Racial and Ethnic Differences in Sodium Sources and Sodium Reduction Behaviors among US Adults: NHANES 2017-2020 pre pandemic.

Background Nearly all US adults exceed sodium recommendations, which increases cardiovascular risk. Understanding racial and ethnic differences in sodium sources and behaviors could lead to nuanced public health messaging, dietary interventions, and clinical guidance to more equitably achieve population-level sodium reduction. Methods Using National Health and Nutrition Examination Survey 2017-2020 pre-pandemic data, racial and ethnic differences in sodium sources and sodium-related behaviors (e.g., salt use at the table and in food preparation, doctor advice to reduce sodium, attempts to reduce sodium, and label reading) were assessed using weighted chi-square. Given the nutrient database?s assumption that rice is salted may be inappropriate for some ethnic groups, we conducted a secondary analysis altering this assumption. Results Pizza, soup, and chicken were top sources of sodium across racial and ethnic groups. For Asian Americans, 4 top sources were unique (e.g., soy-based condiments). Black adults reported the highest rates of reducing sodium (67% vs. 44% among White adults) and receiving physician sodium reduction advice (35% vs.18% among Asian Americans). Asian Americans were the most likely to frequently use salt during food preparation (66% vs. Other Race adults 32%) but reported not using salt at the table (43% vs. 23% among Other Race adults). Assuming rice is unsalted reduces Asian American sodium intake estimates by ~325 mg/day. Conclusions While product reformulation targets and front-of-pack nutrition labeling may help reduce sodium intake across groups, to equitably address sodium intake, culturally appropriate advice on sources of sodium and salt usage may be needed, particularly for Asian Americans.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study.

OBJECTIVE: Adults with serious mental illness have high rates of tobacco use disorder and underuse pharmacotherapy for tobacco cessation. In a previous randomized controlled trial, participants receiving community health worker (CHW) support and education for their primary care providers (PCPs) had higher tobacco abstinence rates at 2 years, partly because of increased initiation of tobacco-cessation pharmacotherapy. The authors aimed to determine the association between CHW-participant engagement and tobacco abstinence outcomes. METHODS: The authors conducted a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of the number and duration of CHW visits, number of smoking-cessation group sessions attended, and number of CHW-attended PCP visits on initiation of tobacco-cessation pharmacotherapy and tobacco abstinence were modeled via logistic regression. Interviews with 12 CHWs, 17 patient participants, and 17 PCPs were analyzed thematically. RESULTS: Year 2 tobacco abstinence was significantly associated with CHW visit number (OR=1.85, 95% CI=1.29-2.66), visit duration (OR=1.51, 95% CI=1.00-2.28), and number of group sessions attended (OR=1.85, 95% CI=1.33-2.58); effects on pharmacotherapy initiation were similar. One to three CHW visits per month across 2 years were optimal for achieving abstinence. Interviews identified CHW-patient engagement facilitators (i.e., trust, goal accountability, skills reinforcement, assistance in overcoming barriers to treatment access, and adherence). Training and supervision facilitated CHW effectiveness; barriers included PCPs' and care teams' limited understanding of the CHW role. CONCLUSIONS: Greater CHW-participant engagement, within feasible dose ranges, was associated with tobacco abstinence among adults with serious mental illness. Implementation of CHW interventions may benefit from further CHW training and integration within clinical teams.

Network spillover effects associated with the ChooseWell 365 workplace randomized controlled trial to promote healthy food choices.

Food choices are closely linked to culture, social relationships, and health. Because many adults spend up to half their time at work, the workplace provides a venue for changing population health-related behaviors and norms. It is unknown whether the effects of a workplace intervention to improve health behaviors might spread beyond participating employees due to social influence. ChooseWell 365 was a randomized controlled trial testing a 12-month healthy eating intervention grounded in principles of behavioral economics. This intervention leveraged an existing cafeteria traffic-light labeling system (green = healthy; red = unhealthy) in a large hospital workplace and demonstrated significant improvements in healthy food choices by employees in the intervention vs. control group. The current study used data from over 29 million dyadic purchasing events during the trial to test whether social ties to a trial participant co-worker (n = 299 intervention, n = 302 control) influenced the workplace food choices of non-participants (n = 7900). There was robust evidence that non-participants who were socially tied to more intervention group participants made healthier workplace food purchases overall, and purchased a greater proportion of healthy (i.e., green) food and beverages, and fewer unhealthy (i.e., red) beverages and modest evidence that the benefit of being tied to intervention participants was greater than being tied to control participants. Although individual-level effect sizes were small, a range of consistent findings indicated that this light-touch intervention yielded spillover effects of healthy eating behaviors on non-participants. Results suggest that workplace healthy eating interventions could have population benefits extending beyond participants.

Association between participation in the supplemental nutrition assistance program and perception of limited availability and choice of healthy foods.

BACKGROUND: Nutrition security encompasses stable and equitable access, availability, affordability, and utilization of healthy foods. AIM: To evaluate the relationship of two newly created dichotomous measures that represent aspects of nutrition security (i.e., perceived limited availability and healthfulness choice) with Supplemental Nutrition Assistance Program (SNAP) participation. METHODS: Logistic regression models were run for each outcome separately with adjustment for age, income-to-poverty ratio, gender, education, race, and food security. RESULTS: Adults using social services (e.g., food pantries) were enrolled (N = 402) in this cross-sectional analysis. SNAP participants (61.7%) were not different from non-SNAP participants in perceiving limited availability (aOR [95% CI]: 1.21 [0.75, 1.95]) or limited ability to choose (aOR [95% CI]: 0.69 [0.43, 1.12]) healthy foods. CONCLUSIONS: Both SNAP and non-SNAP participants with low socioeconomic status report limited availability of healthy foods in their environment and a limited ability to choose healthy foods.

Internal Medicine Program Directors' Perceptions About Accommodating Residents with Disabilities: A Qualitative Study.

BACKGROUND: While 26% of US adults are disabled, only 3.1 to 9.3% of practicing physicians report having a disability. Ableism within medical training and practice diminishes physician diversity and wellbeing and contributes to healthcare disparities. OBJECTIVE: Explore physician barriers to disability equity and inclusion by examining internal medicine (IM) program directors' (PD) perspectives about recruiting and accommodating residents with disabilities (RWD). DESIGN: Qualitative study involving semi-structured virtual interviews (conducted December 2022-September 2023; analyzed through December 2023). PARTICIPANTS: PDs were recruited via email. Purposive sampling captured program diversity in size, location, and affiliations. Convenience sampling ensured PD diversity by gender, race/ethnicity, and age. APPROACH: Coders analyzed thematic and discursive content of interview transcripts to characterize PD perspectives about RWDs and accommodations. KEY RESULTS: Of the 15 programs represented, 4 had ≤ 49 and 8 had ≥ 100 total residents. Three were community-based; the rest had academic affiliations. On average, PDs had 17 (SD 8.2) years in practice. Most (11/15) identified as White race; 8/15 as female; and none as disabled. PDs characterized disability as a source of grit and empathy but also as an intrinsic deficit. They worried RWDs could have unpredictable absences and clinical incompetencies. Perceived accommodation challenges included inexperience, workload distribution, information asymmetry about accommodation needs or options, barriers to disclosure (e.g., discrimination concerns), and insufficient accommodation advertising. Perceived facilitators included advanced planning; clear, publicized processes; and access to expertise (e.g., occupational health, ombudsmen). CONCLUSIONS: PDs held contradictory views of RWDs. PD insights revealed opportunities to alleviate PD-RWD information asymmetry in recruitment/accommodation processes, which could help align needs and improve representation and inclusion.

Comparison of Sales From Vending Machines With 4 Different Food and Beverage Messages: A Randomized Trial.

Importance: Point-of-sale food messaging can encourage healthier purchases, but no studies have directly compared multiple interventions in the field. Objective: To examine which of 4 food and beverage messages would increase healthier vending machine purchases. Design, Setting, and Participants: This randomized trial assessed 13 months (February 1, 2019, to February 29, 2020) of vending sales data from 267 machines and 1065 customer purchase assessments from vending machines on government property in Philadelphia, Pennsylvania. Data analysis was performed from March 5, 2020, to November 8, 2022. Interventions: Study interventions were 4 food and beverage messaging systems: (1) beverage tax posters encouraging healthy choices because of the Philadelphia tax on sweetened drinks; (2) green labels for healthy products; (3) traffic light labels: green (healthy), yellow (moderately healthy), or red (unhealthy); or (4) physical activity equivalent labels (minutes of activity to metabolize product calories). Main Outcomes and Measures: Sales data were analyzed separately for beverages and snacks. The main outcomes analyzed at the transaction level were calories sold and the health status (using traffic light criteria) of each item sold. Additional outcomes were analyzed at the monthly machine level: total units sold, calories sold, and units of each health status sold. The customer purchase assessment outcome was calories purchased per vending trip. Results: Monthly sales data came from 150 beverage and 117 snack vending machines, whereas 1065 customers (558 [52%] male) contributed purchase assessment data. Traffic light labels led to a 30% decrease in the mean monthly number of unhealthy beverages sold (mean ratio [MR], 0.70; 95% CI, 0.55-0.88) compared with beverage tax posters. Physical activity labels led to a 34% (MR, 0.66; 95% CI, 0.51-0.87) reduction in the number of unhealthy beverages sold at the machine level and 35% (MR, 0.65; 95% CI, 0.50-0.86) reduction in mean calories sold. Traffic light labels also led to a 30-calorie reduction (b = -30.46; 95% CI, -49.36 to -11.56) per customer trip in the customer purchase analyses compared to physical activity labels. There were very few significant differences for snack machines. Conclusions and Relevance: In this 13-month randomized trial of 267 vending machines, the traffic light and physical activity labels encouraged healthier beverage purchases, but no change in snack sales, compared with a beverage tax poster. Corporations and governments should consider such labeling approaches to promote healthier beverage choices. Trial Registration: ClinicalTrials.gov Identifier: NCT06260176.

Workplace food purchases, dietary intake, and gut microbial metabolites in a secondary analysis of the ChooseWell 365 study.

BACKGROUND: Dietary choices can affect human health through alterations in gut microbial metabolism, and gut microbial metabolites could serve as biomarkers for disease risk conferred by dietary intake. However, self-reported dietary intake may not reflect true intake. OBJECTIVES: We identified circulating metabolites, including gut microbiome-related metabolites, associated with adherence to a healthy diet in the ChooseWell 365 study. In this randomized clinical trial, the dietary choices of hospital employees were assessed over 24 mo using not only 24-h dietary recalls but also electronic records of hospital cafeteria purchases. METHODS: Plasma metabolites were profiled from 470 participants. Two targeted metabolomics methods were developed and implemented to expand detection coverage for metabolites related to gut microbial activity. Linear regression models were used to associate metabolites with Healthy Purchasing Scores (HPSs) derived from cafeteria purchases and Healthy Eating Index-2015 (HEI-15) scores derived from dietary recalls. RESULTS: Fourteen metabolites were concordantly associated with the HPS and HEI-15 scores in multivariable models adjusted for age, gender, and race, including the gut microbiome-related metabolites indole-3-propionic acid (HPS, ß: 0.16, 95% CI: 0.07, 0.26, P = 7.32 × 10-4; HEI-15, ß: 0.16, 95% CI: 0.07, 0.25, P = 6.79 × 10-4), hippuric acid (HPS, ß: 0.11, 95% CI: 0.02, 0.21, P = 1.97 × 10-2; HEI-15, ß: 0.10, 95% CI: 0.01, 0.19, P = 3.14 × 10-2), and indoxyl sulfate (HPS, ß = -0.13, 95% CI: -0.23, -0.03, P = 8.21 × 10-3; HEI-15, ß: -0.12, 95% CI: -0.22, -0.03, P = 8.50 × 10-3). These gut microbial metabolites were associated with the intake of specific food groups, such as whole fruits. These metabolites were also associated with clinical variables, including blood pressure, diabetes or prediabetes, and body mass index. CONCLUSIONS: In a secondary analysis of the ChooseWell 365 study, associations between circulating gut microbiome-related metabolites and a healthy diet were confirmed using both objective and subjective measures of consumption. Accurate identification of diet-associated metabolites may help guide dietary or microbiome-based interventions aimed at disease prevention.

Using Positive Psychology to Address Emotional Barriers to Physical Activity After Bariatric Surgery: Proof-of-Concept Trial of the Gaining Optimism After Weight Loss Surgery (GOALS) Project.

Physical activity promotes health and longevity after metabolic/bariatric surgery (MBS), but most patients do not meet recommended levels. The Gaining Optimism After weight Loss Surgery (GOALS) Project was a positive psychological intervention designed to address common emotional barriers to physical activity in patients who have recently undergone MBS (e.g., low confidence around exercise, internalized weight bias, fear of injury) and use motivational interviewing and standard behavior change techniques (e.g., self-monitoring) to increase physical activity. This single-arm proof-of-concept trial was designed to refine the intervention, test feasibility and acceptability, and explore pre-post changes in behavioral and psychological outcomes. Participants were 12 adults 6-12 months post-MBS (M age of 46, 58% female, 67% non-Hispanic white). GOALS was a 10-week telephone counseling program that introduced new positive psychological skills and physical activity topics each week. Participants tracked physical activity with a Fitbit and set weekly goals. Results showed that the intervention was feasible (85% of sessions completed) and acceptable (average participant ratings of session ease and utility above 8.0 on a 0-10 scale). There were medium-to-large effect size improvements in physical activity and psychological well-being (e.g., depressive symptoms). The GOALS intervention will next be tested in a pilot randomized controlled trial with longer-term follow-up to assess its effect more robustly.

Association of food insecurity with changes in diet quality, weight, and glycemia over two years in adults with prediabetes and type 2 diabetes on medicaid.

Little is known about longitudinal associations between food insecurity (FI) and diet, weight, and glycemia in people with prediabetes and type 2 diabetes (T2D). In a secondary analysis of Medicaid-enrolled health center patients with prediabetes or T2D in Boston, Massachusetts (N = 188), we examined associations between food security (FS) and measures of diet quality, weight, and hyperglycemia. FS (10-item USDA FS module) was ascertained at baseline, 1-year, and 2-year follow-up and categorized as persistently secure, intermittently insecure, or persistently insecure. Associations between FS category and changes in Healthy Eating Index-2020 (HEI-20), body mass index (BMI), and hemoglobin A1c (A1c) from baseline to year 2 were assessed using multivariate generalized linear models. Participants had median (p25, p75) age of 52 (42, 57); 71.8% were female and 62.8% Hispanic. Over follow-up, 32.4% were persistently food secure, 33.0% intermittently insecure, and 34.5% persistently insecure. Baseline mean (SD) HEI-20, BMI, and A1c were 55.8 (14.5), 35.9 (8.7) kg/m2, 7.1% (1.6) and did not differ by FS category. FS category was not associated with changes in HEI-20, BMI, and A1c at 2 years (all p > 0.05). Results suggest that Medicaid-enrolled adults with prediabetes or T2D, regardless of FS status, would benefit from dietary and weight management interventions.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study.

Objective: Adults with serious mental illness have high tobacco use disorder rates and underutilization of first-line tobacco cessation pharmacotherapy. In a randomized trial, participants offered community health worker (CHW) support and primary care provider (PCP) education had higher tobacco abstinence rates at two years, partly through increased tobacco cessation pharmacotherapy initiation. This study determined the association between participant-CHW engagement and tobacco abstinence outcomes. Methods: This was a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of CHW visit number and duration, CHW co-led smoking cessation group sessions attended, and CHW-attended PCP visit number on tobacco use disorder pharmacotherapy initiation and tobacco abstinence were modeled using logistic regression. Interviews with 12 CHWs, 16 participants, and 17 PCPs were analyzed thematically. Results: Year-two tobacco abstinence was associated with CHW visit number (OR=1.85, 95% CI=[1.29, 2.66]) and duration (OR=1.85, 95% CI=[1.33, 2.58]) and number of groups attended (OR=1.51, 95% CI=[1.00, 2.28]); effects on pharmacotherapy initiation were similar. 1-3 CHW visits per month over two years was optimal for achieving abstinence. Interviews identified engagement facilitators, including CHWs establishing trust, providing goal accountability, skills reinforcement, and assistance overcoming barriers to treatment access and adherence related to social determinants of health and illness factors. Robust training and supervision facilitated CHW effectiveness. Barriers included PCPs' and care teams' limited understanding of the CHW role. Conclusions: Feasible CHW engagement was associated with tobacco abstinence in adults with serious mental illness. CHW implementation may benefit from promoting CHW training and integration within clinical teams.

Social Risk, Social Need, and Use of the Emergency Department.

This cohort study examines the association of social risk and social need with emergency department use by patients within a Medicaid accountable care organization who were screened for adverse social determinants of health in primary care.

Effects of in-store marketing on food and beverage purchases: a longitudinal study of households with children.

OBJECTIVE: Most food retailers display foods in prominent locations as a marketing strategy (i.e. 'placement promotions'). We examined the extent to which households with children change their food and beverage purchases in response to these promotions. DESIGN: We analysed a novel dataset of all products promoted in two supermarkets from 2016 to 2017, including promotion dates and locations (e.g. aisle endcaps and front registers). We linked promotions to all purchases from the supermarkets from 2016 to 2017 by a cohort of households with children. We calculated the number of weekly promotions in each of thirteen food and beverage groups (e.g. bread; candy) and used fixed effects regressions to estimate associations between number of weekly promotions and households' weekly food purchases, overall and by Supplemental Nutrition Assistance Program (SNAP) participation. SETTING: Two large supermarkets in Maine, USA. PARTICIPANTS: Eight hundred and twenty-one households with children. RESULTS: Most promotions (74 %) were for less healthy foods. The most promoted food groups were sweet and salty snacks (mean = 131·0 promotions/week), baked goods (mean = 68·2) and sugar-sweetened beverages (mean = 41·6). Households generally did not change their food group purchases during weeks when they were exposed to more promotions for those groups, except that a 1-sd increase in endcap candy promotions (about 1 promotion/week) was associated with $0·19/week (about 14·5 %) increase in candy purchases among SNAP nonparticipants (adjusted P < 0·001). CONCLUSIONS: In-store placement promotions for food groups were generally not associated with purchases of promoted food groups, perhaps because exposure to unhealthy food marketing was consistently high. Substantial changes to in-store food marketing may be needed to promote healthier purchases.

A Lifestyle Modification Program for Secondary Prevention of Atrial Fibrillation: A Pilot Study.

Background: Lifestyle modification programs, such as cardiac rehabilitation, may reduce atrial fibrillation (AF) burden and improve quality of life (QOL), but remain unproven. The objective of this pilot study was to assess feasibility, acceptability, and preliminary effectiveness of an exercise and nutrition-based cardiac rehabilitation-like program for AF patients. Methods: We enrolled overweight adults aged ≥ 30 years with symptomatic AF in a 12-week cardiac lifestyle group program, including 6 virtual and 6 in-person visits. All visits included discussion and education about nutrition, exercise, and behavior modification. In-person visits included supervised aerobic exercise and strength training. Outcomes at baseline and 12 weeks included feasibility of participation, acceptability, change in weight and BMI, and changes in survey-based AF burden, symptoms, and QOL. Results: From 84 invitees, 11 (13.1%) were enrolled (mean age 64; baseline BMI 38 kg/m2); 9 (82%) completed the program. Patients attended an average of 9.7 (81%) visits (Range: 6-11). Mean weight loss was 9.1 pounds (Range: 0-16); mean BMI decrease was 1.4 kg/m2 (Range: 0-2.6). Patients found the program helpful overall: all reported making diet and exercise changes during the program. Compared to baseline, patients reported decreased AF burden (12.9 vs. 11.7, p = 0.03) and symptom (10.1 vs. 5.6, p = 0.003) scores at the conclusion of the program. Patients also reported increased QOL overall (68.9 vs. 86.4, p = 0.001). Conclusions: Participation in a cardiac rehab-like program was feasible and acceptable for overweight patients with symptomatic AF. Results suggest preliminary effectiveness of the program for reducing AF burden and symptoms and increasing QOL.

Feasibility and Acceptability of a Combined Digital Platform and Community Health Worker Intervention for Patients With Heart Failure: Single-Arm Pilot Study.

BACKGROUND: Heart failure (HF) is one of the leading causes of hospital admissions. Clinical (eg, complex comorbidities and low ejection fraction) and social needs factors (eg, access to transportation, food security, and housing security) have both contributed to hospitalizations, emphasizing the importance of increased clinical and social needs support at home. Digital platforms designed for remote monitoring of HF can improve clinical outcomes, but their effectiveness has been limited by patient barriers such as lack of familiarity with technology and unmet social care needs. To address these barriers, this study explored combining a digital platform with community health worker (CHW) social needs care for patients with HF. OBJECTIVE: We aim to determine the feasibility and acceptability of an intervention combining digital platform use and CHW social needs care for patients with HF. METHODS: Adults (aged ≥18 years) with HF receiving care at a single health care institution and with a history of hospital admission in the previous 12 months were enrolled in a single-arm pilot study from July to November 2021 (N=14). The 30-day intervention used a digital platform within a mobile app that included symptom questionnaire and educational videos connected to a biometric sensor (tracking heart rate, oxygenation, and steps taken), a digital weight scale, and a digital blood pressure monitor. All patients were paired with a CHW who had access to the digital platform data. A CHW provided routine phone calls to patients throughout the study period to discuss their biometric data and to address barriers to any social needs. Feasibility outcomes were patient use of the platform and engagement with the CHW. The acceptability outcome was patient willingness to use the intervention again. RESULTS: Participants (N=14) were 67.7 (SD 11.7) years old; 8 (57.1%) were women, and 7 (50%) were insured by Medicare. Participants wore the sensor for 82.2% (n=24.66) of study days with an average of 13.5 (SD 2.1) hours per day. Participants used the digital blood pressure monitor and digital weight scale for an average of 1.2 (SD 0.17) times per day and 1.1 (SD 0.12) times per day, respectively. All participants completed the symptom questionnaire on at least 71% (n=21.3) of study days; 11 (78.6%) participants had ≥3 CHW interactions, and 11 (78.6%) indicated that if given the opportunity, they would use the platform again in the future. Exit interviews found that despite some platform "glitches," participants generally found the remote monitoring platform to be "helpful" and "motivating." CONCLUSIONS: A novel intervention combining a digital platform with CHW social needs care for patients with HF was feasible and acceptable. The majority of participants were engaged throughout the study and indicated their willingness to use the intervention again. A future clinical trial is needed to determine the effectiveness of this intervention.

Philadelphia Beverage Tax and Association With Prices, Purchasing, and Individual-Level Substitution in a National Pharmacy Chain.

Importance: Taxes on sweetened beverages are being implemented around the globe; an understanding of these taxes on individual-level behavior is necessary. Objective: To evaluate the degree to which the sweetened beverage tax in Philadelphia, Pennsylvania, was associated with changes in beverage prices and individual-level purchasing over time at a national pharmacy chain in Philadelphia compared with Baltimore, Maryland. Design, Setting, and Participants: Using a difference-in-differences approach and generalized linear mixed models, this cohort study examined beverage purchases made by loyalty cardholders at a national chain pharmacy retailer with stores in Philadelphia and Baltimore (control city) from before tax to after tax. Beverage sales (in US dollars) were linked by unique loyalty card numbers to enable longitudinal analyses. Data were collected from January 1, 2015, through December 31, 2017 (2 years before tax and 1 year after tax); data analyses were conducted from January through October 2022. Exposure: Implementation of Philadelphia's 1.5 cents/oz tax on sweetened beverages. Main Outcomes and Measures: The outcomes were the change in mean beverage price per-ounce and mean beverage volume purchased per cardholder transaction. Individual-level point-of-sale scanner data from all beverage purchases were analyzed. Results: A total of 1188 unique beverages were purchased from the same stores before tax and after tax. There were 231 065 unique cardholders in Philadelphia and 82 517 in Baltimore. Mean prices of taxed beverages (n = 2 094 220) increased by 1.6 (95% CI, 1.3-2.0) cents/oz (106.7% pass-through) in Philadelphia compared with Baltimore from before tax to after tax. Philadelphia cardholders purchased 7.8% (95% CI -8.1% to -7.5%) fewer ounces of taxed beverages and 1.1% (95% CI, 0.6%-1.7%) more ounces of nontaxed beverages per transaction. Taxed beverages made up a smaller percentage of cardholders' overall beverage purchases after tax (-13.4% [95% CI, -14.2% to -12.6%]), while nontaxed beverages made up a larger share (9.3% [95% CI, 7.7%-10.7%]). Conclusions and Relevance: In this longitudinal cohort study of the Philadelphia beverage tax, the tax was completely passed through to prices and was associated with a 7.8% decline in ounces of taxed beverages purchased at a national pharmacy chain.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

Importance: Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources. Objective: To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program. Design, Setting, and Participants: This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees. Main Outcomes and Measures: Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness). Results: Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. Conclusions and Relevance: This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.