seeking, encounter, prescribing, prescription adjudication, prescription dispensing, and adherence. Also, 18 barriers were identified. Patient health literacy, cost, insurance, and organizational health literacy were predominant barriers across multiple nodes. CONCLUSIONS: The framework that was developed provides a patient-focused, holistic view of medication access, incorporating access nodes and corresponding barriers. It also provides a structure to consider key opportunities for interventions and measurement to address medication access challenges. DISCLOSURES: This study was conducted with grant support from the National Pharmaceutical Council, which served as a collaborator in the study. Westrich is employed by the National Pharmaceutical Council. Nelson is employed by the Pharmacy Quality Alliance, which was contracted to conduct this study. Pickering, Campbell, and Holland were employed by the Pharmacy Quality Alliance at the time of this study. This research was presented as a professional poster at the American Public Health Association Annual Meeting in October 2019, Philadelphia, PA.

Nutritional Evaluation of an EPA-DHA Oil from Transgenic Camelina sativa in Feeds for Post-Smolt Atlantic Salmon (Salmo salar L.).

Vegetable oils (VO) are possible substitutes for fish oil in aquafeeds but their use is limited by their lack of omega-3 (n-3) long-chain polyunsaturated fatty acids (LC-PUFA). However, oilseed crops can be modified to produce n-3 LC-PUFA such as eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, representing a potential option to fill the gap between supply and demand of these important nutrients. Camelina sativa was metabolically engineered to produce a seed oil with around 15% total n-3 LC-PUFA to potentially substitute for fish oil in salmon feeds. Post-smolt Atlantic salmon (Salmo salar) were fed for 11-weeks with one of three experimental diets containing either fish oil (FO), wild-type Camelina oil (WCO) or transgenic Camelina oil (DCO) as added lipid source to evaluate fish performance, nutrient digestibility, tissue n-3 LC-PUFA, and metabolic impact determined by liver transcriptome analysis. The DCO diet did not affect any of the performance or health parameters studied and enhanced apparent digestibility of EPA and DHA compared to the WCO diet. The level of total n-3 LC-PUFA was higher in all the tissues of DCO-fed fish than in WCO-fed fish with levels in liver similar to those in fish fed FO. Endogenous LC-PUFA biosynthetic activity was observed in fish fed both the Camelina oil diets as indicated by the liver transcriptome and levels of intermediate metabolites such as docosapentaenoic acid, with data suggesting that the dietary combination of EPA and DHA inhibited desaturation and elongation activities. Expression of genes involved in phospholipid and triacylglycerol metabolism followed a similar pattern in fish fed DCO and WCO despite the difference in n-3 LC-PUFA contents.

Modulation of selenium tissue distribution and selenoprotein expression in Atlantic salmon (Salmo salar L.) fed diets with graded levels of plant ingredients.

Increased substitution of marine ingredients by terrestrial plant products in aquafeeds has been proven to be suitable for Atlantic salmon farming. However, a reduction in n-3 long-chain PUFA is a consequence of this substitution. In contrast, relatively little attention has been paid to the effects of fishmeal and oil substitution on levels of micronutrients such as Se, considering fish are major sources of this mineral for human consumers. To evaluate the effects of dietary marine ingredient substitution on tissue Se distribution and the expression of Se metabolism and antioxidant enzyme genes, Atlantic salmons were fed three feeds based on commercial formulations with increasing levels of plant proteins (PP) and vegetable oil. Lipid content in flesh did not vary at any sampling point, but it was higher in the liver of 1 kg of fish fed higher PP. Fatty acid content reflected dietary input and was related to oxidation levels (thiobarbituric acid-reactive substances). Liver had the highest Se levels, followed by head kidney, whereas the lowest contents were found in brain and gill. The Se concentration of flesh decreased considerably with high levels of substitution, reducing the added value of fish consumption. Only the brain showed significant differences in glutathione peroxidase, transfer RNA selenocysteine 1-associated protein 1b and superoxide dismutase expression, whereas no significant regulation of Se-related genes was found in liver. Although Se levels in the diets satisfied the essential requirements of salmon, high PP levels led to a reduction in the supply of this essential micronutrient.

Influence of dietary oil content and conjugated linoleic acid (CLA) on lipid metabolism enzyme activities and gene expression in tissues of Atlantic salmon (Salmo salar L.).

The overall objective is to test the hypothesis that conjugated linoleic acid (CLA) has beneficial effects in Atlantic salmon as a result of affecting lipid and FA metabolism. The specific aims of the present study were to determine the effects of CLA on some key pathways of FA metabolism, including FA oxidation and highly unsaturated FA (HUFA) synthesis. Salmon smolts were fed diets containing two levels of fish oil (low, approximately 17%, and high, approximately 34%) containing three levels of CLA (a 1:1 mixture of cis-9,trans-11 and trans-10,cis-12 at 0, 1, and 2% of diet) for 3 mon. The effects of dietary CLA on HUFA synthesis and beta-oxidation were measured, and the expression of key genes in the FA oxidation and HUFA synthesis pathways, and the potentially important transcription factors peroxisome proliferators activated receptors (PPAR), were determined in selected tissues. Liver HUFA synthesis and desaturase gene expression was increased by dietary CLA and decreased by high dietary oil content. Carnitine palmitoyltransferase-I (CPT-I) activity and gene expression were generally increased by CLA in muscle tissues although they were relatively unaffected by dietary oil content. In general CPT-I activity or gene expression was not correlated with P-oxidation. Dietary CLA tended to increase PPARalpha and beta gene expression in both liver and muscle tissues, and PPARgamma in liver. In summary, gene expression and activity of the FA pathways were altered in response to dietary CLA and/or oil content, with data suggesting that PPAR are also regulated in response to CLA. Correlations were observed between dietary CLA, liver HUFA synthesis and desaturase gene expression, and liver PPARalpha expression, and also between dietary CLA, CPT-I expression and activity, and PPARalpha expression in muscle tissues. In conclusion, this study suggests that dietary CLA has effects on FA metabolism in Atlantic salmon and on PPAR transcription factors. However, further work is required to assess the potential of CLA as a dietary supplement, and the role of PPAR in the regulation of lipid metabolism in fish.

Influence of dietary conjugated linoleic acid (CLA) on lipid and fatty acid composition in liver and flesh of Atlantic salmon (Salmo salar).

The aim of the present study was to determine the effects of conjugated linoleic acid (CLA) on lipid and fatty acid metabolism in Atlantic salmon. The overall objective being to test the hypotheses that CLA has beneficial effects in salmon including growth enhancement, improved flesh quality through decreased adiposity and lipid deposition thereby minimising detrimental effects of feeding high fat diets, and increased nutritional quality through increased levels of beneficial fatty acids including n-3 highly unsaturated fatty acids (HUFA) and CLA itself. Salmon smolts were fed diets containing two levels of fish oil (low, approximately 18% and high, approximately 34%) containing three levels of CLA (a 1:1 mixture of 9-cis,trans-11 and trans-10,cis-12. at 0, 1 and 2% of diet) for 3 months and the effects on growth performance, liver and muscle (flesh) lipid contents and class compositions, and fatty acid compositions determined. The diets were also specifically formulated to investigate whether the effects of CLA, if any, were more dependent upon absolute content of CLA in the diet (as percentage of total diet) or the relative level of CLA to other fatty acids. Dietary CLA in salmon smolts had no effect on growth parameters or biometric parameters. However, there was a clear trend of increased total lipid and triacylglycerol contents in both liver and flesh in fish fed CLA, particularly in fish fed the high oil diets. Finally, CLA was incorporated into tissue lipids, with levels in flesh being 2-fold higher than in liver, but importantly, incorporation in liver was at the expense of saturated and monounsaturated fatty acids whereas in flesh it was at the expense of n-3HUFA.

Effects of water temperature and diets containing palm oil on fatty acid desaturation and oxidation in hepatocytes and intestinal enterocytes of rainbow trout (Oncorhynchus mykiss).

Food grade fisheries have reached their sustainable limits while aquaculture production has increased to meet consumer demands. However, for growth in aquaculture to continue and utilise sustainable, feeding ingredients, alternatives to fish oil (FO), the predominant lipid component of fish diets, must be developed. Therefore, there is currently considerable interest in the regulation of fatty acid metabolism in fish in order to determine strategies for the best use of plant oils in diets for commercially important cultured fish species. Plant oils are characteristically rich in C18 polyunsaturated fatty acids (PUFA) but devoid of C20 and C22 highly unsaturated fatty acids (HUFA) found in FO. The fatty acyl desaturase enzyme activities involved in the biosynthesis of HUFA from PUFA are known to be under nutritional regulation and can be increased in fish fed diets rich in plant oils. However, fatty acid desaturase activity is also known to be modulated by water temperature in fish. The present study aimed to investigate the interaction between water temperature and diet in the regulation of fatty acid metabolism in rainbow trout. Trout, acclimatized to 7, 11 or 15 degrees C, were fed for 4 weeks on diets in which the FO was replaced in a graded manner by palm oil. At the end of the trial, fatty acyl desaturation/elongation and beta-oxidation activities were determined in isolated hepatocytes and intestinal enterocytes using [1-14C]18:3n-3 as substrate, and samples of liver were collected for analysis of lipid and fatty acid composition. The most obvious effect of temperature was that fatty acid desaturation/elongation and beta-oxidation were reduced in both hepatocytes and intestinal enterocytes from fish maintained at the highest water temperature (15 degrees C). There were differences between the two tissues with the highest desaturation/elongation and beta-oxidation activities tending to be in fish held at 11 degrees C in the case of hepatocytes, but 7 degrees C in enterocytes. Correlations between fatty acid metabolism and dietary palm oil were most clearly observed in desaturation/elongation activities in both hepatocytes and enterocytes at 11 degrees C. The highest beta-oxidation activities were generally observed in fish fed FO alone in both hepatocytes and enterocytes with palm oil having differential effects in the two cell types.

Interactive effects of dietary palm oil concentration and water temperature on lipid digestibility in rainbow trout, Oncorhynchus mykiss.

An experiment was conducted to evaluate the interactive effects of dietary crude palm oil (CPO) concentration and water temperature on lipid and FA digestibility in rainbow trout. Four isolipidic diets with 0, 5, 10, or 20% (w/w) CPO, at the expense of fish oil, were formulated and fed to groups of trout maintained at water temperatures of 7, 10, or 15 degrees C. The apparent digestibility (AD) of the FA, measured using yttrium oxide as an inert marker, decreased with increasing chain length and increased with increasing unsaturation within each temperature regimen irrespective of CPO level fed to the fish. PUFA of the n-3 series were preferentially absorbed compared to n-6 PUFA in all diet and temperature treatments. Except for a few minor FA, a significant (P < 0.05) interaction between diet and temperature effects on FA digestibility was found. Increasing dietary levels of CPO lead to significant reductions in the AD of saturates and, to a lesser extent, also of the other FA. Lowering water temperature reduced total saturated FA digestibility in trout regardless of CPO level. Based on the lipid class composition of trout feces, this reduction in AD of saturates was due in part to the increasing resistance of dietary TAG to digestion. Increasing CPO level and decreasing water temperature significantly increased TAG content in trout fecal lipids, with saturates constituting more than 60% of the FA composition. Total monoene and PUFA digestibilities were not significantly affected by water temperature in fish fed up to 10% CPO in their diet. The potential impact of reduced lipid and FA digestibility in cold-water fish fed diets supplemented with high levels of CPO on fish growth performance requires further research.