Physician- versus practice-level primary care continuity and association with outcomes in Medicare beneficiaries.

OBJECTIVE: To compare physician-level versus practice-level primary care continuity and their association with expenditure and acute care utilization among Medicare beneficiaries and evaluate whether continuity of outpatient primary care at either/both physician or/and practice level could be useful quality measures. DATA SOURCE: Medicare Fee-For-Service claims data for community dwelling beneficiaries without end-stage renal disease who were attributed to a national random sample of primary care practices billing Medicare (2011-2017). STUDY DESIGN: Retrospective secondary data analysis at per Medicare beneficiary per year level. We used multivariable linear regression with practice-level fixed effects to estimate continuity of care score at physician versus practice level and their associations with outcomes. DATA COLLECTION/EXTRACTION METHOD: We calculated clinician- and practice-level Bice-Boxerman continuity of care index scores, ranging from 0 to 1, using primary care outpatient claims. Medicare expenditures, hospital admissions, emergency department (ED) visits, and readmissions were obtained from the Medicare Beneficiary Summary File: Cost and Utilization Segment. Ambulatory care sensitive conditions (ACSC) were defined using diagnosis codes on inpatient claims. PRINCIPAL FINDINGS: We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditure per beneficiary per year (p < 0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (p < 0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, ED visit, admissions for ACSC, and readmission. CONCLUSIONS: Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice-level continuity.

Measuring State-Level Racial Inequity in Severe Maternal Morbidity in the Medicaid Population.

OBJECTIVE: Severe maternal morbidity represents a "near miss" mortality and is an important measure of quality and safety. Racial inequity in maternal morbidity is stark and the reasons for this disparity are poorly understood. We aimed to identify states achieving racial equity in maternal morbidity in order to identify policies that may promote racial equity. METHODS: We analyzed Medicaid deliveries from 2008 to 2009 in a sample that included 28 states and the District of Columbia. This dataset included approximately 80% of all Medicaid enrollees and 90% of minority Medicaid enrollees in the US. We determined the Non-Hispanic Black/Non-Hispanic white SMMI rate ratio for each state and categorized the states into groups by rate ratio. We described demographic features of both the general population and study population for these groups of states. RESULTS: In a sample that included a total of 1,489,134 births, we found that no state/district is achieving equity in severe maternal morbidity. The severe maternal morbidity rate is higher for Non-Hispanic Black than Non-Hispanic white patients in every state included. With a rate ratio ranging from 1.14 to 2.66, there are varying degrees of inequity. States in the group with the most equitable maternal morbidity rates had less inequity across racial subgroups with respect to educational attainment and poverty. CONCLUSIONS: Identifying geographic areas with varying degrees of inequity may be key to identifying policies to promote equity. Socioecological disparities and inadequate access to care may be factors in racial inequity in maternal morbidity.

Physicochemical and Storage Characteristics of Hanwoo Tteokgalbi Treated with Onion Skin Powder and Blackcurrant Powder.

We evaluated the physicochemical and storage characteristics of Hanwoo Tteokgalbi treated with onion skin powder (OSP) and blackcurrant fruit powder (BFP). The experimental design included seven treatments: a control (ascorbic acid 0.1%), T1: OSP 0.3%, T2: OSP 0.6%, T3: BFP 0.3%, T4: BFP 0.6%, T5: OSP 0.15%+BFP 0.15%, and T6: OSP 0.3%+BFP 0.3%. The OSP was higher in both polyphenol and flavonoid contents compared to BFP (p<0.05). The moisture and ash contents of all Tteokgalbi samples with a large amount of added natural antioxidant powder (0.6%) were higher than those with small amounts of added antioxidant (0.3%). The cooking loss and water holding capacity were outstanding in the T2 treatment compared to the others (p<0.05). The lightness, redness, and yellowness values were reduced on the addition of 0.6% antioxidant powder (p<0.05). The springiness and cohesiveness values of the Tteokgalbi samples were higher for the 0.3% addition than the control and 0.6% addition (p<0.05). The Tteokgalbi samples with natural antioxidants showed similar sensory attribute scores compared to the control. The pH values reduced as the BFP increased (p<0.05), and the total microbial count increased after OSP addition. The 2-thiobarbituric acid reactive substance values of the samples treated with OSP were significantly lower than the control after day 10 (p<0.05). As a result, the addition of OSP or BFP did not have a significant negative influence on the quality characteristics of Hanwoo Tteokgalbi. In particular, the addition of 0.6% OSP was effective in increasing water retentivity and inhibiting lipid oxidation.

Effect of Rice Bran and Wheat Fibers on Microbiological and Physicochemical Properties of Fermented Sausages during Ripening and Storage.

This study investigated the effect of rice bran fiber (RBF) and wheat fibers (WF) on microbiological and physicochemical properties of fermented sausages during ripening and storage. The experimental design included three treatments: Control, no addition; RBF, 1.5%; and WF, 1.5%. During the ripening periods, the addition of dietary fibers rapidly decreased pH and maintained high water activity values of fermented sausages (p<0.05). Lactic acid bacteria were more prevalent in fermented sausages with rice bran fiber than control and sausages with added wheat fiber. During cold storage, lower pH was observed in sausages with dietary fibers (p<0.05), and the water activity and color values were reduced as the storage period lengthened. Fermented sausages containing dietary fibers were higher in lactic acid bacteria counts, volatile basic nitrogen and 2-thiobarbituric acid reactive substance values compared to the control (p<0.05). The results indicate that, the addition of dietary fibers in the fermented sausages promotes the growth of lactic bacteria and fermentation, and suggests that development of functional fermented sausages is possible.

Medicaid use by documented and undocumented farm workers.

BACKGROUND: Despite considerable debate surrounding the use of Medicaid by undocumented immigrants, few studies address the extent of this use or estimate differences in the use between documented and undocumented households. METHOD: We analyzed data from the National Agricultural Workers Survey annual cross sections from 1993 through 2009, N = 41,342. Simple mean differences and logistic regressions predicted participation in Medicaid over 2-year intervals. RESULTS: Without adjustments for covariates, 12.2% of undocumented farm workers' households and 22.6% of documented households received Medicaid benefits, corresponding to an odds ratio of 0.48 (95% confidence interval, 0.33 to 0.69). By adding only covariates reflecting presence of children in the household, the odds ratio increased to 0.86 (95% confidence interval, 0.73 to 1.02). CONCLUSIONS: Undocumented farm workers' households were roughly half as likely to use Medicaid as documented households, and undocumented households' participation was especially responsive to the presence of children.

Characterization and application of enterocin RM6, a bacteriocin from Enterococcus faecalis.

Use of bacteriocins in food preservation has received great attention in recent years. The goal of this study is to characterize enterocin RM6 from Enterococcus faecalis OSY-RM6 and investigate its efficacy against Listeria monocytogenes in cottage cheese. Enterocin RM6 was purified from E. faecalis culture supernatant using ion exchange column, multiple C18-silica cartridges, followed by reverse-phase high-performance liquid chromatography. The molecular weight of enterocin RM6 is 7145.0823 as determined by mass spectrometry (MS). Tandem mass spectrometry (MS/MS) analysis revealed that enterocin RM6 is a 70-residue cyclic peptide with a head-to-tail linkage between methionine and tryptophan residues. The peptide sequence of enterocin RM6 was further confirmed by sequencing the structural gene of the peptide. Enterocin RM6 is active against Gram-positive bacteria, including L. monocytogenes, Bacillus cereus, and methicillin-resistant Staphylococcus aureus (MRSA). Enterocin RM6 (final concentration in cottage cheese, 80 AU/mL) caused a 4-log reduction in population of L. monocytogenes inoculated in cottage cheese within 30 min of treatment. Therefore, enterocin RM6 has potential applications as a potent antimicrobial peptide against foodborne pathogens in food.

Inactivation of barotolerant strains of Listeria monocytogenes and Escherichia coli O157:H7 by ultra high pressure and tert-butylhydroquinone combination.

Antimicrobial efficacy of ultra-high-pressure (UHP) can be enhanced by application of additional hurdles. The objective of this study was to systematically assess the enhancement in pressure lethality by TBHQ treatment, against barotolerant strains of Escherichia coli O157:H7 and Listeria monocytogenes. Two L. monocytogenes Scott A and the barotolerant OSY-328 strain, and two E. coli O157:H7 strains, EDL-933 and its barotolerant mutant, OSY-ASM, were tested. Cell suspensions containing TBHQ (50 ppm, dissolved in dimethyl sulfoxide) were pressurized at 200 to 500 MPa (23+/-2 degrees C) for 1 min, plated on tryptose agar and enumerated the survivors. The TBHQ-UHP combination resulted in synergistic inactivation of both pathogens, with different degrees of lethality among strains. The pressure lethality threshold, for the combination treatment, was lower for E. coli O157:H7 (> or = 200 MPa) than for L. monocytogenes (> 300 MPa). E. coli O157:H7 strains were extremely sensitive to the TBHQ-UHP treatment, compared to Listeria strains. Interestingly, a control treatment involving DMSO-UHP combination consistently resulted in higher inactivation than that achieved by UHP alone, against all strains tested. However, sensitization of the pathogens to UHP by the additives (TBHQ in DMSO) was prominently greater for UHP than DMSO. Differences in sensitivities to the treatment between these two pathogens may be attributed to discrepancies in cellular structure or physiological functions.

Genes of Escherichia coli O157:H7 that are involved in high-pressure resistance.

Seventeen Escherichia coli O157:H7 strains were treated with ultrahigh pressure at 500 MPa and 23 +/- 2 degrees C for 1 min. This treatment inactivated 0.6 to 3.4 log CFU/ml, depending on the strain. The diversity of these strains was confirmed by pulsed-field gel electrophoresis (PFGE) analysis, and there was no apparent association between PFGE banding patterns and pressure resistance. The pressure-resistant strain E. coli O157:H7 EC-88 (0.6-log decrease) and the pressure-sensitive strain ATCC 35150 (3.4-log decrease) were treated with a sublethal pressure (100 MPa for 15 min at 23 +/- 2 degrees C) and subjected to DNA microarray analysis using an E. coli K-12 antisense gene chip. High pressure affected the transcription of many genes involved in a variety of intracellular mechanisms of EC-88, including the stress response, the thiol-disulfide redox system, Fe-S cluster assembly, and spontaneous mutation. Twenty-four E. coli isogenic pairs with mutations in the genes regulated by the pressure treatment were treated with lethal pressures at 400 MPa and 23 +/- 2 degrees C for 5 min. The barotolerance of the mutants relative to that of the wild-type strains helped to explain the results obtained by DNA microarray analysis. This study is the first report to demonstrate that the expression of Fe-S cluster assembly proteins and the fumarate nitrate reductase regulator decreases the resistance to pressure, while sigma factor (RpoE), lipoprotein (NlpI), thioredoxin (TrxA), thioredoxin reductase (TrxB), a trehalose synthesis protein (OtsA), and a DNA-binding protein (Dps) promote barotolerance.

Use of phenolic compounds for sensitizing Listeria monocytogenes to high-pressure processing.

Three Listeria monocytogenes strains (Scott A, OSY-8578, and OSY-328) that differ considerably in barotolerance were grown to stationary phase and suspended individually in phosphate buffer (pH 7.0). Twelve phenolic compounds, including commercially used food additives, were screened for the ability to sensitize L. monocytogenes to high-pressure processing (HPP). Each L. monocytogenes strain was exposed to each of the 12 phenolic compounds (100 ppm each) for 60 min; this was followed by a pressure treatment at 400 MPa for 5 min. Six phenolic compounds increased the efficacy of HPP against L. monocytogenes but tert-butylhydroquinone (TBHQ) was the most effective. The additives alone at 100 ppm were not lethal for L. monocytogenes. Subsequently, the three L. monocytogenes strains were exposed to TBHQ before or after pressure treatments at 400 or 500 MPa for 5 min. When TBHQ was added after the pressure treatment, the combined treatment was more lethal than was pressure alone. However, the lethality attributable to TBHQ was greater when the additive was applied before rather than after pressure treatment. The inactivation kinetics of the L. monocytogenes strains at 300, 500, and 700 MPa, in the presence or absence of TBHQ, was investigated. All survivor plots showed non-linear inactivation kinetics, but tailing behavior was most pronounced when HPP was used alone. Combinations of TBHQ and HPP eliminated tailing behavior when survivors were monitored by direct plating or an enrichment procedure. Pressure and phenolic additives are apparently a potent bactericidal combination against L. monocytogenes.

Inactivation of barotolerant Listeria monocytogenes in sausage by combination of high-pressure processing and food-grade additives.

Food-grade additives were used to enhance the efficacy of high-pressure processing (HPP) against barotolerant Listeria monocytogenes. Three strains of L. monocytogenes (Scott A, OSY-8578, and OSY-328) were compared for their sensitivity to HPP, nisin, tert-butylhydroquinone (TBHQ), and their combination. Inactivation of these strains was evaluated in 0.2 M sodium phosphate buffer (pH 7.0) and commercially sterile sausage. A cell suspension of L. monocytogenes in buffer (10(9) CFU/ml) was treated with TBHQ at 100 ppm, nisin at 100 IU/ml, HPP at 400 MPa for 5 min, and combinations of these treatments. Populations of strains Scott A, OSY-8578, and OSY-328 decreased 3.9, 2.7, and 1.3 log with HPP alone and 6.4, 5.2, and 1.9 log with the HPP-TBHQ combination, respectively. Commercially sterile sausage was inoculated with the three L. monocytogenes strains (10(6) to 10(7) CFU/g) and treated with selected combinations of TBHQ (100 to 300 ppm), nisin (100 and 200 ppm), and HPP (600 MPa, 28 degrees C, 5 min). Samples were enriched to detect the viability of the pathogen after the treatments. Most of the samples treated with nisin, TBHQ, or their combination were positive for L. monocytogenes. HPP alone resulted in a modest decrease in the number of positive samples. L. monocytogenes was not detected in any of the inoculated commercial sausage samples after treatment with HPP-TBHQ or HPP-TBHQ-nisin combinations. These results suggest that addition of TBHQ or TBHQ plus nisin to sausage followed by in-package pressurization is a promising method for producing Listeria-free ready-to-eat products.