The Effect of City-Level Sugar-Sweetened Beverage Taxes on Longitudinal HbA1c and Incident Diabetes in Adults With Prediabetes.

OBJECTIVE: Prediabetes, which is a condition characterized by higher-than-normal blood glucose levels that are under the threshold for diabetes, impacts over one-third of U.S. adults. Excise taxes on sugar-sweetened beverages (SSBs) are a proposed policy intervention to lower population consumption of SSBs and generate revenue to support health-related programs, thus potentially delaying or preventing the development of diabetes in individuals with prediabetes. We leveraged data from Kaiser Permanente in California to examine the impact of SSB taxes in California on individual-level mean HbA1c levels and rates of incident diabetes. RESEARCH DESIGN AND METHODS: We compared two outcomes, mean HbA1c levels and rates of incident diabetes, among a matched cohort of adults with prediabetes who lived and did not live in SSB excise tax cities, using outcomes collected in the 6 years prior and 4 years following SSB tax implementation. We used multivariable linear mixed effects models to analyze longitudinal mean HbA1c and discrete-time survival models for incident diabetes. RESULTS: We included 68,658 adults in the analysis. In adjusted models, longitudinal mean HbA1c (percent) was 0.007 (95% CI 0.002, 0.011) units higher in the tax cities compared with controls; while the estimated difference was statistically significant, it was not clinically significant (HbA1c < 0.5%). There was no significant difference in the risk of incident diabetes between individuals living in tax and control cities. CONCLUSIONS: We found no clinically significant association between SSB taxes and either longitudinal mean HbA1c or incident diabetes among adults with prediabetes in the 4 years following SSB tax implementation.

Feasibility and Acceptability of Standardizing Portions in Restaurants.

Most restaurants serve customers excess calories which significantly contributes to the obesity epidemic. This pilot study tested the feasibility and acceptability of offering customers standardized portions to reduce caloric consumption when dining out in three restaurants. Portions were developed to limit quantity of food served, with lunches and dinners ≤ 700 cal and breakfast ≤ 500 cal. Participating restaurants developed an alternative "Balanced Portions Menu." Training and instructions were provided with respect to the volume and weight of food to be plated following the standardized guidelines and providing at least one cup of vegetables per lunch/dinner. We invited local residents to help us evaluate the new menu. We monitored restaurant adherence to guidelines, obtained feedback from customers, and incentivized customers to complete dietary recalls to determine how the new menus might have impacted their daily caloric consumption. Of the three participating restaurants, all had a positive experience after creating the new menus and received more foot traffic. One restaurant that did not want to change portion sizes simply plated the appropriate amount and packed up the rest to-go, marketing the meals as "Dinner today, lunch tomorrow." Two of the restaurants followed the guidelines precisely, while one sometimes plated more rice than the three-fourths cup that was recommended. A significant number of customers ordered from the Balanced Portions menus. Two of the three restaurants have decided to keep offering the Balanced Portions menus indefinitely. Following standardized portions guidelines is both feasible for restaurants and acceptable to customers.

Measuring Primary Care Spending in the US by State.

This case series identifies states' estimates of primary care spending and recommends steps policymakers can take toward standardizing these estimates.

Association Between Park Use and Moderate-to-Vigorous Activity During COVID-19 Years among a Cohort of Low-Income Youth.

Neighborhood parks are important venues to support moderate-to-vigorous (MVPA) activity. There has been a noticeable increase promoting physical activity among youth in neighborhood parks. This paper aims to assess the association between park use and MVPA among low-income youth in a large urban area. We recruited a cohort of 434 youth participants during the COVID pandemic years (2020-2022) from low-income households in Washington, D.C. We collected multiple data components: accelerometry, survey, and electronic health record data. We explored the bivariate relationship between the accelerometer-measured daily MVPA time outcome and survey-based park use measures. A mixed-effect model was fitted to adjust the effect estimate for participant-level and time-varying confounders. The overall average daily MVPA time is 16.0 min (SD = 12.7). The unadjusted bivariate relation between daily MVPA time and frequency of park visit is 1.3 min of daily MVPA time per one day with park visits (p < 0.0001). The model-adjusted estimate is 0.7 daily MVPA minutes for 1 day with park visit (p = 0.04). The duration of a typical park visit is not a significant predictor to daily MVPA time with or without adjustments. The initial COVID outbreak in 2020 resulted in a significant decline in daily MVPA time (- 4.7 min for 2020 versus 2022, p < 0.0001). Park visit frequency is a significant predictor to low-income youth's daily MVPA time with considerable absolute effect sizes compared with other barriers and facilitators. Promoting more frequent park use may be a useful means to improve low-income youth's MVPA outcome.

Global prediction of extreme floods in ungauged watersheds.

Floods are one of the most common natural disasters, with a disproportionate impact in developing countries that often lack dense streamflow gauge networks1. Accurate and timely warnings are critical for mitigating flood risks2, but hydrological simulation models typically must be calibrated to long data records in each watershed. Here we show that artificial intelligence-based forecasting achieves reliability in predicting extreme riverine events in ungauged watersheds at up to a five-day lead time that is similar to or better than the reliability of nowcasts (zero-day lead time) from a current state-of-the-art global modelling system (the Copernicus Emergency Management Service Global Flood Awareness System). In addition, we achieve accuracies over five-year return period events that are similar to or better than current accuracies over one-year return period events. This means that artificial intelligence can provide flood warnings earlier and over larger and more impactful events in ungauged basins. The model developed here was incorporated into an operational early warning system that produces publicly available (free and open) forecasts in real time in over 80 countries. This work highlights a need for increasing the availability of hydrological data to continue to improve global access to reliable flood warnings.

An Affordable and Sustainable Thrifty-Like Meal Plan, FoodRx, That Meets the Recommended Dietary Allowances.

There is considerable controversy as to whether a healthy diet is affordable given recent inflation. In order to determine whether a healthy, climate-friendly sustainable diet can be obtained within the allotments of the Supplemental Nutrition Assistance Program (SNAP), we created and purchased 26 weeks of meal plans designed to meet the EAT-Lancet sustainability guidelines and > 90% of the RDAs for 23 macro/micronutrients for households with at least 2 adults and 1-3 children. We compared the food quantities and cost of a healthy sustainable diet purchased in Los Angeles, 2023, to the Thrifty Food Plan, 2021. We compared the volume of food and cost of basic groceries to those recommended in the Thrifty Food Plan, 2021. The costs of the sustainable diet fell within the 2023 SNAP allotments as long as the average calories required per person did not exceed 2000. The volume of fruits, vegetables, legumes, nuts, and seeds were considerably higher for the sustainable diet compared to the Thrifty Food Plan. Given that calorie needs are the determinants of food quantity and costs, the USDA may consider offering supplemental coverage for individuals with higher calorie needs to make healthy eating affordable.

Evidence-based practice attitudes and nutrition support guideline knowledge between holders and nonholders of the Certified Nutrition Support Clinician credential.

BACKGROUND: Clinical practice frequently changes, and professionals should stay abreast of evidence-based practice (EBP) guidelines. Negative attitudes towards EBP are a barrier to guideline adoption. This study explored EBP attitudes and knowledge of a complex nutrition support clinical case scenario of individuals holding or not holding the Certified Nutrition Support Clinician (CNSC) credential. METHODS: This cross-sectional study used an online survey sent to American Society for Parenteral and Enteral Nutrition (ASPEN) members with and without the CNSC credential and all CNSC credential holders from the National Board of Nutrition Support Certification email list. The survey included the Evidence-Based Practice Attitude Scale Score (EBPAS-15) and eight knowledge questions using a nutrition support case scenario. An independent samples t test compared knowledge and EBPAS-15 total scores and subscores between CNSC holders and nonholders. Pearson correlation determined the correlation between knowledge and EBPAS-15 scores. RESULTS: The response rate was 7.8% (N = 706). CNSC holders (n = 536) had significantly higher mean knowledge scores (4.7 ± 1.6 out of 8) than nonholders (n = 159, 4.1 ± 1.7) (P < 0.001). Total EBPAS-15 scores were not significantly different between CNSC holders (n = 542, 2.9 ± 0.4 out of 4) and nonholders (n = 164, 2.8 ± 0.7) (P = 0.434), and knowledge scores and total EBPAS-15 scores (P = 0.639) or subscores were not significantly correlated. CONCLUSIONS: Regardless of holding the CNSC credential, EBPAS-15 scores indicated respondents had positive EBP attitudes. CNSC holders had significantly higher knowledge scores of recent nutrition support EBP guidelines compared with non-CNSC credential holders. Positive EBP attitudes are a precursor to clinical decision-making, but future research should determine the use of guidelines in clinical practice.

Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study.

BACKGROUND: Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed. OBJECTIVE: To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care. DESIGN: Comparative case study, using video- and telephone-based semi-structured interviews. PARTICIPANTS: Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system. APPROACH: Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process. KEY RESULTS: Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. CONCLUSIONS: Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

Food recovery and produce distribution as a system strategy for increasing access to healthy food among populations experiencing food insecurity: lessons for post-pandemic planning.

Using data from an intercept survey of 428 adults who received free surplus produce at five distribution sites and qualitative data from 15 interviews with site personnel, we examined facilitators (e.g. community partnerships, coalition support) and challenges (e.g. limited refrigerated storage, lack of transportation infrastructure) to operating a food recovery and distribution program in Los Angeles County. Overall, this food system intervention appeared to fill an unmet need for recipients, nearly 80% of whom were food insecure and 60% visited a site several months/year or monthly. For many living in this county's underserved communities, this effort was instrumental in increasing access to healthy food before and during the COVID-19 pandemic. To sustain/expand this program's reach, local governments and food assistance programs should provide greater coordination and oversight, and invest more resources into this food recovery and distribution infrastructure.

How Young Adults with Serious Mental Health Diagnoses Navigate Poverty Post-emancipation: The Complex Roles of Community Mental Health Services & Informal Social Support.

Serious mental health diagnoses are prevalent among youth who "age out" of foster care by reaching the maximum age for child welfare service eligibility. Post-emancipation, little is known about how youth engage in community mental health services, or leverage informal social networks, to navigate independence. Twenty emancipating youth completed three interviews over 16 months. All emancipated into poverty; most lived alone and initially connected to adult community mental health teams. Four service use and informal support profiles emerged from analysis: (1) Navigators (n = 2) actively used mental health services and provided limited informal support; Treaders (n = 9) passively used mental health services and heavily exchanged informal support; Survivors (n = 5) used mental health services when in crisis and heavily provided informal support; and Strugglers (n = 4) avoided mental health services and took resources from informal connections. Findings have implications for both child and adult mental health and social service providers.

Older People's Descriptions of Their Engagement in Fall Prevention.

Evidence-based strategies to decrease fall rates are well established. However, little is understood about how older people engage in fall prevention strategies. Motivational Interviewing (MI) sessions aimed to facilitate individuals' engagement in fall prevention can be analyzed to learn what it means for older people to engage in fall prevention. Thus, the purpose of this study was to explore how older people describe their engagement in fall prevention. Participants in our parent project, MI for Fall Prevention (MI-FP), who received MI sessions were purposively selected for maximum variation in age, sex, fall risks, and MI specialist assigned. The first (of 8) MI sessions from 16 participants were recorded, transcribed, and analyzed using qualitative content analysis. Three researchers first deductively analyzed fall prevention strategies that participants described using an evidence-based fall prevention guideline as a reference. Then, we inductively analyzed the characteristics of these strategies and how participants engaged in them. Finally, we used the Capability, Opportunity, Motivation, Behavior (COM-B) model to organize our results about factors influencing engagement. We found (1) older adults engage in unique combinations of fall prevention strategies and (2) decisions about engagement in fall prevention strategies were influenced by multiple factors that were personal (e.g., who I am, capability, motivation, and opportunities). This study highlighted how fall prevention can be a life-long lifestyle decision for older people. Understanding older people's perspectives about engaging in fall prevention is essential to develop interventions to promote evidence-based fall prevention strategies in real-world settings.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care.

Importance: Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. Objective: To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. Design, Setting, and Participants: This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Main Outcomes and Measures: Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. Results: This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. Conclusions and Relevance: The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Perspectives of young adults diagnosed with early psychosis using coordinated specialty care in Texas on substance use and substance use interventions.

AIM: Despite known prevalence of substance use (SU) among young people experiencing early psychosis and increasing evidence for the relationship between certain substances (e.g., cannabis) and psychosis, there are no specialized interventions developed for effectively addressing substance use among young people participating in coordinated early psychosis services. This study elicited the perspectives of young people with early psychosis participating in Coordinated Specialty Care (CSC) programs about their substance use, including their motivations and concerns around their use, and their ideas on how to best support young people who are interested in reducing or quitting substance use. METHODS: We recruited young adults (ages 18 to 30) from CSC programs across Texas through flyers sent to program staff inviting young persons willing to talk about substance use to engage in a 60-90 min person-centered, semi-structured, audio-recorded Zoom interview. RESULTS: A total of 22 young adults were recruited and 18 completed an interview. Participants described mixed positive and negative responses to substance use, and while many understood the importance of discontinuing substance use, many expressed ambivalence related to social, contextual, mental and physical factors that motivated them to keep using. Participants desired practical substance use information, opportunities to explore their substance use ambivalence in supportive relationships, positive peer communities to support healthy choices, help engage, with work, school, and hobbies, and strategies for addressing psychological and physical pain that did not include substance use. CONCLUSION: Study findings illuminate what motivates young people with early psychosis to initiate, continue, or cut back on substance use, and ideas for CSC practices for exploring substances and helping young people to reduce substance use.

Motivational Interviewing for Fall Prevention (MI-FP) pilot study: Older Adults' readiness to participate in fall prevention.

Older adults' readiness to participate in fall prevention behaviors is largely unknown. We evaluated the feasibility of recruitment for a fall prevention intervention and participants' readiness to participate in fall prevention activities. Patients ≥ 65 years at high fall risk were recruited. Feasibility of recruitment was assessed by reaching the goal sample size (200), and recruitment rate (50%). Surveys assessed participants' readiness to participate in fall prevention activities (confidence to manage fall risks [0-10 scale; 10 most confident] and adherence to fall prevention recommendations). We recruited 200 patients (46.3% of eligible patients), and 185 completed surveys. Participants reported high confidence (range 7.48 to 8.23) in addressing their risks. Their adherence to clinician recommendations was mixed (36.4% to 90.5%). We nearly met our recruitment goals, and found that older adults are confident to address their fall risks, but do not consistently engage in fall prevention recommendations.

Expanding Early Psychosis Care across a Large and Diverse State: Implementation Lessons Learned from Administrative Data and Clinical Team Leads in Texas.

The U.S. is facing an unprecedented youth mental health crisis. Translating the findings from mental health intervention trials into large scale, accessible community-based services poses substantial challenges. Examination of state actions as a result of research-informed federal policy to improve youth access to quality mental healthcare is necessary. This mixed-methods study examines the implementation of evidence-informed multidisciplinary coordinated specialty care (CSC) for first-episode psychosis (FEP) services across Texas. The study explores CSC service model components, site location and participant characteristics, and implementation barriers. This cross-sectional study analyzes State of Texas public mental health administrative data from 2015 to 2020, including CSC site (n = 23) characteristics and CSC participant (n = 1682) demographics. Texas CSC site contracts were compared to OnTrackNY, a leading CSC model in the U.S. for CSC service element comparison. In-depth interviews with CSC Team Leads (n = 22) were analyzed to further understand CSC service elements and implementation barriers using qualitative content analysis. CSC was implemented across three waves in 2015, 2017, and 2019-serving 1682 participants and families. CSC sites were located in adult mental health programs; approximately one third of CSC participants were under 18 years. CSC implementation challenges reported by Team Leads included: staff role clarification, collaboration and turnover, community outreach and referrals, child and adult service billing issues, and adolescent and family engagement. Study findings have implications for large state-wide evidence-based practice implementation in transition-to-adulthood community mental health.