Lost in transition: A protocol for a retrospective, longitudinal cohort study for addressing challenges in opioid treatment for transition-age adults.

BACKGROUND: In the United States, there has been a concerning rise in the prevalence of opioid use disorders (OUD) among transition-age (TA) adults, 18 to 25-years old, with a disproportionate impact on individuals and families covered by Medicaid. Of equal concern, the treatment system continues to underperform for many young people, emphasizing the need to address the treatment challenges faced by this vulnerable population at a pivotal juncture in their life course. Pharmacotherapy is the most effective treatment for OUD, yet notably, observational studies reveal gaps in the receipt of and retention in medications for opioid use disorder (MOUD), resulting in poor outcomes for many TA adults in treatment. Few current studies on OUD treatment quality explicitly consider the influence of individual, organizational, and contextual factors, especially for young people whose social roles and institutional ties remain in flux. METHODS: We introduce a retrospective, longitudinal cohort design to study treatment quality practices and outcomes among approximately 65,000 TA adults entering treatment for OUD between 2012 and 2025 in New York. We propose to combine data from multiple sources, including Medicaid claims and encounter data and a state registry of substance use disorder (SUD) treatment episodes, to examine three aspects of OUD treatment quality: 1) MOUD use, including MOUD option (e.g., buprenorphine, methadone, or extended-release [XR] naltrexone); 2) adherence to pharmacotherapy and retention in treatment; and 3) adverse events (e.g., overdoses). Using rigorous analytical methods, we will provide insights into how variation in treatment practices and outcomes are structured more broadly by multilevel processes related to communities, treatment programs, and characteristics of the patient, as well as their complex interplay. DISCUSSION: Our findings will inform clinical decision making by patients and providers as well as public health responses to the rising number of young adults seeking treatment for OUD amidst the opioid and polysubstance overdose crisis in the U.S.

Impacts of the Affordable Care Act Medicaid Expansion on Mental Health Treatment Among Low-income Adults Across Racial/Ethnic Subgroups, 2010-2017.

This study examines whether the Affordable Care Act (ACA) Medicaid expansion (ME) was associated with changes in racial/ethnic disparities in insurance coverage, utilization, and quality of mental health care among low-income adults with probable mental illness using the National Survey on Drug Use and Health with state identifiers. This study employed difference-in-difference models to compare ME states to non-expansion states before (2010-2013) and after (2014-2017) expansion and triple difference models to examine these changes across non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino racial/ethnic subgroups. Insurance coverage increased significantly for all racial/ethnic groups in expansion states relative to non-expansion states (DD: 9.69; 95% CI: 5.17, 14.21). The proportion low-income adults that received treatment but still had unmet need decreased (DD: -3.06; 95% CI: -5.92, -0.21) and the proportion with unmet need and no mental health treatment increased (DD: 2.38; 95% CI: 0.03, 4.73). ME was not associated with reduced disparities.

Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain.

Importance: Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear. Objective: To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results. Design, Setting, and Participants: A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023. Exposure: Menu labeling policies in 6 US jurisdictions. Main Outcomes and Measures: The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium. Results: The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period. Conclusions and Relevance: In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.

Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients.

Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.

A Matched Analysis of the Association Between Federally Mandated Smoke-Free Housing Policies and Health Outcomes Among Medicaid-Enrolled Children in Subsidized Housing, New York City, 2015-2019.

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory tract infections, and upper respiratory tract infections in the early post-policy intervention period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to the policy) to children living in lots with other subsidized housing (unexposed to the policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015, and December 31, 2019 (the policy was introduced on July 30, 2018). We also examined effect modification by baseline age group (≤2, 3-6, or 7-15 years). In New York City, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early postpolicy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient upper respiratory tract infection claims (incidence rate ratio = 1.05, 95% confidence interval: 1.01, 1.08), a result most pronounced among children aged 3-6 years. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use.

BACKGROUND: Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use. METHODS: We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months. RESULTS: Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention. CONCLUSIONS: This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

Performance of 2 Single-Item Screening Questions to Identify Future Homelessness Among Emergency Department Patients.

Importance: Despite increasing interest in assessing patient social needs in health care settings, there has been little research examining the performance of housing-related screening questions. Objective: To examine the performance of 2 single-item screening questions assessing emergency department (ED) patients' self-perceived risk of future homelessness. Design, Setting, and Participants: This prospective cohort study was conducted among a randomly selected sample of adult ED patients from 2016 to 2017 in a public hospital ED in New York City. Data were analyzed from September 2019 through October 2021. Exposures: Responses on patient surveys conducted at the baseline ED visit for 2 single-item screening questions on self-perceived risk for future housing instability and homelessness were collected. One question asked patients if they were worried about having stable housing in the next 2 months, and the other question asked them to rate the likelihood that they would enter a homeless shelter in the next 6 months. Outcomes: Homeless shelter entry 2, 6, and 12 months after an ED visit, assessed using shelter administrative data in the study city, which was linked with participant baseline survey responses. Results: There were 1919 study participants (976 [51.0%] men and 931 [48.6%] women among 1915 individuals with gender data; 700 individuals aged 31-50 years [36.5%] among 1918 individuals with age data; 1126 Hispanic or Latinx individuals [59.0%], 368 non-Hispanic Black individuals [19.3%], and 225 non-Hispanic White individuals [11.8%] among 1908 individuals with race and ethnicity data). Within 2, 6, and 12 months of the ED visit, 45 patients (2.3%), 66 patients (3.4%), and 95 patients (5.0%) had entered shelter, respectively. For both single-item screening questions, participants who answered affirmatively had significantly higher likelihood of future shelter entry at each time point examined (eg, at 2 months: 31 participants responding yes [6.5%] vs 14 participants responding no [1.0%] to the question concerning being worried about having stable housing in the next 2 months). Sensitivity of the screening questions ranged from 0.27 to 0.69, specificity from 0.76 to 0.97, positive predictive value from 0.07 to 0.27, and area under the receiver operating characteristic curve from 0.62 to 0.72. Conclusions and Relevance: This study found that 2 single-item screening questions assessing ED patient self-perceived risk of future housing instability and homelessness had adequate to good performance in identifying risk for future shelter entry. Such single-item screening questions should be further tested before broad adoption.

Association of substance use characteristics and future homelessness among emergency department patients with drug use or unhealthy alcohol use: Results from a linked data longitudinal cohort analysis.

Background: Homelessness and substance use are intricately related, and both are prevalent among emergency department (ED) patients. This study examined the longitudinal association of substance use characteristics with future homeless shelter entry among ED patients with any drug use or unhealthy alcohol use. Methods: We present results from a longitudinal cohort study of public hospital ED patients who screened positive for drug use or unhealthy alcohol use and who were not homeless at their baseline (index) ED visit. The primary outcome was homeless shelter entry within 12 months of baseline, ascertained in city homeless shelter administrative data. Primary independent variables of interest were alcohol use severity (AUDIT), drug use severity (DAST-10), and types of drugs used, as reported on baseline survey questionnaires. Results: Analyses included 1,210 ED patients. By 12 months following the baseline ED visit, 114 (9.4%) had entered a homeless shelter. Among patients with the most severe problems related to drug use (DAST-10 score 9-10), 40.9% entered a shelter within 12 months. Past shelter use was the strongest predictor of future shelter entry; once adjusting for historic shelter use the relationship of AUDIT and DAST-10 scores with future shelter entry was no longer statistically significant in multivariable models. Conclusions: ED patients with past year drug use or unhealthy alcohol use had relatively high likelihood of future shelter entry. Risk for homelessness should be addressed in future interventions with this population. Findings illustrate the complexity of relationships between substance use and homelessness.

Development of a homelessness risk screening tool for emergency department patients.

OBJECTIVE: To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes. DATA SOURCES: Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database. STUDY DESIGN: Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires. DATA COLLECTION/EXTRACTION METHODS: Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching. PRINCIPAL FINDINGS: Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry. CONCLUSIONS: Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.

Impact of New York State's Health Home program on access to care among patients with diabetes.

INTRODUCTION: Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care. RESEARCH DESIGN AND METHODS: Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods. RESULTS: We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit. CONCLUSIONS: New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs.

Health-Related Social Needs Among Emergency Department Patients with HIV.

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.

RESUMEN: Pocas investigaciones han examinado las necesidades sociales relacionadas con la salud de los pacientes del departamento de emergencias que tienen VIH. Encuestamos una muestra aleatoria de pacientes del departamento de emergencias de un hospital público y comparamos las necesidades sociales de los pacientes con y sin VIH. Las necesidades sociales eran altas entre todos los pacientes, pero los pacientes con VIH informaron niveles significativamente más altos de inseguridad alimentaria (65.0% vs. 50.3%, p = 0.01) y estado sin hogar o compartir una habitación (33.8% vs. 21.0%, p < 0.01) que otros pacientes. Nuestros resultados sugieren la importancia de evaluar las necesidades sociales en las intervenciones en departamentos de emergencias para pacientes con VIH.

Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department Use.

INTRODUCTION: Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients. METHODS: We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status. RESULTS: One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models. CONCLUSION: The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.

Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis.

STUDY OBJECTIVE: Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. METHODS: We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. RESULTS: Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. CONCLUSION: In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

Health-related material needs and substance use among emergency department patients.

Background: Emergency department (ED) visits related to substance use are common. ED patients also have high levels of health-related material needs (HRMNs), such as homelessness and food insecurity. However, little research has examined the intersection between ED patient HRMNs and substance use. Methods: We surveyed a random sample of public hospital ED patients. Surveys included validated single-item screeners for unhealthy alcohol and any drug use and questions on self-reported past-year material needs. We compared individual HRMNs and cumulative number of HRMNs by substance use screening status using bivariate and multivariable analyses. Results: A total of 2312 surveys were completed. Nearly one third of patients (32.3%, n = 747) screened positive for unhealthy alcohol use, and 21.8% (n = 503) screened positive for drug use. Prevalence of HRMNs for all patients-including food insecurity (50.8%), inability to meet essential expenses (40.8%), cost barriers to medical care (24.6%), employment issues (23.8%), and homelessness (21.4%)-was high and was significantly higher for patients with unhealthy alcohol use or drug use. In multivariable analyses, homelessness was independently associated with unhealthy alcohol use (adjusted odds ratio [aOR]: 1.61, 95% confidence interval [CI]: 1.24-2.09) and drug use (aOR: 2.30, 95% CI: 1.74-3.05). There was a significant stepwise increase in the odds of patient unhealthy alcohol or drug use as number of HRMNs increased. Conclusions: ED patients with unhealthy alcohol or drug use have higher prevalence of HRMNs than those without. Our findings suggest that HRMNs may act additively and that homelessness is particularly salient. Patients' comorbid HRMNs may affect the success of ED-based substance use interventions.

Disparities in food access around homes and schools for New York City children.

Demographic and income disparities may impact food accessibility. Research has not yet well documented the precise location of healthy and unhealthy food resources around children's homes and schools. The objective of this study was to examine the food environment around homes and schools for all public school children, stratified by race/ethnicity and poverty status. This cross-sectional study linked data on the exact home and school addresses of a population-based sample of public school children in New York City from 2013 to all corner stores, supermarkets, fast-food restaurants, and wait-service restaurants. Two measures were created around these addresses for all children: 1) distance to the nearest outlet, and 2) count of outlets within 0.25 miles. The total analytic sample included 789,520 K-12 graders. The average age was 11.78 years (SD ± 4.0 years). Black, Hispanic, and Asian students live and attend schools closer to nearly all food outlet types than White students, regardless of poverty status. Among not low-income students, Black, Hispanic, and Asian students were closer from home and school to corner stores and supermarkets, and had more supermarkets around school than White students. The context in which children live matters, and more nuanced data is important for development of appropriate solutions for childhood obesity. Future research should examine disparities in the food environment in other geographies and by other demographic characteristics, and then link these differences to health outcomes like body mass index. These findings can be used to better understand disparities in food access and to help design policies intended to promote healthy eating among children.

Undocumented Latino Immigrants and Research: New Challenges in Changing Times.

Latinos are the largest immigrant group in the United States, representing 17.6% of the total U.S. population, and are therefore critical to include in research. However, Latino immigrants-and particularly those who are undocumented residents-may be increasingly wary of participating in research amidst hostile anti-immigrant rhetoric and high profile cases of deportation. In this commentary we discuss challenges of conducting research with undocumented Latino immigrants in the current sociopolitical climate. We provide suggestions for data collection, data protection, and research recruitment techniques that may mitigate some of these challenges.

Patient-Centered Care in Small Primary Care Practices in New York City: Recognition Versus Reality.

BACKGROUND: The Primary Care Information Project (PCIP) is a program administered by the New York City Department of Health and Mental Hygiene to help primary care providers adopt a fully functional electronic health record (EHR) and focus on population health. PCIP also offers practices assistance with the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition application. The objectives of this study were to assess the presence of key dimensions of PCMH among PCIP practices with 5 or fewer providers and to determine whether and to what extent NCQA recognition was related to the presence of these dimensions. METHODS: Analyses relied on data collected from a comprehensive practice assessment survey of PCIP practices administered in summer 2012. The survey was developed to assess discrete dimensions of the PCMH model and other practice characteristics. The study population includes practices for which survey results were available among PCIP practices with 5 or fewer providers (63% response rate; n = 83). RESULTS: At the time of survey, 57% of practices had received some level of NCQA recognition (n = 47). Practices with recognition scored significantly higher on several dimensions, including whole person orientation, team-based care, care coordination and integration, and quality and safety. CONCLUSIONS: Results indicate that very small urban practices in New York City are implementing many key features of PCMH. In general, practices with NCQA recognition scored higher on PCMH constructs and domains relative to practices without recognition; however, there is room for improvement on construct and domain scores in both groups.

The Introduction of a Supermarket via Tax-Credits in a Low-Income Area.

PURPOSE: Interest and funding continue to grow for bringing supermarkets to underserved areas, yet little is known about their impact. DESIGN: A quasi-experimental study was used to determine the impact of a new supermarket opening as a result of tax and zoning incentives. SETTING: The study took place in the South Bronx, New York City, New York. SUBJECTS: Studied were residents of two South Bronx neighborhoods deemed high need. MEASURES: Food purchasing and consumption were examined via surveys and 24-hour dietary recalls before and at two points after the supermarket opened (1-5, 13-17 months). ANALYSIS: Data were analyzed using difference-in-difference models controlling for gender, race and ethnicity, age, education, marital status, and self-reported income. Ordinary least squares and logistic regression models were estimated for continuous and binary outcomes, respectively. RESULTS: At baseline, 94% to 97% of consumers shopped at a supermarket. There was a 2% increase in this behavior in the intervention community ( p < .05) not seen in the comparison community. One year later there was a 7% net increase in eating at home ( p < .1) and a 20% decrease in drinking sugary beverages ( p < .05), but no appreciable change in fruit/vegetable consumption or overall dietary quality. CONCLUSION: The new supermarket did not result in substantial or broad changes in purchasing patterns or nutritional quality of food consumed, though smaller, positive changes were observed over a 1-year period. Future work should examine different contexts and a broader set of outcomes, including economic development.

Variation in Payment Rates under Medicare's Inpatient Prospective Payment System.

OBJECTIVE: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.