First Report of a Phytoplasma Strain in the Elm Yellows Group (16SrV) associated with Virginia Creeper in Maryland, USA.

Virginia creeper (Parthenocissus quinquefolia [L.] Planch.) is a deciduous flowering vine in the Vitaceae family. Native to eastern North America, it is often used ornamentally as a climbing vine or as ground cover due to its rapid growth and foliage color in the fall. In July of 2022, along exterior walls of a private property in Lanham, MD, two Virginia creeper (VC) vines were observed displaying symptoms of yellow mottling and premature reddening of leaves. To investigate the cause of these symptoms, two symptomatic leaf samples and one asymptomatic leaf samples from a third vine in the same vicinity were collected for further analysis. A Qiagen DNeasy Plant Mini Kit was used to extract total DNA from leaf tissues according to the manufacturer's instructions. A phytoplasma-specific real-time PCR (Hodgetts et al. 2009) was used to test the DNA extracts, which detected the presence of phytoplasmas in the two DNA samples derived from symptomatic vines. The near full-length of the 16S ribosomal RNA gene was then amplified by seminested PCR from these samples with primers P1/16S-SR followed by P1A/16S-SR (Deng, and Hiruki 1991; Lee et al. 2004) and Sanger sequenced using primers P1A and 16S-SR. Analysis of the obtained 16S rDNA sequences revealed no variation between the two plant samples, and one sequence was deposited in GenBank representing the phytoplasma strain named VC-MD1 (GenBank PP746981). A BLASTn search of the 16S rRNA gene sequence in the NCBI nucleotide database, showed 99.93% sequence identity with the phytoplasma strain AldY-WA1 (GenBank MZ557341) from red alder in Washington, a phytoplasma associated with VC plants in southern Florida (GenBank AF305198) (Harrison et al. 2001), and other strains detected in grapevines in Europe described as "flavescence dorée" phytoplasma (GenBank AF176319) (Davis, and Dally 2001). The virtual restriction fragment length polymorphism pattern derived from iPhyClassifier (Zhao et al. 2009), indicated that VC-MD1 is indeed a member of the 16SrV-C phytoplasma subgroup. To confirm the identification, the partial spc operon and the partial tuf gene were amplified as previously described (Lee et al. 2010; Makarova et al. 2012). Specifically, the spc operon region was amplified using a nested PCR approach with primer set L15F1A-a/MapR1 followed by L15F1A-b/MapR1A-b. Sequence data obtained from the two loci were deposited to GenBank with accession numbers PP746982 (spc) and PP746983 (tuf). BLAST searches querying the nucleotide sequences of the spc operon and tuf gene showed 95.39% and 99.05% identity, respectively, to the corresponding loci of 'Candidatus Phytoplasma rubi' strain RS (GenBank CP114006) and hemp dogbane yellows phytoplasma strain HD1 (GenBank FR686506). Phylogenetic analysis based on secY and tuf gene sequences suggest that the VC-MD1 strain is evolutionary closest to 16SrV-C phytoplasma strains detected in various hosts in the United States, including HD1 and AldY-WA1. These North American strains cluster together on a distinct branch within the elm yellows group phytoplasmas. For the State of Maryland, this detection represents the first report of a phytoplasma strain member of the16SrV-C subgroup infecting VC plants. A phytoplasma of the same subgroup was previously detected in Florida in asymptomatic VC vines (Harrison et al. 2001). The 16S rRNA gene sequences of the two VC phytoplasma strains are nearly identical, differing by just a single nucleotide. The disease transmission vectors of the VC-MD1 strain and the prevalence of the disease in the region remains undetermined.

Widespread exposure to anticoagulant rodenticides among common urban mesopredators in Chicago.

Anticoagulant rodenticides (ARs) are currently the most common method to control rats in cities, but these compounds also cause morbidity and mortality in non-target wildlife. Little attention has been focused on AR exposure among mesopredators despite their ecological role as scavengers and prey for larger carnivores, thus serving as an important bridge in the biomagnification of rodenticides in food webs. In this study, we sampled liver tissue from raccoons (Procyon lotor; n = 37), skunks (Mephitis mephitis; n = 15), and Virginia opossums (Didelphis virginiana; n = 45) euthanized by pest professionals and brown rats (Rattus norvegicus; n = 101) trapped in alleys in Chicago, USA to evaluate how often these species are exposed to ARs. We tested whether mesopredators had a higher prevalence of ARs and to more AR compounds compared to rats and calculated biomagnification factors (mean concentration in mesopredators/rats) as indicators of biomagnification. Of 93 sampled mesopredators, 100 % were exposed to at least one AR compound, mainly brodifacoum (≥80 %), and 79 % were exposed to multiple AR compounds. We also documented teal stomach contents consistent with the consumption of rat bait and altricial young tested positive to the same AR as their mother, suggesting mammary transfer. Of the 101 rats, 74 % tested positive to at least one AR compound and 32 % were exposed to multiple AR compounds. All mesopredator species had biomagnification factors exceeding 1.00 for brodifacoum (6.57-29.07) and bromadiolone (1.08-4.31). Our results suggest widespread exposure to ARs among urban mesopredators and biomagnification of ARs in mesopredators compared to rats. Policies that limit AR availability to non-target species, such as restricting the sale and use of ARs to licensed professionals in indoor settings, education on alternatives, and more emphasis on waste management may reduce health risks for urban wildlife and people in cities around the world.

Cytotoxic Activity of Lepidium virginicum L. Methanolic Extract on Human Colorectal Cancer Cells, Caco-2, through p53-Mediated Apoptosis.

Colorectal cancer (CRC) is the third most common type of cancer worldwide. Its treatment options have had a limited impact on cancer remission prognosis. Therefore, there is an ongoing need to discover novel anti-cancer agents. Medicinal plants have gained recognition as a source of anti-cancer bioactive compounds. Recently, ethanolic extract of L. virginicum stems ameliorated dinitrobenzene sulfonic acid (DNBS)-induced colitis by modulating the intestinal immune response. However, no scientific study has demonstrated this potential cytotoxic impact on colon cancer cells. The objective of this study was to evaluate the cytotoxic effect of the methanolic extract of L. virginicum (ELv) on a human colorectal adenocarcinoma cell line (Caco-2) and to identify and quantify the phenolic compounds present in ELv extracts by liquid chromatography-mass spectrometry analysis. The cytotoxic activity was assessed using cell viability assays by reduction in the compound 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and lactate dehydrogenase (LDH). MTT and LDH assays revealed that the ELv decreases cell viability in the Caco-2 cell line in a concentration-dependent manner. Cell death was a result of DNA fragmentation and p53-mediated apoptosis. Eight phenolic acids and five flavonoids were identified and quantified in the stems. In conclusion, our findings demonstrate that the extract of L. virginicum possesses cytotoxic properties on Caco-2 cell line, suggesting that it could be a potential source of new drugs against CRC.

An evaluation of a new rapid qPCR test for the detection of 2019-novel coronavirus nucleocapsid (N1) gene in wastewater in Roanoke and Salem VA sewersheds.

The COVID-19 pandemic initiated public interest in wastewater-based epidemiology (WBE). Public and private entities responded to the need to produce timely and accurate data. LuminUltra and Hach partnered to provide a rapid, field-based quantitative polymerase chain reaction (qPCR) test for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in wastewater. This study evaluates the Hach GeneCount SARS-CoV-2 Wastewater RT-qPCR Assay Kit and LuminUltra GeneCount® Q-16 RT-PCR instrument. The Hach LuminUltra methods were compared to the Promega Wizard® Enviro Total Nucleic Acid kit and Bio-Rad CFX Opus 96 Real-time PCR Detection System. Over a 12-week period, wastewater samples were collected weekly from seven locations in the Roanoke/Salem, VA sewersheds. Concentration and extraction of the viral RNA were followed by qPCR analysis. The target gene for detection was the nucleocapsid gene (N1) of the SARS-CoV-2 virus. Costs, ease of use, time to produce results, sample preparation, and data comparisons were considered. The comparison determined that the Hach LuminUltra method and instrument were more affordable, consumed less time, and required less technical expertise. While the new method was specific, it had low sensitivity. This evaluation suggests the Hach LuminUltra method should be reserved for limited situations requiring onsite field analysis where data accuracy is not essential.

Chi-Squared Automatic Interaction Detection Decision Tree Analysis of Social Determinants for Low Birth Weight in Virginia.

This study provides additional context to the literature regarding the social inequities that impact birth outcomes in Virginia using a decision tree analysis. Chi-squared automatic interaction detection data analysis (CHAID) was performed using data from the Virginia birth registry for the years 2015-2019. Birth weight was the outcome variable, while sociodemographic factors and maternity care deserts were the explanatory variables. The prevalence of low birth weight in Virginia was of 8.1%. The CHAID decision tree model demonstrated multilevel interaction among risk factors with three levels, with a total of 34 nodes. All the variables reached significance in the model, with race/ethnicity being the first major predictor variable, each category of race and ethnicity having different significant predictors, followed by prenatal care and maternal education in the next levels. These findings signify modifiable risk factors for low birth weight, in prioritizing efforts such as programs and policies. CHAID decision tree analysis provides an effective approach to detect target populations for further intervention as pathways derived from this decision tree shed light on the different predictors of high-risk population in each of the race/ethnicity demographic categories in Virginia.

Using the social cognitive theory to examine spontaneous attempts to quit illicit substance use.

Rural areas in the US exhibit high rates of illicit substance use. This study aimed to investigate the Social Cognitive Theory factors associated with spontaneous attempts to quit illicit substance use in a sample of users. A cross-sectional survey was administered through face-to-face interviews. Data was collected from adult (≥ 18 years of age) current illicit substance users who were not receiving professional addiction treatment. Binary logistic regression analyses were utilized to answer the research question. Data from 230 illicit substance users met the eligibility criteria. The mean age was 38 years, whereas the average history of illicit substance use was 14 years. Users with a higher perceived value of quitting illicit substance use were significantly more likely to attempt to quit use spontaneously. Health behavior interventions that incorporate the perceived value of quitting illicit substance use can be effective in encouraging spontaneous attempts to quit illicit substance use.

The Need to Consider Food Systems in Health-Oriented Food Policy and Programs.

Produce prescription programs (PPPs) are place-based interventions at the intersection of public health and local food advocacy. These programs have expanded significantly across the United States since 2010, particularly taking off in the state of West Virginia. This article draws on a 4-y institutional ethnography of PPP programs and associated policy. Although the possibilities of building support for improving community health alongside the livelihoods of small-scale producers is compelling, there exists an overall decontextualization from broader social and political determinants of health. This article concludes that although programs are able to meet some acute needs for program participants and provide income for small-scale producers, this decontextualization results from a lack of consideration of wider systems within policy and program construction, leading to missed opportunities for food system transformation.

Generous dissonance and wanderings: form and politics in Virginia Woolf's Mrs. Dalloway and Ali Smith's Hotel World.

This essay looks at, and compares, Hotel World by Ali Smith and Mrs. Dalloway by Virginia Woolf and attempts to understand the differences within both the formal and philosophical/political outlook of the two works. Presuming stream-of-consciousness as both a set of formal prosaic styles and a genre, the essay argues that the way the novels utilize formal style is indicative of their individual politics in counterintuitive ways. Furthermore, it argues that by looking at these two novels we can begin to map a lineage of queer stream-of-consciousness works and explore how those perspectives have changed over time.

Epidemiology of Hepatitis C infection in pregnancy: Patterns and trends in West Virginia using statewide surveillance data.

BACKGROUND: The increasing rate of Hepatitis C virus (HCV) infection has been attributed to the substance use epidemic. There is limited data on the current rates of the paralleling HCV epidemic. OBJECTIVES: To estimate the prevalence of maternal HCV infection in West Virginia (WV) and identify contributing factors. METHODS: Population-based retrospective cohort study of all pregnant individual(s) who gave birth in WV between 01/01/2020 to 01/30/2024 (N = 69,925). Multiple log-binomial regression models were used to estimate the adjusted risk ratio (ARR) and the 95% confidence intervals (CI). RESULTS: The rate of maternal HCV infection was 38 per 1,000 deliveries. The mean age of pregnant individual(s) with HCV was 29.99 (SD 4.95). The risk of HCV was significantly higher in White vs. minority racial groups [ARR 1.93 (1.50, 2.49)], those with less than [ARR 1.57 (1.37, 1.79)] or at least high school [ARR 1.31 (1.17, 1.47)] vs. more than high school education, those on Medicaid [ARR 2.32 (1.99, 2.71)] vs. private health insurance, those residing in small-metro [ARR 1.32 (1.17, 1.48)] and medium-metro [ARR 1.41 (1.24, 1.61)], vs. rural areas, and those who smoked [ARR 3.51 (3.10, 3.97)]. HCV risk was highest for those using opioids [ARR 4.43 (3.95, 4.96)]; followed by stimulant use [ARR = 1.79 (1.57, 2.04)]. CONCLUSIONS: Our findings highlight that maternal age, race, education, and type of health insurance are associated with maternal HCV infection. The magnitude of association was highest for pregnant individual(s) who smoked and used opioids and stimulants during pregnancy in WV.

Enhancing human resilience against climate change: Assessment of hydroclimatic extremes and sea level rise impacts on the Eastern Shore of Virginia, United States.

Coastal regions face climate-induced threats that have likely increased over the past four decades. In this work, we quantify the future climate impacts on hydroclimatic extremes in the risk-prone, 15-m-above-sea-level Eastern Shore of Virginia (ESVA) region, utilizing the Sixth International Coupled Model Intercomparison Project (CMIP6) Assessment Report 6 (AR6) and General Circulation Models (GCMs). We incorporate historical data on demographics and disasters, land use land cover (LULC), Landsat imagery, and sea level rise (SLR) to better understand and highlight the correlation between hydroclimatic extremes and societal components in this region. The hydrological model Soil and Water Assessment Tool (SWAT), Standardized Precipitation Index (SPI), Normalized Difference Water Index (NDWI), and Interquartile Range (IQR) method have been used to evaluate the intensity and frequency of projected climate extremes, in which SLR projections under different greenhouse gas emission pathways are temporally and spatially quantified. Our findings include (1) a trend towards wetter conditions is found with an increase in the number of flood events and up to an 8.9 % rise in the severity of flood peaks compared to the 2003-2020 period; (2) current coastal high-risk regions, identified using historical data of natural disasters, demographics, and LULC, are projected to be more susceptible to future climate impacts; and (3) low-lying coastal towns and regions are identified as currently vulnerable to coastal and SLR-induced flooding and are projected to become even more susceptible by 2100. This is the first effort that provides a valuable scientific basis for anticipated shifts in future climate patterns, essential for natural hazard prevention in ESVA. It highlights the need for authorities and decision-makers to plan and implement adaptive strategies and sustainable policies for the ESVA region and other coastal areas across the United States.

Manganese exposure from spring and well waters in the Shenandoah Valley: interplay of aquifer lithology, soil composition, and redox conditions.

Manganese (Mn) is of particular concern in groundwater, as low-level chronic exposure to aqueous Mn concentrations in drinking water can result in a variety of health and neurodevelopmental effects. Much of the global population relies on drinking water sourced from karst aquifers. Thus, we seek to assess the relative risk of Mn contamination in karst by investigating the Shenandoah Valley, VA region, as it is underlain by both karst and non-karst aquifers and much of the population relies on water wells and spring water. Water and soil samples were collected throughout the Shenandoah Valley, to supplement pre-existing well water and spring data from the National Water Information System and the Virginia Household Water Quality Program, totaling 1815 wells and 119 springs. Soils were analyzed using X-ray fluorescence and Mn K-Edge X-ray absorption near-edge structure spectroscopy. Factors such as soil type, soil geochemistry, and aquifer lithology were linked with each location to determine if correlations exist with aqueous Mn concentrations. Analyzing the distribution of Mn in drinking water sources suggests that water wells and springs within karst aquifers are preferable with respect to chronic Mn exposure, with < 4.9% of wells and springs in dolostone and limestone aquifers exceeding 100 ppb Mn, while sandstone and shale aquifers have a heightened risk, with > 20% of wells exceeding 100 ppb Mn. The geochemistry of associated soils and spatial relationships to various hydrologic and geologic features indicates that water interactions with aquifer lithology and soils contribute to aqueous Mn concentrations. Relationships between aqueous Mn in spring waters and Mn in soils indicate that increasing aqueous Mn is correlated with decreasing soil Mn(IV). These results point to redox conditions exerting a dominant control on Mn in this region.

"Fighting demons": Stigma and shifting norms in explicit mention of overdose in obituaries, 2010-2019.

Obituaries are often the only published record of an individual's life and elicit community reactions, including stigmatization. Because obituaries are typically written by the bereaved, their content reflects the writer's perceptions of mores governing the social context of the next-of-kin and decedent. When a cause of death is stigmatized, it can influence the way the bereaved write the obituary. However, what constitutes a stigmatized cause of death may change as larger societal discourses of morality shift and conditions or events become framed differently. Using a sample of obituaries (N = 210) from obituary aggregator Legacy.com of "off-time," or premature, deaths in West Virginia from 2010, 2015, 2017, and 2019, this article explores whether the presentation of overdose deaths in obituaries changes alongside the shift in the public framing of the opioid crisis as medical rather than criminal. I find obituaries including terms associated with drug use and overdose become both more common and explicit over the course of the study period. This suggests that the shift in public framing of the opioid crisis from criminalization to medicalization corresponds with a decrease in drug stigmatization in obituaries. Obituary analysis can be a useful means of exploring the stigmatization of other controversial causes of death, such as suicide, cirrhosis, and lung cancer.

Surveying the Knowledge and Practices of Primary Care Residents in Managing Adult Patients with Obesity.

BACKGROUND: The prevalence of obesity is increasing worldwide at an alarming rate, yet obesity remains under-addressed during clinic encounters. A lack of training in how to treat obesity is one crucial factor contributing to this deficiency. OBJECTIVE: This study explored resident physicians' perceptions of their education on obesity and its relationship with confidence and practice behaviors when caring for patients with obesity. DESIGN: A survey was distributed to residency directors to share with residents in their programs. Participation was voluntary and anonymous. Data was collected over a 3-month period. PARTICIPANTS: Residents in Family Medicine and Internal Medicine programs in West Virginia and Indiana who saw adult patients in an ambulatory care setting. MAIN MEASURES: The electronic survey queried the presence of a formal curriculum on Obesity Medicine (OM) and each resident's knowledge, confidence, practice behaviors, and attitudes pertaining to OM. KEY RESULTS: The survey was distributed to 490 residents in 12 programs. Response rate was 22.9% (112 resident physicians). All respondents felt that medical training in obesity should be strengthened. Residents who reported having a formal curriculum on OM were more likely than those without a curriculum to rate their confidence as "high" when discussing weight (35.0% vs. 16.7%, p = 0.03) and when counseling patients about diet and nutrition (37.5% vs. 18.1%, p = 0.02). They also more frequently reported learning enough from faculty to manage obesity (65.0% vs. 29.2%, p < 0.001). Residents with an OM curriculum reported discussing obesity as a problem with patients (100.0% vs. 86.1%, p = 0.01), and completing motivational interviews (90.0% vs. 58.3%, p = < 0.001), more frequently than their peers without a curriculum. CONCLUSIONS: Residents with a formal OM curriculum were more confident in addressing and discussing obesity with patients. Formal training in OM will strengthen resident training to better address and treat patients with obesity.

Identifying Strategies for Strengthening the Health Care Workforce in the Commonwealth of Virginia.

Like the United States as a whole, Virginia faces a significant shortage of health care workers in nursing, primary care, and behavioral health. If current trends persist, these shortages will increase across Virginia. The authors of this study identify interventions that can help the Virginia Health Workforce Development Authority (VHWDA) address these health care workforce shortages. To accomplish this goal, they applied an analytic framework to existing or potential interventions for retaining, recruiting, and improving the structural efficiency of the nursing, primary care, and behavioral health workforces in Virginia. In this study, they highlight which interventions VHWDA should prioritize based on its desired outcomes and policy goals.

Nomenclatural history of Megalonyx Jefferson, 1799 (Mammalia, Xenarthra, Pilosa, Megalonychidae).

Both authorship and spelling of the extinct giant sloth genus Megalonyx and its type species, M.jeffersonii (Mammalia, Xenarthra, Pilosa, Megalonychidae), have been inconsistent. The genus-group name has been cited with two different authorships and three dates, and it has been spelled with two different suffixes. The species-group name has been cited with four different authors and dates, and it has been spelled with two different endings. Megalonyx Jefferson, 1799 is the first valid use of the genus-group name; the correct original spelling has the -onyx suffix. The type species of Megalonyx is Megatheriumjeffersonii Desmarest, 1822; the correct original spelling has an -ii ending. A vernacular word, megalonyx, refers to species classified in the genus Megalonyx Jefferson, 1799.

The COVID-19 pandemic and its impact on the development of gestational diabetes mellitus (GDM) in West Virginia.

OBJECTIVE: To examine the rate of gestational diabetes mellitus (GDM) prevalence before and during the COVID-19 pandemic. RESULTS: Analysis revealed that GDM prevalence was significantly higher during the COVID-19 pandemic compared to pre-pandemic (8.59 % vs 7.77 %). The risk of GDM was 12 % higher during the pandemic vs. pre-pandemic (aRR = 1.12, 95 % CI 1.06, 1.19) and the aRD = 0.95 % (95 % CI 0.56 %, 1.33 %) adjusting for maternal age and substance use in pregnancy. CONCLUSIONS: GDM rates in WV increased from the period directly before the COVID-19 pandemic to during the COVID-19 pandemic. More research is needed to understand the pathophysiological mechanisms of pandemics and pandemic-related risk factors for this observed association. Supporting pregnant individuals during such events is critical to both maternal and child health.

Geographic Variation and Environmental Predictors of Nontuberculous Mycobacteria in Laboratory Surveillance, Virginia, USA, 2021-20231.

Because epidemiologic and environmental risk factors for nontuberculous mycobacteria (NTM) have been reported only infrequently, little information exists about those factors. The state of Virginia, USA, requires certain ecologic features to be included in reports to the Virginia Department of Health, presenting a unique opportunity to study those variables. We analyzed laboratory reports of Mycobacterium avium complex (MAC) and M. abscessus infections in Virginia during 2021-2023. MAC/M. abscessus was isolated from 6.19/100,000 persons, and 2.37/100,000 persons had MAC/M. abscessus lung disease. M. abscessus accounted for 17.4% and MAC for 82.6% of cases. Saturated vapor pressure was associated with MAC/M. abscessus prevalence (prevalence ratio 1.414, 95% CI 1.011-1.980; p = 0.043). Self-supplied water use was a protective factor (incidence rate ratio 0.304, 95% CI 0.098-0.950; p = 0.041). Our findings suggest that a better understanding of geographic clustering and environmental water exposures could help develop future targeted prevention and control efforts.

Access to MAT: Participants' Experiences With Transportation, Non-Emergency Transportation, and Telehealth.

INTRODUCTION: Access to medication assisted treatment (MAT) for opioid use disorder (OUD) in the United States is a significant challenge for many individuals attempting to recover and improve their lives. Access to treatment is especially challenging in rural areas characterized by lack of programs, few prescribers, and transportation barriers. This study aims to better understand the roles that transportation, Medicaid-funded non-emergency medical transportation (NEMT), and telehealth play in facilitating access to MAT in West Virginia (WV). METHODS: We developed this survey using an exploratory sequential mixed methods approach following a review of current peer-reviewed literature plus information gained from 3 semi-structured interviews and follow-up discussions with 5 individuals with lived experience in MAT. Survey results from 225 individuals provided rich context on the influence of transportation in enrolling and remaining in treatment, use of NEMT, and experiences using telehealth. Data were collected from February through August 2021. RESULTS: We found that transportation is a significant factor in entering into and remaining in treatment, with 170 (75.9%) respondents agreeing or strongly agreeing that having transportation was a factor in deciding to go into a MAT program, and 176 (71.1%) agreeing or strongly agreeing that having transportation helps them stay in treatment. NEMT was used by one-quarter (n = 52, 25.7%) of respondents. Only 13 (27.1%) noted that they were picked up on time and only 14 (29.2%) noted that it got them to their appointment on time. Two thirds of respondents (n = 134, 66.3%) had participated in MAT services via telehealth video or telephone visits. More preferred in-person visits to telehealth visits but a substantial number either preferred telehealth or reported no preference. However, 18 (13.6%) reported various challenges in using telehealth. CONCLUSIONS: This study confirms that transportation plays a significant role in many people's decisions to enter and remain in treatment for OUD in WV. Additionally, for those who rely on NEMT, services can be unreliable. Finally, findings demonstrate the need for individualized care and options for accessing treatment for OUD in both in-person and telehealth-based modalities. Programs and payers should examine all possible options to ensure access to care and recovery.

Physician-Level Continuity of Care and Patient Outcomes in All-Payer Claims Database.

INTRODUCTION: Being one of the few existing measures of primary care functions, physician-level continuity of care (Phy-CoC) is measured by the weighted average of patient continuity scores. Compared with the well-researched patient-level continuity, Phy-CoC is a new instrument with limited evidence from Medicare beneficiaries. This study aimed to expand the patient sample to include patients of all ages and all types of insurance and reassess the associations between full panel-based Phy-CoC scores and patient outcomes. METHODS: Cross-sectional analysis at patient-level using Virginia All-Payer Claims Database (VA-APCD). Phy-CoC scores were calculated by averaging patient's Bice-Boxerman Index scores and weighted by the total number of visits. Patient outcomes included total cost and preventable hospitalization. RESULTS: In a sample of 1.6 million Virginians, patients who lived in rural areas or had Medicare as primary insurance were more likely to be attributed to physicians with the highest Phy-CoC scores. Across all adult patient populations, we found that being attributed to physicians with higher Phy-CoC was associated with 7%-11.8% higher total costs, but was not associated with the odds of preventable hospitalization. Results from models with interactions revealed nuanced associations between Phy-CoC and total cost with patient's age and comorbidity, insurance payer, and the specialty of their physician. CONCLUSIONS: In this comprehensive examination of Phy-CoC using all populations from the VA-APCD, we found an overall positive association of higher full panel-based Phy-CoC with total cost, but a non-significant association with the risk of preventable hospitalization. Achieving higher full panel-based Phy-CoC may have unintended cost implications.