Impact of the Philadelphia Beverage Tax on Perceived Beverage Healthfulness, Tax Awareness, and Tax Opinions.

OBJECTIVE: To assess the impact of the Philadelphia Beverage Tax on perceived beverage healthfulness, and awareness and opinions of the tax. DESIGN: Natural experiment SETTING: Small independent stores in Philadelphia (n = 61) and Baltimore (untaxed control site; n = 65) PARTICIPANTS: Shoppers in Philadelphia (n = 2,731) and Baltimore (n = 4,600) pre- and post-tax implementation. MAIN OUTCOME MEASURES: Perceptions of 4 beverages (unhealthy vs healthy/neutral), tax awareness, and tax opinions (oppose vs favor/neutral). ANALYSIS: Mixed-effects linear probability models estimated changes in perceived beverage healthfulness in Philadelphia, relative to Baltimore, following a difference-in-differences approach. Mixed-effects linear probability models estimated pre-post changes in tax awareness and opinions in Philadelphia-only. RESULTS: The probability of perceiving taxed beverages as unhealthy increased 2-years post-tax relative to Baltimore (regular soda: 5.7% [95% confidence interval (CI), 0.9-10.6], P = 0.02; diet soda: 7.7% [95% CI, 1.5-13.8], P < 0.001; sports drinks: 6.4% [95% CI, 0.4-12.4], P = 0.04), with similar changes at 1-year post-tax, whereas perceived healthfulness of untaxed 100% fruit juice did not change. Tax awareness was high at baseline (72%) and increased post-implementation; however, the probability of opposing the tax (22%) also increased over time. CONCLUSIONS AND IMPLICATIONS: Decreases in the perceived healthfulness of taxed beverages suggest the tax had a health-signaling effect. Consumer awareness and health education efforts could complement tax policies to enhance understanding of health risks.

Advertising and Stocking at Small Retailers: A Sweetened Beverage Excise Tax in Philadelphia.

INTRODUCTION: In 2017, Philadelphia enacted a $0.015 per ounce excise tax on SBs that covered both sugar-sweetened beverages and artificially-sweetened beverages, which reduced purchasing and consumption. This study assessed whether the tax also changed beverage advertising or stocking practices that could influence consumer behavior among stores in Philadelphia, Baltimore, and Philadelphia-adjacent counties not subject to the tax. METHODS: Using a longitudinal difference-in-differences approach, beverage advertising and availability changes were evaluated from 4-month pretax to 6-, 12-, and 24-month post-implementation in small independent stores in Philadelphia (n=34) and Philadelphia-adjacent counties (n=38) versus Baltimore (n=43), a demographically similar city without a tax. Mixed effects models tested whether beverage advertising/availability increased in Philadelphia and surrounding counties after implementation versus Baltimore, included store-level random intercepts, and were stratified by beverage tax status, type, size, and store ZIP code income. Data were collected from 2016 to 2018, and analyses were performed in 2022-2023. RESULTS: SB advertising increased post-tax in Philadelphia (6 months= +1.04 advertisements/store [95% CI=0.27, 1.80]; 12 months= +1.54 [95% CI=0.57, 2.52]; 24 months= +0.91 [95% CI=0.09, 1.72]) relative to Baltimore. This was driven by increased advertising of sweetened beverages in low-income ZIP codes. Marketing of SBs increased significantly in Philadelphia-adjacent counties relative to Baltimore. Although SB availability in Philadelphia did not change, it increased in surrounding county stores (6 months= +0.20 [95% CI=0.15, 0.25]; 12 months= +0.08 [95% CI=0.03, 0.12]) relative to Baltimore. CONCLUSIONS: Marketing of SBs, especially in low-income neighborhoods and in surrounding counties, increased following Philadelphia's beverage tax among small, independent retailers. These increases in advertising might have dampened the tax's effect on purchasing behaviors, although estimated effects on sales remained large.

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

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

Economics of a health system's direct-to-consumer telemedicine for its employees.

OBJECTIVES: To compare the mean per-episode unit cost for a direct-to-consumer (DTC) telemedicine service for medical center employees (OnDemand) with that of in-person care and to estimate whether the offered service increased the use of care. STUDY DESIGN: Propensity score-matched retrospective cohort study of adult employees and dependents of a large academic health system between July 7, 2017, and December 31, 2019. METHODS: To estimate differences in per-episode unit costs within 7 days, we compared costs between OnDemand encounters and conventional in-person encounters (primary care, urgent care, and emergency department) for any similar condition using a generalized linear model. We used interrupted time series analyses limited to the top 10 clinical conditions managed by OnDemand to estimate the effect of OnDemand's availability on the trends for overall employee per-month encounters. RESULTS: A total of 10,826 encounters among 7793 beneficiaries were included (mean [SD] age, 38.5 [10.9] years; 81.6% were women). The mean (SE) 7-day per-episode cost among employees and beneficiaries was lower for OnDemand encounters at $379.76 ($19.83) relative to non-OnDemand encounters at $493.49 ($25.53), a mean per-episode savings of $113.73 (95% CI, $50.36-$177.10; P < .001). After the introduction of OnDemand, among employees with encounters for the top 10 clinical conditions managed by OnDemand, the trend for encounter rates per 100 employees per month increased marginally (0.03; 95% CI, 0.00-0.05; P = .03). CONCLUSIONS: These results suggest that DTC telemedicine staffed by an academic health system and offered directly to employees reduced the per-episode unit costs and only marginally increased utilization, suggesting lower cost overall.

Changes in Dental Outcomes After Implementation of the Philadelphia Beverage Tax.

INTRODUCTION: Beverage taxes are associated with declines in sugar-sweetened beverage sales and consumption, but few studies have evaluated the associations of these taxes with health outcomes. This study analyzed changes in dental decay after the implementation of the Philadelphia sweetened beverage tax. METHODS: Electronic dental record data were obtained on 83,260 patients living in Philadelphia and control areas from 2014 to 2019. Difference-in-differences analyses compared the number of new Decayed, Missing, and Filled Teeth with that of new Decayed, Missing, and Filled Surfaces before (January 2014-December 2016) and after (January 2019-December 2019) tax implementation in Philadelphia and control patients. Analyses were conducted in older children/adults (aged ≥15 years) and younger children (aged <15 years). Subgroup analyses stratified by Medicaid status. Analyses were conducted in 2022. RESULTS: The number of new Decayed, Missing, and Filled Teeth did not change after tax implementation in Philadelphia in panel analyses of older children/adults (difference-in-differences= -0.02, 95% CI= -0.08, 0.03) or younger children (difference-in-differences=0.07, 95% CI= -0.08, 0.23). There were similarly no post-tax changes in the number of new Decayed, Missing, and Filled Surfaces. However, in cross-sectional samples of patients on Medicaid, the number of new Decayed, Missing, and Filled Teeth was lower after tax implementation in older children/adults (difference-in-differences= -0.18, 95% CI= -0.34, -0.03; -22% decline) and younger children (difference-in-differences= -0.22, 95% CI= -0.46, 0.01; -30% decline), with similar results for number of new Decayed, Missing, and Filled Surfaces. CONCLUSIONS: The Philadelphia beverage tax was not associated with reduced tooth decay in the general population, but it was associated with reduced tooth decay in adults and children on Medicaid, suggesting potential health benefits for low-income populations.

A regression framework for a probabilistic measure of cost-effectiveness.

To make informed health policy decisions regarding a treatment, we must consider both its cost and its clinical effectiveness. In past work, we introduced the net benefit separation (NBS) as a novel measure of cost-effectiveness. The NBS is a probabilistic measure that characterizes the extent to which a treated patient will be more likely to experience benefit as compared to an untreated patient. Due to variation in treatment response across patients, uncovering factors that influence cost-effectiveness can assist policy makers in population-level decisions regarding resource allocation. In this paper, we introduce a regression framework for NBS in order to estimate covariate-specific NBS and find determinants of variation in NBS. Our approach is able to accommodate informative cost censoring through inverse probability weighting techniques, and addresses confounding through a semiparametric standardization procedure. Through simulations, we show that NBS regression performs well in a variety of common scenarios. We apply our proposed regression procedure to a realistic simulated data set as an illustration of how our approach could be used to investigate the association between cancer stage, comorbidities and cost-effectiveness when comparing adjuvant radiation therapy and chemotherapy in post-hysterectomy endometrial cancer patients.

Sustained Impact of the Philadelphia Beverage Tax on Beverage Prices and Sales Over 2 Years.

INTRODUCTION: It is unclear whether changes in beverage price and sales after beverage tax implementation can be sustained long term. This study aims to quantify the changes in beverage prices and sales in large retailers 2 years after the implementation of the 1.5 cents per ounce Philadelphia beverage tax. METHODS: Data on price and volume sales of beverages and potential food substitutes were collected from 109 supermarkets, 45 mass merchandizers, and 350 pharmacies in Philadelphia, Baltimore (control), and Pennsylvania ZIP codes bordering Philadelphia (to investigate potential cross-border shopping for tax avoidance). Difference-in-differences analyses compared beverage prices and volume sales in the year before tax implementation (2016) to 2 years after (2018). Data were analyzed in 2020-2021. RESULTS: Difference-in-differences analyses found that after tax implementation, taxed beverage prices in Philadelphia increased by 1.02 cents per ounce (95% CI=0.94, 1.11; 68% pass through), and taxed beverage volume sales in stores decreased by 50% (95% CI=36%, 61%). After accounting for cross-border shopping, taxed beverage volume sales decreased in Philadelphia by 35% in 2018. Volume sales of nontaxed beverages did not change after tax implementation (difference-in-differences=4%, 95% CI= -3%, 12%). Volume sales of nontaxed beverage concentrates increased on average by 34% (95% CI=19%, 51%), but there was no evidence of substitution to high-calorie foods. CONCLUSIONS: There was a large reduction in taxed beverage volume sales 2 years after Philadelphia tax implementation, even after accounting for cross-border shopping. Increases in nontaxed beverage concentrate sales likely partially offset this decline, but there was no evidence of post-tax food substitution.

US local public health department spending between 2008 and 2016 did not increase for communities in need.

BACKGROUND: Greater US local public health department (LPHD) spending has been associated with decreases in population-wide mortality. We examined the association between changes in LPHD spending between 2008 and 2016 and county-level sociodemographic indicators of public health need. METHODS: Multivariable linear regression was used to estimate the association between changes in county-level per-capita LPHD spending and 2008 sociodemographic indicators of interest: percent of population that was over 65 years old, Black, Hispanic, in poverty, unemployed, and uninsured. A second model assessed the relationship between changes in LPHD spending and sociodemographic shifts between 2008 and 2016. RESULTS: LPHD spending increases were associated with higher percentage points of 2008 adults over 65 years of age (+$0.53 per higher percentage point; 95% CI: +$0.01 to +$1.06) and unemployment (-$1.31; 95% CI: -$2.34 to -$0.27). Spending did not increase for communities with a higher proportion of people who identified as Black or Hispanic, or those with a greater proportion of people in poverty or uninsured, using either baseline or sociodemographic shifts between 2008 and 2016. CONCLUSION: Future LPHD funding decisions should consider increasing investments in counties serving disadvantaged communities to counteract the social, political, and structural barriers which have historically prevented these communities from achieving better health.

Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients.

BACKGROUND: Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. METHODS: The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. CONCLUSION: The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

Purchases of Nontaxed Foods, Beverages, and Alcohol in a Longitudinal Cohort After Implementation of the Philadelphia Beverage Tax.

BACKGROUND: Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases. OBJECTIVES: We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax. METHODS: A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore. RESULTS: Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54). CONCLUSIONS: In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

Changes in Supplemental Nutrition Assistance Program Policies and Diabetes Prevalence: Analysis of Behavioral Risk Factor Surveillance System Data From 2004 to 2014.

OBJECTIVE: Food insecurity is associated with diabetes. The Supplemental Nutrition Assistance Program (SNAP) is the largest U.S. government food assistance program. Whether such programs impact diabetes trends is unclear. The objective of this study was to evaluate the association between changes in state-level policies affecting SNAP participation and county-level diabetes prevalence. RESEARCH DESIGN AND METHODS: We evaluated the association between change in county-level diabetes prevalence and changes in the U.S. Department of Agriculture SNAP policy index-a measure of adoption of state-level policies associated with increased SNAP participation (higher value indicating adoption of more policies associated with increased SNAP participation; range 1-10)-from 2004 to 2014 using g-computation, a robust causal inference methodology. The study included all U.S. counties with diabetes prevalence data available from the Centers for Disease Control and Prevention's U.S. Diabetes Surveillance System. RESULTS: The study included 3,135 of 3,143 U.S. counties. Mean diabetes prevalence increased from 7.3% (SD 1.3) in 2004 to 9.1% (SD 1.8) in 2014. The mean SNAP policy index increased from 6.4 (SD 0.9) to 8.2 (SD 0.6) in 2014. After accounting for changes in demographic-, economic-, and health care-related variables and the baseline SNAP policy index, a 1-point absolute increase in the SNAP policy index between 2004 and 2014 was associated with a 0.050 (95% CI 0.042-0.057) percentage point lower diabetes prevalence per year. CONCLUSIONS: State policies aimed at increasing SNAP participation were independently associated with a lower rise in diabetes prevalence between 2004 and 2014.

Association of a Sweetened Beverage Tax With Soda Consumption in High School Students.

Importance: Sweetened beverage taxes are one policy approach to reduce intake of added sugars. Soda is the leading source of added sugars in the US diet, but few studies have examined how such taxes influence sweetened beverage intake in youth. Objective: To estimate the association between the Philadelphia, Pennsylvania, beverage tax and adolescent soda intake. Design, Setting, and Participants: This economic evaluation of school district-level Youth Risk Behavior Surveillance System data from September 2013 to December 2019 compared weekly soda intake in high school students in Philadelphia, a city with a sweetened beverage tax, with that in 7 comparison cities without beverage taxes. Difference-in-differences regression modeling was used to estimate change in soda intake in Philadelphia compared with control cities. Secondary analyses compared 100% juice and milk intake to explore potential substitution associations. Subgroup analyses evaluated differences by race and ethnicity and weight status (obesity and overweight or obesity). Analyses were performed between August 20 and October 20, 2020. School districts that had weighted data and a survey question on weekly soda intake from 2013 to 2019 were included. The study included high school students, grades 9 to 12, in school districts participating in the Youth Risk Behavior Surveillance System from 2013 to 2019. Exposures: Implementation of a sweetened beverage tax in Philadelphia, Pennsylvania, in January 2017. Main Outcomes and Measures: Reported weekly servings of soda, 100% juice, and milk. Results: A total of 86 928 participants (weighted mean [SD] age, 15.8 [1.3] years; 49% female) from 8 US cities (including Philadelphia) were included. Before the tax, adolescents in the 7 comparison cities had a mean intake of 4 servings of soda per week compared with 5.4 servings per week in Philadelphia. Philadelphia's tax was associated with a reduction of 0.81 servings of soda per week (95% CI, -1.48 to -0.14 servings; P = .02) 2 years after tax implementation. There was no significant difference in 100% juice or milk intake, although Philadelphia adolescents consumed more juice than those in nontaxed cities. In subgroup analyses, the tax was associated with a reduction of 1.13 servings per week in Hispanic/Latinx adolescents (95% CI, -2.04 to -0.23 servings; P = .01) and 1.2 servings per week in adolescents with obesity (95% CI, -2.33 to -0.13 servings; P = .03). Conclusions and Relevance: This economic evaluation found that a sweetened beverage tax was associated with a reduction in soda intake among adolescents, providing evidence that such taxes can improve dietary behaviors.

Association of a Sweetened Beverage Tax With Purchases of Beverages and High-Sugar Foods at Independent Stores in Philadelphia.

Importance: The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items. Objective: To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia's neighboring counties. Main Outcomes and Measures: Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods. Results: Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P < .001), with 137% of the tax passed through to prices 2 years after tax implementation, while nontaxed beverage prices had no statistically significant change. A total of 116 independent stores and 4738 customer purchases (1950 [41.2%] women; 4351 [91.8%] age 18 years or older; 1006 [21.2%] White customers, 3185 [67.2%] Black customers) at independent stores were assessed for price and purchase comparisons. Purchases of taxed beverages declined by 6.1 fl oz (95% CI, -9.9 to -2.4 fl oz; P < .001), corresponding to a 42% decline in Philadelphia compared with Baltimore; there were no significant changes in purchases of nontaxed beverages. Although there was no significant moderation by neighborhood income or customer education level, exploratory stratified analyses revealed that declines in taxed beverage purchases were larger among customers shopping in low-income neighborhoods (-7.1 fl oz; 95% CI, -13.0 to -1.1 fl oz; P = .001) and individuals with lower education levels (-6.9 fl oz; 95% CI, -12.5 to -1.3 fl oz; P = .001). Conclusions and Relevance: This cross-sectional study found that a tax on sweetened beverages was associated with increases in price and decreases in purchasing. Beverage excise taxes may be an effective policy to sustainably decrease purchases of sweetened drinks and calories from sugar in independent stores, with large reductions in lower-income areas and among customers with lower levels of education.

Net benefit separation and the determination curve: A probabilistic framework for cost-effectiveness estimation.

Considerations regarding clinical effectiveness and cost are essential in comparing the overall value of two treatments. There has been growing interest in methodology to integrate cost and effectiveness measures in order to inform policy and promote adequate resource allocation. The net monetary benefit aggregates information on differences in mean cost and clinical outcomes; the cost-effectiveness acceptability curve was developed to characterize the extent to which the strength of evidence regarding net monetary benefit changes with fluctuations in the willingness-to-pay threshold. Methods to derive insights from characteristics of the cost/clinical outcomes besides mean differences remain undeveloped but may also be informative. We propose a novel probabilistic measure of cost-effectiveness based on the stochastic ordering of the individual net benefit distribution under each treatment. Our approach is able to accommodate features frequently encountered in observational data including confounding and censoring, and complements the net monetary benefit in the insights it provides. We conduct a range of simulations to evaluate finite-sample performance and illustrate our proposed approach using simulated data based on a study of endometrial cancer patients.

Association Between County-Level Change in Economic Prosperity and Change in Cardiovascular Mortality Among Middle-aged US Adults.

Importance: After a decline in cardiovascular mortality for nonelderly US adults, recent stagnation has occurred alongside rising income inequality. Whether this is associated with underlying economic trends is unclear. Objective: To assess the association between changes in economic prosperity and trends in cardiovascular mortality in middle-aged US adults. Design, Setting, and Participants: Retrospective analysis of the association between change in 7 markers of economic prosperity in 3123 US counties and county-level cardiovascular mortality among 40- to 64-year-old adults (102 660 852 individuals in 2010). Exposures: Mean rank for change in 7 markers of economic prosperity between 2 time periods (baseline: 2007-2011 and follow-up: 2012-2016). A higher mean rank indicates a greater relative increase or lower relative decrease in prosperity (range, 5 to 92; mean [SD], 50 [14]). Main Outcomes and Measures: Mean annual percentage change (APC) in age-adjusted cardiovascular mortality rates. Generalized linear mixed-effects models were used to estimate the additional APC associated with a change in prosperity. Results: Among 102 660 852 residents aged 40 to 64 years living in these counties in 2010 (51% women), 979 228 cardiovascular deaths occurred between 2010 and 2017. Age-adjusted cardiovascular mortality rates did not change significantly between 2010 and 2017 in counties in the lowest tertile for change in economic prosperity (mean [SD], 114.1 [47.9] to 116.1 [52.7] deaths per 100 000 individuals; APC, 0.2% [95% CI, -0.3% to 0.7%]). Mortality decreased significantly in the intermediate tertile (mean [SD], 104.7 [38.8] to 101.9 [41.5] deaths per 100 000 individuals; APC, -0.4% [95% CI, -0.8% to -0.1%]) and highest tertile for change in prosperity (100.0 [37.9] to 95.1 [39.1] deaths per 100 000 individuals; APC, -0.5% [95% CI, -0.9% to -0.1%]). After accounting for baseline prosperity and demographic and health care-related variables, a 10-point higher mean rank for change in economic prosperity was associated with 0.4% (95% CI, 0.2% to 0.6%) additional decrease in mortality per year. Conclusions and Relevance: In this retrospective study of US county-level mortality data from 2010 to 2017, a relative increase in county-level economic prosperity was significantly associated with a small relative decrease in cardiovascular mortality among middle-aged adults. Individual-level inferences are limited by the ecological nature of the study.

No Evidence of Food or Alcohol Substitution in Response to a Sweetened Beverage Tax.

INTRODUCTION: Evidence suggests real-world beverage taxes reduce sweetened beverage purchases, but it is unknown if consumers consequently increase food or alcohol purchases. This study examines whether Philadelphia's 1.5 cents/ounce beverage tax was associated with substitution to 3 kinds of hypothesized substitutes: snacks, nontaxed beverage concentrates, and alcohol. METHODS: Using commercial retail sales data and a difference-in-differences approach, analyses compared logged volume and dollar sales of snacks and beverage concentrates between 2016 (pretax) and 2017 (post-tax) at chain food retail stores in Philadelphia (n=180) and Baltimore (nontaxed control city; n=60), and logged volume and dollar sales of wine and spirits at liquor stores in Philadelphia (n=44) and nearby Pennsylvania counties (alternate control; n=66). Additional food analyses examined change in logged volume sales of hypothesized products compared to control products (other foods). Analyses were conducted in 2020. RESULTS: Across store types, analyses showed no statistically significant increases in logged volume or dollar sales of snacks or spirits in Philadelphia stores compared to control sites (decreased, ranging from -10% to 0%). Supermarket analyses showed substitution to nontaxed beverage concentrates (27% increase in volume, 36% increase relative to other food) but remained a relatively small percentage of overall beverage dollar sales (12% at baseline, 15% at post). CONCLUSIONS: At the population level, there is no evidence that Philadelphia's decline in taxed beverage purchases is offset by increases in snacks or spirits purchasing, but there is evidence of substitution to beverage concentrates in supermarkets. Future studies should explore individual-level purchasing changes.

A Bayesian nonparametric model for zero-inflated outcomes: Prediction, clustering, and causal estimation.

Researchers are often interested in predicting outcomes, detecting distinct subgroups of their data, or estimating causal treatment effects. Pathological data distributions that exhibit skewness and zero-inflation complicate these tasks-requiring highly flexible, data-adaptive modeling. In this paper, we present a multipurpose Bayesian nonparametric model for continuous, zero-inflated outcomes that simultaneously predicts structural zeros, captures skewness, and clusters patients with similar joint data distributions. The flexibility of our approach yields predictions that capture the joint data distribution better than commonly used zero-inflated methods. Moreover, we demonstrate that our model can be coherently incorporated into a standardization procedure for computing causal effect estimates that are robust to such data pathologies. Uncertainty at all levels of this model flow through to the causal effect estimates of interest-allowing easy point estimation, interval estimation, and posterior predictive checks verifying positivity, a required causal identification assumption. Our simulation results show point estimates to have low bias and interval estimates to have close to nominal coverage under complicated data settings. Under simpler settings, these results hold while incurring lower efficiency loss than comparator methods. We use our proposed method to analyze zero-inflated inpatient medical costs among endometrial cancer patients receiving either chemotherapy or radiation therapy in the SEER-Medicare database.

Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings.

Importance: The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings. Objective: To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance. Design, Setting, and Participants: A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019. Exposures: Patient-physician racial/ethnic and gender concordance. Main Outcomes and Measures: The primary outcome was receipt of the maximum score for the "likelihood of your recommending this care provider to others" question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance. Results: In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90). Conclusions and Relevance: In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician's patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.

Economic outcomes of insurer-led care management for high-cost Medicaid patients.

OBJECTIVES: To evaluate the impact of the Community-Based Care Management (CBCM) program on total costs of care and utilization among adult high-need, high-cost patients enrolled in a Medicaid managed care organization (MCO). CBCM was a Medicaid insurer-led care coordination and disease management program staffed by nurse care managers paired with community health workers. STUDY DESIGN: Retrospective cohort analysis. METHODS: We obtained deidentified health plan claims data, enrollment information, and the MCO's monthly registry of the top 10% of costliest patients. The analysis included 896 patients enrolled in CBCM over the course of 2 years (January 2016 to December 2017) and a propensity score-matched cohort of high-cost patients (n = 2152) who received primary care at sites that did not participate in CBCM during the same time period. The primary outcomes were total costs of care and utilization in the 12-month period after enrollment. Secondary outcomes included utilization by care setting: outpatient, inpatient, emergency department, pharmacy, postacute care, and all other remaining sites. We used zero-inflated gamma and Poisson regression models to estimate average differences in postperiod costs and utilization between CBCM enrollees versus non-CBCM enrollees. RESULTS: We did not observe meaningful differences in total costs or visit frequency among CBCM enrollees relative to non-CBCM enrollees. CONCLUSIONS: Although our study found no association between the CBCM program and subsequent cost or utilization outcomes, understanding why these outcomes were not achieved will inform how future Medicaid programs are designed to achieve better patient outcomes and lower costs.

Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials.

OBJECTIVE: To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING: Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN: The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS: The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS: Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS: Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.