Interrupted Time Series Analysis of Bar/Tavern Closing Hours and Violent Crime.

Importance: It is well established that alcohol outlets (ie, places that sell alcohol) attract crime, particularly during late-night hours. Objective: To evaluate the association of Maryland Senate Bill 571 (SB571), which reduced the hours of sale for bars/taverns in 1 Baltimore neighborhood from 6 am to 2 am to 9 am to 10 pm, with violent crime within that neighborhood. Design, Setting, and Participants: This controlled interrupted time series analysis compared the change in violent crime density within an 800-ft buffer around bars/taverns in the treatment neighborhood (ie, subject to SB571) and 2 control areas with a similar mean baseline crime rate, alcohol outlet density, and neighborhood disadvantage score in the City of Baltimore between May 1, 2018, and December 31, 2022. The interrupted time series using Poisson regression with overdispersion adjustment tested whether the violent crime density differed before vs after the policy change in the treatment neighborhood and whether this difference was localized to the treatment neighborhood. Exposure: Statutory reduction of bar/tavern selling hours from 20 to 13 hours per day in the treatment neighborhood. Main Outcomes and Measures: The primary outcome was all violent crime, including homicide, robbery, aggravated and common assault, and forcible rape. Secondary outcomes were homicides and assaults. All violent crime measures summed the monthly incidents within 800 ft of bars/taverns from 8 pm to 4 am. For each outcome, a level change estimated the immediate change (first month after implementation), and a slope change estimated the sustained change after implementation (percent reduction after the first month). These level and slope changes were then compared between the treatment and control neighborhoods. Results: The treatment neighborhood included 26 bars/taverns (mean [SD] population, 524.6 [234.6] residents), and the control neighborhoods included 41 bars/taverns (mean [SD] population per census block, 570.4 [217.4] residents). There was no immediate level change in density of all violent crimes the month after implementation of SB571; however, compared with the control neighborhoods, the slope of all violent crime density decreased by 23% per year in the treatment neighborhood after SB571 implementation (annualized incidence rate ratio, 0.77; 95% CI, 0.60-0.98; P = .04). Similar results were seen for homicides and assaults. Several sensitivity analyses supported the robustness of these results. Conclusions and Relevance: This study's findings suggest that alcohol policies that reduce hours of sale could be associated with a reduction in violent crimes. Given these findings, SB571 may serve as a model for other cities looking to create safer neighborhoods.

Will all youth answer sexual orientation and gender-related survey questions? An analysis of missingness in a large U.S. survey of adolescents and young adults.

Some researchers and clinicians may feel hesitant to assess sexual orientation and gender-related characteristics in youth surveys because they are unsure if youth will respond to these questions or are concerned the questions will cause discomfort or offense. This can result in missed opportunities to identify LGBTQ+ youth and address health inequities among this population. The aim of this study was to examine the prevalence and sociodemographic patterns of missingness among survey questions assessing current sexual orientation, gender identity and expression (SOGIE), and past change in sexual orientation (sexual fluidity) among a diverse sample of U.S. youth. Participants (N = 4,245, ages 14-25 years; 95% cisgender, 70% straight/heterosexual, 53% youth of color), recruited from an online survey panel, completed the Wave 1 survey of the longitudinal Sexual Orientation Fluidity in Youth (SO*FLY) Study in 2021. Current SOGIE, past sexual fluidity, and sociodemographic characteristics were assessed for missingness. Overall, 95.7% of participants had no missing questions, 3.8% were missing one question, and 0.5% were missing ≥ 2 questions. Past sexual fluidity and assigned sex were most commonly missing. Sociodemographic differences between participants who skipped the SOGIE questions and the rest of the sample were minimal. Missingness for the examined items was low and similar across sociodemographic characteristics, suggesting that almost all youth are willing to respond to survey questions about SOGIE. SOGIE and sexual fluidity items should be included in surveys and clinical assessments of youth to inform clinical care, policy-making, interventions, and resource development to improve the health of all youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

"Wanna cry this out real quick?": an examination of secondary traumatic stress risk and resilience among post-overdose outreach staff in Massachusetts.

BACKGROUND: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. METHODS: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). RESULTS: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. CONCLUSION: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Social media use, brand engagement, and tobacco product initiation among youth: Evidence from a prospective cohort study.

OBJECTIVE: To evaluate whether frequent social media use and liking/following tobacco brand accounts was associated with increased risk of tobacco and polytobacco initiation over approximately 1-year follow-up among youth with no prior tobacco use. METHODS: Associations between measures of social media engagement (daily social media use and liking/following tobacco brands) and tobacco initiation risk were examined using data from Waves 2 and 3 (2014-2015) of the US Population Assessment for Tobacco and Health study. Separate log-binomial models, accounting for missing data via multiple imputation and using propensity score adjustment to address confounding, estimated the adjusted relative risk (aRR) of any tobacco initiation and poly-use (2 + products) initiation at 1-year follow-up. RESULTS: Among the 8,672 youth with no prior tobacco use (49.3% female, mean [SD] age 14.1 [1.7]), 63.5% used social media at least daily, and 3.3% reported liking/following ≥ 1 tobacco brands on social media. Those reporting daily or more frequent social media use (compared to less) were at increased risk for tobacco (aRR 1.67; 95% CI 1.38-2.02) and polytobacco initiation (aRR 1.32; 95% CI 0.98-1.78). Although results were imprecise, liking/following ≥ 1 tobacco brands on social media (versus none) was associated with tobacco (aRR 1.34; 95% CI 0.95-1.89) or polytobacco initiation (aRR 1.60; 95% CI 0.99-2.60). In sensitivity analyses, liking/following cigarette or cigarillo brands was associated with polytobacco initiation. CONCLUSIONS: This study adds to a growing evidence-base describing the exposure of youth to tobacco-related social media content. Such content-often generated by tobacco companies-may contribute to youth tobacco initiation.

Privacy and confidentiality in Massachusetts' post-overdose outreach programs: Mixed methods analysis of outreach staff surveys and interviews.

BACKGROUND: Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. METHODS: In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019-2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. RESULTS: Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. CONCLUSIONS: Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion.

Racial Disparities in Accessing Care along the Continuum of Cancer Genetic Service Delivery.

BACKGROUND: Public health calls to ensure equity in genomics and precision medicine necessitate a closer examination of how these efforts might differentially affect access to genetic services across demographic subgroups. This study set out to examine racial/ethnic disparities along the cancer genetic service delivery continuum. METHODS: Retrospective data are drawn from 15 clinical sites across 6 U.S. States. Individuals who screened at-risk for hereditary cancer were: (i) referred/scheduled to see a genetic counselor (referral workflow), or (ii) offered genetic testing at the point-of-care (POC testing workflow). Logistic regression analyses evaluated the associations between race/ethnicity and several outcomes including appointment scheduling, genetic counseling, and genetic testing, controlling for demographics, clinical factors, and county-level covariates. RESULTS: A total of 14,527 patients were identified at-risk. Genetic testing uptake was significantly higher at POC sites than referral sites (34% POC vs. 11% referral, P < 0.001). Race/ethnicity was significantly associated with testing uptake among all sites, with non-Hispanic Blacks having lower odds of testing compared with non-Hispanic Whites [aOR = 0.84; 95% confidence interval (CI), 0.71-1.00; P = 0.049]. Moreover, this disparity was observed at referral sites, but not POC sites. Among patients scheduled, non-Hispanic Blacks had lower odds of counseling (aOR = 0.28; 95% CI, 0.17-0.47; P < 0.001). CONCLUSIONS: Findings suggest that factors influencing genetic counseling show rates may be driving disparities in genetic testing. IMPACT: Strategies to reduce barriers to seeing a genetic counselor, including modifications to clinical workflow, may help mitigate racial/ethnic disparities in genetic testing.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic.

INTRODUCTION: This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care. METHODS: This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit. RESULTS: Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96). CONCLUSIONS: There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

Alcohol Use Patterns Among Underage Autistic and Non-Autistic Youth.

PURPOSE: We explored factors predicting repeated or hazardous alcohol use among autistic and non-autistic U.S. youth ages 16 to 20 years. METHODS: Autistic (n = 94) and non-autistic (n = 92) youth completed an online survey. By design, half of each group reported past-year alcohol use. We compared drinking patterns for autistic and non-autistic youth, and within each group between abstinent or infrequent drinkers (0-1 drinking episodes in past year) versus those who drank 2 + times in past year. RESULTS: Autistic (vs. non-autistic) youth who drank did so less frequently and consumed fewer drinks per occasion. However, 15% of autistic youth who drank in the past year reported heavy episodic drinking and 9.3% screened positive for AUDIT-C hazardous drinking. For autistic youth only, a diagnosis of depression, bullying or exclusion histories were positively associated with drinking 2 + times in the past year. Autistic youth who put more effort into masking autistic traits were less likely to report drinking 2 + times in the past year. As compared to non-autistic youth, autistic participants were less likely to drink for social reasons, to conform, or to enhance experiences, but drank to cope at similar rates. CONCLUSION: Repeated and hazardous underage alcohol occur among autistic youth. Targeted prevention programs designed to address the specific drinking profiles of autistic youth are needed.

Characteristics of post-overdose outreach programs and municipal-level opioid overdose in Massachusetts.

BACKGROUND: Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. METHODS: Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. RESULTS: There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66-0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78-0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. CONCLUSION: Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design.

The police paradox: A qualitative study of post-overdose outreach program implementation through public health-public safety partnerships in Massachusetts.

BACKGROUND: Post-overdose outreach has emerged in the United States as an increasingly common response to non-fatal overdose. This qualitative study investigates the implementation of such programs through public health-public safety partnerships in Massachusetts. METHODS: We conducted semi-structured interviews with post-overdose outreach team members, overdose survivors, and family members who received outreach. Interview transcripts were inductively analyzed to identify emergent themes and subsequently organized within the framework of Ecological Systems Theory. RESULTS: Forty-nine interviews were conducted, including 15 police officers (80% male, 100% non-Hispanic White); 23 public health partners (48% male, 87% non-Hispanic White); 8 overdose survivors who received outreach services and 3 parents of survivors who received services (collectively 27% male, 64% non-Hispanic White). Implementation factors identified across all levels (macrosystem, exosystem, mesosystem, and microsystem) of Ecological Systems Theory included key program facilitators, such as access to police data and funding (macro), interagency collaboration (exo), shared recognition of community needs (exo), supportive relationships among team members (meso), and program champions (micro). Common barriers included inherent contradictions between policing and public health mandates (macro), poor local treatment and service capacity (exo), divergent staff views of program goals (exo), overdose survivors' prior negative experiences with law enforcement (meso), difficulty locating overdose survivors (meso), and police officers' lack of qualifications or training in providing psycho-social services (micro). CONCLUSIONS: Most post-overdose outreach programs in this study were dependent on funding and data-sharing partnerships, which police agencies largely controlled. Yet, police participation, especially during outreach visits presented numerous challenges for engaging overdose survivors and establishing non-coercive linkages with evidence-based services, which may undermine the public health goals of these programs. These findings should inform state and federal efforts to expand the role of law enforcement in behavioral health initiatives.

Fluidity in Gender Identity and Sexual Orientation Identity in Transgender and Nonbinary Youth.

Changes in sexual orientation identity (SOI) and gender identity (GI) have rarely been studied in transgender and/or nonbinary youth (TNBY), but documenting such changes is important for understanding identity development and gender transition and supporting the needs of TNBY. This study examined the frequency and patterning of changes in GI and SOI across 3 months (T1-T2) and 1.5 years (T1-T4) among 183 TNBY (baseline age 14-17 years; 83.6% White, 16.9% Hispanic/Latinx) who participated in a longitudinal US study. Participants completed online surveys including measures of GI and SOI. The most common gender identity selected at T1 (with or without another gender identity) was nonbinary (56.3%), and more than half (57.4%) of youth identified with a plurisexual identity (e.g., bisexual, pansexual). GI fluidity from T1-T2 was 13.2% and from T1-T4 was 28.9%. It was equally common to move toward a nonbinary gender identity as toward a binary gender identity. SOI fluidity was more common (30.6% from T1-T2; 55.8% from T1-T4) than GI fluidity. Shifts toward plurisexual identities were more common than shifts toward monosexual identities (e.g., straight, gay). Findings highlight the need to assess changes in GI and SOI in research and clinical practice to address the unique needs of TNBY accurately and effectively.

Comparison of a national commercial pharmacy naloxone data source to state and city pharmacy naloxone data sources-Rhode Island, Massachusetts, and New York City, 2013-2019.

OBJECTIVE: Accurate naloxone distribution data are critical for planning and prevention purposes, yet sources of naloxone dispensing data vary by location, and completeness of local datasets is unknown. We sought to compare available datasets in Massachusetts, Rhode Island, and New York City (NYC) to a commercially available pharmacy national claims dataset (Symphony Health Solutions). DATA SOURCES AND STUDY SETTING: We utilized retail pharmacy naloxone dispensing data from NYC (2018-2019), Rhode Island (2013-2019), and Massachusetts (2014-2018), and pharmaceutical claims data from Symphony Health Solutions (2013-2019). STUDY DESIGN: We conducted a descriptive, retrospective, and secondary analysis comparing naloxone dispensing events (NDEs) captured via Symphony to NDEs captured by local datasets from the three jurisdictions between 2013 and 2019, when data were available from both sources, using descriptive statistics, regressions, and heat maps. DATA COLLECTION/EXTRACTION METHODS: We defined an NDE as a dispensing event documented by the pharmacy and assumed that each dispensing event represented one naloxone kit (i.e., two doses). We extracted NDEs from local datasets and the Symphony claims dataset. The unit of analysis was the ZIP Code annual quarter. PRINCIPAL FINDINGS: NDEs captured by Symphony exceeded those in local datasets for each time period and location, except in RI following legislation requiring NDEs to be reported to the PDMP. In regression analysis, absolute differences in NDEs between datasets increased substantially over time, except in RI before the PDMP. Heat maps of NDEs by ZIP code quarter showed important variations reflecting where pharmacies may not be reporting NDEs to Symphony or local datasets. CONCLUSIONS: Policymakers must be able to monitor the quantity and location of NDEs in order to combat the opioid crisis. In regions where NDEs are not required to be reported to PDMPs, proprietary pharmaceutical claims datasets may be useful alternatives, with a need for local expertise to assess dataset-specific variability.

Decreasing Decision-to-Incision Times for Unscheduled, Urgent Cesarean Deliveries.

OBJECTIVE: To standardize the preprocedure process for urgent, unscheduled cesarean deliveries to decrease the time from decision to skin incision to improve maternal and fetal outcomes. METHODS: In our quality-improvement project, we selected indications that require urgent cesarean deliveries, created a standard algorithm, then implemented a multidisciplinary process intended to reduce decision-to-incision time. This initiative was conducted from May 2019 to May 2021, with a preimplementation period from May 2019 to November 2019 (n=199), implementation period from December 2019 to September 2020 (n=283), and postimplementation period from October 2020 to May 2021 (n=160). An interrupted time series calculation was performed, with stratification by patient race and ethnicity. The primary process measure was mean decision-to-incision time. The secondary outcomes were neonatal status as measured by 5-minute Apgar score and quantitative blood loss during the cesarean delivery. RESULTS: We analyzed 642 urgent cesarean deliveries; 199 were preimplementation of the standard algorithm, and 160 were postimplementation. The mean decision-to-incision time improved from 88 minutes (95% CI 75-101 min) to 50 minutes (95% CI 47-53 min) from the preimplementation period to the postimplementation period. When stratified by race and ethnicity, the mean decision-to-incision time among Black non-Hispanic patients improved from 98 minutes (95% CI 73-123 min) to 50 minutes (95% CI 45-55 min) (t=3.27, P <.01); it improved from 84 minutes (95% CI 66-103 min) to 49 minutes (95% CI 44-55 min) among Hispanic patients (t=3.51, P <.001). There was no significant improvement in decision-to-incision time among patients in other racial and ethnic groups. When the cesarean delivery was performed for fetal indications, Apgar scores were significantly higher in the postimplementation period compared with the preimplementation period (8.5 vs 8.8 beta=0.29, P <.01). CONCLUSION: Development and implementation of a standard algorithm to expedite decision-to-incision time for unscheduled, urgent cesarean deliveries led to a significant decrease in decision-to-incision time.

Identifying and describing trajectories of alcohol use frequency and binge drinking frequency among those aged 15-30 years in a national cohort of US adolescents: A group-based trajectory modeling approach.

BACKGROUND AND AIMS: Analyzing long-term trajectories of alcohol use has the potential to strengthen policy and intervention priorities and timing. We identified and described trajectories of alcohol use and binge drinking frequency from mid-adolescence to early adulthood and measured the association of the role of early drinking initiation with trajectory membership. DESIGN, SETTING, PARTICIPANTS: This was a longitudinal cohort study conducted in the United States. The National Longitudinal Survey of Youth 1997 is a nationally representative cohort of youth aged 12-16 years at baseline. The analytic sample included individuals who participated in two or more annual interviews between ages 15 and 30 years (n = 8809). MEASUREMENTS: Participants self-reported the number of days in the past 30 days they: (1) drank alcohol and (2) binge drank (five or more drinks on one occasion). We used group-based trajectory modeling to identify distinct trajectories from ages 15-30 years of past 30-day drinking and past 30-day binge drinking. Using multinomial logistic regression, we evaluated associations between early drinking initiation (≤ 14 years) and key demographics with trajectory membership. FINDINGS: We identified five past 30-day drinking groups: late-escalating (16.0%), moderate frequency (19.0%), high frequency (11.2%), low frequency (35.4%) and no/infrequent (18.4%). Early drinking initiation (versus later) was associated with higher odds of membership in the moderate [adjusted multinomial odds ratio (aMOR) = 4.88; 95% confidence interval (CI) = 4.00, 5.94] and high-frequency groups (aMOR = 4.68; 95% CI = 3.74, 5.86) than in the no/infrequent comparator trajectory. We identified five groups with distinct binge drinking frequency patterns: later escalating (9.9%), high frequency (3.9%), low frequency (28.7%), earlier onset (9.5%) and no/infrequent (48.0%). Early initiation was associated with increased odds of membership in earlier-onset and high-frequency groups compared with the no/infrequent group. For both outcomes, additional differences in probability of group membership were identified by gender, racial identity, parental factors (religiosity, high school completion) and household characteristics (household size, income, and region of residence). CONCLUSIONS: Youth in the United States appear to follow heterogeneous drinking and binge drinking trajectories from adolescence into adulthood. These may include higher-use trajectories as well as trajectories with different escalation timing (e.g. earlier versus later). Early initiation of drinking may increase risk of membership in higher- and earlier-use trajectory groups.

Compliance With the US Food and Drug Administration's Guidelines for Health Warning Labels and Engagement in Little Cigar and Cigarillo Content: Computer Vision Analysis of Instagram Posts.

Background: Health warnings in tobacco advertisements provide health information while also increasing the perceived risks of tobacco use. However, existing federal laws requiring warnings on advertisements for tobacco products do not specify whether the rules apply to social media promotions. Objective: This study aims to examine the current state of influencer promotions of little cigars and cigarillos (LCCs) on Instagram and the use of health warnings in influencer promotions. Methods: Instagram influencers were identified as those who were tagged by any of the 3 leading LCC brand Instagram pages between 2018 and 2021. Posts from identified influencers, which mentioned one of the three brands were considered LCC influencer promotions. A novel Warning Label Multi-Layer Image Identification computer vision algorithm was developed to measure the presence and properties of health warnings in a sample of 889 influencer posts. Negative binomial regressions were performed to examine the associations of health warning properties with post engagement (number of likes and comments). Results: The Warning Label Multi-Layer Image Identification algorithm was 99.3% accurate in detecting the presence of health warnings. Only 8.2% (n=73) of LCC influencer posts included a health warning. Influencer posts that contained health warnings received fewer likes (incidence rate ratio 0.59, P<.001, 95% CI 0.48-0.71) and fewer comments (incidence rate ratio 0.46, P<.001, 95% CI 0.31-0.67). Conclusions: Health warnings are rarely used by influencers tagged by LCC brands' Instagram accounts. Very few influencer posts met the US Food and Drug Administration's health warning requirement of size and placement for tobacco advertising. The presence of a health warning was associated with lower social media engagement. Our study provides support for the implementation of comparable health warning requirements to social media tobacco promotions. Using an innovative computer vision approach to detect health warning labels in influencer promotions on social media is a novel strategy for monitoring health warning compliance in social media tobacco promotions.

Association of Implementation of Postoverdose Outreach Programs With Subsequent Opioid Overdose Deaths Among Massachusetts Municipalities.

Importance: Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services. Objective: To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs. Design, Setting, and Participants: This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022. Exposures: The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period. Main Outcomes and Measures: The primary outcome was quarterly municipal opioid fatality rate per 100 000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100 000 population. Results: The mean (SD) population size across 93 municipalities was 47 622 (70 307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P = .20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P = .003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P = .007). Several sensitivity analyses yielded similar findings. Conclusions and Relevance: In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness.

Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows.

PURPOSE: National efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. METHODS: This study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. RESULTS: In 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). CONCLUSION: Study findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

A Pharmacy Liaison-Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization: A Nonrandomized Controlled Trial.

Importance: Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. Objective: To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). Design, Setting, and Participants: This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. Interventions: Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. Main Outcomes and Measures: The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. Results: Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. Conclusions and Relevance: The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03919084.

Sociodemographic Patterns in Retrospective Sexual Orientation Identity and Attraction Change in the Sexual Orientation Fluidity in Youth Study.

PURPOSE: This study examined sociodemographic patterns of retrospective fluidity in sexual orientation identity (i.e., any change from one identity to another) and attractions (i.e., any change in attractions to one or more gender(s)) in a large sample of US youth. METHODS: Participants were 4,087 youth (58% cisgender girls/women, 38% cisgender boys/men, 5% transgender or nonbinary individuals), ages 14-25 years, from across the United States, who were recruited from an online survey panel. Sexual and gender minorities and people of color were oversampled. Participants completed the Wave 1 survey of the longitudinal Sexual Orientation Fluidity in Youth study, which assessed sociodemographic characteristics and retrospective fluidity in sexual orientation identity and attractions. RESULTS: Across the sample, 17% reported a retrospective change in identity and 33% reported a change in attractions. Participants who were most likely to report identity change were in the younger age group (14-17 years), were transgender or nonbinary, had a plurisexual identity (pansexual, queer), and reported attractions to more than one gender. Participants who were most likely to report attraction change were nonbinary, had a plurisexual identity (pansexual, queer, bisexual), and reported attractions to more than one gender. DISCUSSION: This study found retrospective changes in sexual orientation identity and attractions were common in this sample of youth, with the prevalence of these changes differing by sociodemographic characteristics. Results from this study inform future research on adolescent health and have implications for supporting and caring for this age group, for whom sexual fluidity is common.

Evaluating the Impact of Alcohol Policy on Suicide Mortality: A Sex-Specific Time-Series Analysis for Lithuania.

OBJECTIVE: It is reasonable to believe that the alcohol policy environment can impact the suicide mortality rates in a given country, considering the well-known link between alcohol use and death by suicide. The current literature, albeit limited, suggests that an increase in alcohol taxation may result in a decrease in deaths by suicide and that the effect is sex-specific. Therefore, the objective of the current study was to test the impact of three alcohol control policy enactments (in 2008, 2017 and 2018) on suicide mortality among adults 25-74 years of age in Lithuania, by sex. METHODS: To estimate the unique impact of three alcohol control policies, we conducted interrupted time-series analyses by employing a generalized additive mixed model on monthly sex-specific age-standardized suicide mortality rates from January 2001 to December 2018. RESULTS: Analyses showed a significant impact of the 2017 (p = 0.016) alcohol control policy on suicide mortality for men only. Specifically, we estimated that in the year following the 2017 policy enactment, approximately 57 (95% CI: 9-107) deaths by suicide were prevented among men, 25-74 years of age. The three policy enactments tested were not found to significantly impact the suicide mortality rate among women. CONCLUSION: Alcohol control policies involving pricing, which result in a notable decrease in alcohol affordability, could be a cost-effective indirect suicide prevention mechanism in not only countries of the former Soviet Union, but in other high-income countries with a comparable health care system to that in Lithuania. HIGHLIGHTSIncreasing excise tax on alcohol was found to have a sex-specific impact on suicide mortalityThe 2017 alcohol policy prevented 57 deaths by suicide among men, 25-74 years of age, in the following yearAlcohol pricing policies may be a cost-effective indirect suicide prevention mechanism.