The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015.

OBJECTIVES: Opioid-related overdoses are commonly attributed to prescription opioids. We examined data on opioid-related overdose decedents in Massachusetts. For each decedent, we determined which opioid medications had been prescribed and dispensed and which opioids were detected in postmortem medical examiner toxicology specimens. METHODS: Among opioid-related overdose decedents in Massachusetts during 2013-2015, we analyzed individually linked postmortem opioid toxicology reports and prescription drug monitoring program records to determine instances of overdose in which a decedent had a prescription active on the date of death for the opioid(s) detected in the toxicology report. We also calculated the proportion of overdoses for which prescribed opioid medications were not detected in decedents' toxicology reports. RESULTS: Of 2916 decedents with complete toxicology reports, 1789 (61.4%) had heroin and 1322 (45.3%) had fentanyl detected in postmortem toxicology reports. Of the 491 (16.8%) decedents with ≥1 opioid prescription active on the date of death, prescribed opioids were commonly not detected in toxicology reports, specifically: buprenorphine (56 of 97; 57.7%), oxycodone (93 of 176; 52.8%), and methadone prescribed for opioid use disorder (36 of 112; 32.1%). Only 39 (1.3%) decedents had an active prescription for each opioid detected in toxicology reports on the date of death. CONCLUSION: Linking overdose toxicology reports to prescription drug monitoring program records can help attribute overdoses to prescribed opioids, diverted prescription opioids, heroin, and illicitly made fentanyl.

Using Electronic Referrals to Address Health Disparities and Improve Blood Pressure Control.

INTRODUCTION: Massachusetts developed and used bidirectional electronic referrals to connect clinical patients across the state to interventions run by community organizations. The objective of our study was to determine whether the use of Massachusetts's electronic referral system (MA e-Referral) reached racial/ethnic groups experiencing health disparities and whether it was associated with improved health outcomes. METHODS: We assembled encounter-level medical records from September 2013 through June 2017 for patients at Massachusetts clinics funded by the Clinical Community Partnerships for Prevention into 2 cohorts. First, all patients meeting program eligibility guidelines for an e-Referral (N = 21,701) were examined to assess the distribution of e-Referrals among populations facing health disparities; second, a subset of 3,817 people with hypertension were analyzed to detect changes in blood pressure after e-Referral to an evidence-based community intervention. RESULTS: Non-Hispanic black (OR, 1.4; 95% confidence interval [CI], 1.2-1.6) and Hispanic patients (OR, 1.3; 95% CI, 1.1-1.4) had higher odds than non-Hispanic white patients of being referred electronically. Patients completing their hypertension intervention had 74% (95% CI, 1.2-2.5) higher odds of having an in-control blood pressure reading than patients who were not electronically referred. CONCLUSION: Clinical to community linkage to interventions through MA e-Referral reached non-Hispanic black, Hispanic, and Spanish-speaking populations and was associated with improved blood pressure control.

Rationale and design of the Clinic and Community Approaches to Healthy Weight Randomized Trial.

BACKGROUND: Recent studies have demonstrated the effectiveness of family-centered, pediatric weight management programs in reducing childhood obesity. Yet, programs to optimize the care of low-income children with obesity are needed. We sought to examine the comparative effectiveness of two, potentially scalable pediatric weight management programs delivered to low-income children in a clinical or community setting. MATERIALS AND METHODS: The Clinic and Community Approaches to Healthy Weight Trial is a randomized trial in two communities in Massachusetts that serve a large population of low-income children and families. The two-arm trial compares the effects of a pediatric weight management program delivered in the Healthy Weight Clinics of two federally qualified health centers (FQHC) to the Healthy Weight and Your Child programs delivered in two YMCAs. Eligible children are 6 to 12 years old with a body mass index (BMI) ≥ 85th percentile seen in primary care at the two FQHCs. Both programs are one-year in duration and have at least 30 contact hours throughout the year. Measures are collected at baseline, 6 months, and 1 year. The main outcome is 1-year change in BMI (kg/m2) and percent change of the 95th percentile (%BMIp95). CONCLUSION: The Clinic and Community Approaches to Healthy Weight Trial seeks to 1) examine the comparative effects of a clinical and community based intervention in improving childhood obesity, and 2) inform the care of >7 million children with obesity covered by the Children's Health Insurance Program or Medicaid.

Using School Staff Members to Implement a Childhood Obesity Prevention Intervention in Low-Income School Districts: the Massachusetts Childhood Obesity Research Demonstration (MA-CORD Project), 2012-2014.

INTRODUCTION: Although evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts' capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing "Eat Well and Keep Moving" and "Planet Health" behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts. METHODS: The intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability. RESULTS: MA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district's staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers. CONCLUSION: Future interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

Declining Trends and Widening Disparities in Overweight and Obesity Prevalence Among Massachusetts Public School Districts, 2009-2014.

OBJECTIVES: We evaluated the overall and sociodemographic disparities in trends in prevalence of childhood overweight and obesity in Massachusetts public school districts between 2009 and 2014. METHODS: In 2009, Massachusetts mandated annual screening of body mass index for students in grades 1, 4, 7, and 10. This was part of the statewide Mass in Motion prevention programs. We assessed trends in the prevalence of overweight and obesity between 2009 and 2014 by district, gender, grade, and district income. RESULTS: From 2009 to 2014, prevalence decreased 3.0 percentage points (from 34.3% to 31.3%) statewide. The 2014 district-level rates ranged from 13.9% to 54.5% (median = 31.2%). When stratified by grade, the decreasing trends were significant only for grades 1 and 4. Although rates of districts with a median household income greater than $37, 000 improved notably, rates of the poorest remain unchanged and were approximately 40%. CONCLUSIONS: Although overall prevalence began to decrease, the geographic and socioeconomic disparities in childhood obesity are widening and remain a public health challenge in Massachusetts. Special efforts should be made to address the needs of socioeconomically disadvantaged districts and to narrow the disparities in childhood obesity.

Community stakeholders' perceptions of barriers to childhood obesity prevention in low-income families, Massachusetts 2012-2013.

INTRODUCTION: The etiology of childhood obesity is multidimensional and includes individual, familial, organizational, and societal factors. Policymakers and researchers are promoting social-ecological approaches to obesity prevention that encompass multiple community sectors. Programs that successfully engage low-income families in making healthy choices are greatly needed, yet little is known about the extent to which stakeholders understand the complexity of barriers encountered by families. The objective of this study was to contextually frame barriers faced by low-income families reported by community stakeholders by using the Family Ecological Model (FEM). METHODS: From 2012 through 2013, we conducted semistructured interviews with 39 stakeholders from 2 communities in Massachusetts that were participating in a multisector intervention for childhood obesity prevention. Stakeholders represented schools; afterschool programs; health care; the Special Supplemental Nutrition Program for Women, Infants, and Children; and early care and education. Interviews were audio-recorded, transcribed, coded, and summarized. RESULTS: Stakeholder reports of the barriers experienced by low-income families had a strong degree of overlap with FEM and reflected awareness of the broader contextual factors (eg, availability of community resources, family culture, education) and social and emotional dynamics within families (eg, parent knowledge, social norms, distrust of health care providers, chronic life stressors) that could affect family adoption of healthy lifestyle behaviors. Furthermore, results illustrated a level of consistency in stakeholder awareness across multiple community sectors. CONCLUSION: The congruity of stakeholder perspectives with those of low-income parents as summarized in FEM and across community sectors illustrates potential for synergizing the efforts necessary for multisector, multilevel community interventions for the prevention of childhood obesity.

Disparities in access to healthy and unhealthy foods in central Massachusetts: implications for public health policy.

OBJECTIVES: To analyze geographic and income disparities in access to healthy foods in central Massachusetts. METHODS: We surveyed 106 (92% of all) food stores longitudinally in the study area between 2007 and 2010. We analyzed the geographic and temporal variations in community- and store-level healthy food availability indices (HFAI) and unhealthy food availability indices (UFAI) overall and by select store and community characteristics. RESULTS: Twenty-seven of 68 communities in the study area (39.7%) had no food store and 5 (8.3%) had one or few stores with very limited availability of healthy foods, affecting 23.7% of the county population. Lack of food stores was associated strongly with lower housing density and upper tertile of median household income. About 45% of the surveyed stores had inadequate availabilities of healthy food. Store-level HFAI and UFAI scores were highly correlated, and higher among larger stores affiliated with a chain (vs independent). Though healthy foods were usually most available in larger stores, unhealthy foods were widely available in all stores. CONCLUSIONS: Over half of central Massachusetts communities, mostly rural and small, had either no food store or few stores with limited availabilities of healthy foods. Immediate policy interventions on the food environment are necessary in these communities. Further, without examining what is actually sold in stores, analysis of disparities in access to healthy food relies on the number of food stores, which can lead to a distorted picture of accessibility and mislead community health policies.

Design of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study.

BACKGROUND: Childhood obesity is highly prevalent, is associated with both short- and long-term adverse outcomes, disproportionately affects racial/ethnic minority and economically deprived children, and represents a major threat to public health. Among the most promising approaches for its prevention and management are multilevel, multisector strategies. METHODS/DESIGN: The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study was a comprehensive, systematic intervention to prevent and reduce childhood obesity among low-income children ages 2-12 years in two selected cities in Massachusetts. Building on the Obesity Chronic Care Model, MA-CORD expanded a state public health department community-level obesity prevention initiative that incorporated evidence-based interventions in primary healthcare, the Women, Infants, and Children program, early care and education, schools/afterschool programs, as well as community-wide programs to improve food, beverage, physical activity (PA), and messaging environments. The study used a combination of pre- and post-time series and quasi-experimental designs to examine the extent to which the intervention resulted in changes in BMI, individual-level lifestyle behaviors, satisfaction with healthcare services, and quality of life among children, as well as changes in health policies, programs, and environments in the two intervention cities, compared to a comparison city. The intervention period was 2 years. CONCLUSIONS: MA-CORD will determine the extent to which a multisetting, multilevel intervention that integrates activities in primary care with broader public health interventions in schools, early care and education, and the community at large can improve children's dietary and PA behaviors and ultimately reduce obesity in low-income children.

Access to healthy food stores modifies effect of a dietary intervention.

BACKGROUND: Recent evidence suggests that opening a grocery store in a food desert does not translate to better diet quality among community residents. PURPOSE: This study evaluated the influence of proximity to a healthy food store on the effect of a dietary behavioral intervention on diet among obese adults randomized to either a high fiber or American Heart Association diet intervention. METHODS: Participants were recruited from Worcester County, Massachusetts, between June 2009 and January 2012. Dietary data were collected via 24-hour recalls at baseline and 3, 6, and 12 months post-intervention. Based on in-store inspection data, a store was considered as having adequate availability of healthy foods if it had at least one item available in each of 20 healthy food categories. Linear models evaluated maximum change in dietary outcomes in relation to road distance from residence to the nearest June healthy food store. The analysis was conducted in January to June 2014. RESULTS: On average, participants (N=204) were aged 52 years, BMI=34.9, and included 72% women and 89% non-Hispanic whites. Shorter distance to a healthy food store was associated with greater improvements in consumption of fiber (b=-1.07 g/day per mile, p<0.01) and fruits and vegetables (b=-0.19 servings/day per mile, p=0.03) with and without covariate adjustment. CONCLUSIONS: The effectiveness of dietary interventions is significantly influenced by the presence of a supportive community nutrition environment. Considering the nationwide efforts on promotion of healthy eating, the value of improving community access to healthy foods should not be underestimated. CLINICAL TRIAL REGISTRATION NUMBER: NCT00911885.

Smokeless tobacco products sold in Massachusetts from 2003 to 2012: trends and variations in brand availability, nicotine contents and design features.

BACKGROUND: Sales of smokeless tobacco products have increased in the USA. More than one in eight males in the 12th grade are current users of smokeless tobacco. Surveillance data examining nicotine levels of smokeless tobacco subsequent to 2006 have not been reported in the literature. METHODS: Data on nicotine levels and design features (eg, pH, moisture content, leaf cut and flavour) of smokeless tobacco products sold in Massachusetts were obtained from manufacturers between 2003 and 2012. Design features, levels and temporal trends in unionised (free) nicotine and nicotine content of smokeless tobacco products were analysed overall and by manufacturer and product type. RESULTS: The annual total number of moist snuff products increased from 99 in 2003 to 127 in 2012. The annual total number of reported snus products increased from 4 in 2003 to the highest level of 62 in 2011, before decreasing to 26 in 2012. Overall, mean unionised (free) nicotine remained relatively stable (ß=0.018 (95% CI -0.014 to 0.050) mg/g dry weight/year) from 2003 to 2012. However, both levels and temporal trends of mean free nicotine varied significantly among manufacturers (p<0.001). Since 2003, the free nicotine content of snus has increased at an overall rate of 0.192 (95% CI 0.138 to 0.246) mg/g dry weight/year, but varied by manufacturer (p<0.001). CONCLUSIONS: The number of smokeless tobacco products increased in the Massachusetts market. Further, mean unionised (free) nicotine levels in smokeless tobacco products of several manufacturers continued to rise despite decreasing levels from other manufacturers. The current success in tobacco control is very likely undermined without government surveillance, regulation and widespread public disclosure of nicotine levels in these products.

Tailoring community-based wellness initiatives with latent class analysis--Massachusetts Community Transformation Grant projects.

INTRODUCTION: Community-based approaches to preventing chronic diseases are attractive because of their broad reach and low costs, and as such, are integral components of health care reform efforts. Implementing community-based initiatives across Massachusetts' municipalities presents both programmatic and evaluation challenges. For effective delivery and evaluation of the interventions, establishing a community typology that groups similar municipalities provides a balanced and cost-effective approach. METHODS: Through a series of key informant interviews and exploratory data analysis, we identified 55 municipal-level indicators of 6 domains for the typology analysis. The domains were health behaviors and health outcomes, housing and land use, transportation, retail environment, socioeconomics, and demographic composition. A latent class analysis was used to identify 10 groups of municipalities based on similar patterns of municipal-level indicators across the domains. RESULTS: Our model with 10 latent classes yielded excellent classification certainty (relative entropy = .995, minimum class probability for any class = .871), and differentiated distinct groups of municipalities based on health-relevant needs and resources. The classes differentiated healthy and racially and ethnically diverse urban areas from cities with similar population densities and diversity but worse health outcomes, affluent communities from lower-income rural communities, and mature suburban areas from rapidly suburbanizing communities with different healthy-living challenges. CONCLUSION: Latent class analysis is a tool that may aid in the planning, communication, and evaluation of community-based wellness initiatives such as Community Transformation Grants projects administrated by the Centers for Disease Control and Prevention.

Integrating tobacco cessation quitlines into health care: Massachusetts, 2002-2011.

QuitWorks is a Massachusetts referral program that links health care organizations, providers, and patients to the state's tobacco cessation quitline and provides feedback reporting. Designed collaboratively with all major Massachusetts health plans, QuitWorks was launched in April 2002. In 2010, approximately 340 institutions and practices used QuitWorks. Between April 2002 and March 2011, approximately 3,000 unique providers referred patients and 32,967 tobacco users received referrals. An analysis of QuitWorks data showed 3 phases in referrals between April 2002 and March 2011: referrals increased from April 2002 through November 2005, plateaued during December 2005 through January 2009, then substantially increased during February 2009 through March 2011. Factors responsible include partnerships with stakeholders, periodic program promotions, hospital activities in response to Joint Commission tobacco use measures, service evolutions, provision of nicotine replacement therapy for referred patients, and electronic referral options. QuitWorks' history demonstrates that tobacco cessation referral programs can be successfully sustained over time; reach substantial numbers of tobacco users, benefit providers and health care organizations; and contribute to sustainable systems-level changes in health care.

Who underreports smoking on birth records: a Monte Carlo predictive model with validation.

BACKGROUND: Research has shown that self-reports of smoking during pregnancy may underestimate true prevalence. However, little is known about which populations have higher rates of underreporting. Availability of more accurate measures of smoking during pregnancy could greatly enhance the usefulness of existing studies on the effects of maternal smoking offspring, especially in those populations where underreporting may lead to underestimation of the impact of smoking during pregnancy. METHODS AND FINDINGS: In this paper, we develop a statistical Monte Carlo model to estimate patterns of underreporting of smoking during pregnancy, and apply it to analyze the smoking self-report data from birth certificates in the state of Massachusetts. Our results illustrate non-uniform patterns of underreporting of smoking during pregnancy among different populations. Estimates of likely underreporting of smoking during pregnancy were highest among mothers who were college-educated, married, aged 30 years or older, employed full-time, and planning to breastfeed. The model's findings are validated and compared to an existing underreporting adjustment approach in the Maternal and Infant Smoking Study of East Boston (MISSEB). CONCLUSIONS: The validation results show that when biological assays are not available, the Monte Carlo method proposed can provide a more accurate estimate of the smoking status during pregnancy than self-reports alone. Such methods hold promise for providing a better assessment of the impact of smoking during pregnancy.

A longitudinal study of medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease.

BACKGROUND: Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period. METHODS AND FINDINGS: Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%-70%) and 49% (95% confidence interval 6%-72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated. CONCLUSIONS: Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.

Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence.

BACKGROUND: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. METHODS AND FINDINGS: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. CONCLUSION: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.