Factors predicting staging and treatment initiation for patients with chronic hepatitis C infection: insurance a key predictor.

BACKGROUND: Chronic hepatitis C (HCV) infection affects over 2.4 million Americans and accounts for 18 000 deaths per year. Treatment initiation in this population continues to be low even after introduction of highly effective and shorter duration direct-acting antivirals. This study assesses factors that influence key milestones in the HCV care continuum. METHODS: Retrospective time-to-event analyses were performed to assess factors influencing liver fibrosis staging and treatment initiation among individuals confirmed with chronic HCV infection at University of Illinois Hospital and Health Sciences System between 1 August 2015 and 24 October 2016 and followed through 28 January 2018. Cox regression models were utilized for multivariable analyses. RESULTS: Individuals tested at the liver clinic (hazard ratio [HR] = 2.03; 95% confidence interval [CI]: 1.19-3.46) and at the federally qualified health center (HR = 3.51; 95% CI: 2.19-5.64) had higher instantaneous probability of being staged compared with individuals tested at the emergency department (ED) or inpatient setting. And probability of treatment initiation increased with advancing liver fibrosis especially for Medicaid beneficiaries (HR = 1.64; 95% CI: 1.35-1.99). CONCLUSIONS: The study demonstrates a need for improving access for patients with early stages of the disease in order to reduce HCV-related morbidity and mortality, especially those tested at nontraditional care locations such as the ED or the inpatient setting.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019).

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Did Playground Renovations Equitably Benefit Neighborhoods in Chicago?

Between 2013 and 2016, the Chicago Park District renovated 327 playgrounds in need of repair across Chicago through a $44 million investment. This study evaluated whether short-term and longer-term impacts of renovations on park use and park-based moderate-to-vigorous physical activity (MVPA) differed by neighborhood income level and neighborhood concentration of Black residents. A total of 39 parks with renovated playgrounds and 39 matched comparison parks with playgrounds that needed repair but not selected for renovation in year 1 were studied. Three waves of observational data were collected at each park: baseline, 12 months post-renovation, and 24 months post-renovation. Difference-in-differences mixed-effects Poisson regression models estimated renovation effects. The effects of renovations differed by the income level and concentration of Black residents in the neighborhoods where parks were located. In low-income neighborhoods, renovations were associated with reductions in park use and park-based MVPA over the longer term. In contrast, renovations were associated with short- and longer-term increases in park use and park-based MVPA in medium-income neighborhoods and with longer-term increases in MVPA in high-income neighborhoods. Renovations were generally not associated with any changes in park use or park-based MVPA in high-percent Black neighborhoods, but they were associated with increased park use and park-based MVPA in low-percent Black neighborhoods. This study suggests playground renovations in Chicago may have had unintended consequences, increasing neighborhood income and racial disparities in park use and park-based MVPA. Future playground renovation efforts may need to allocate more resources for renovating the broader park where in disrepair, more intensely involve neighborhood residents, and employ complementary strategies such as additional park programming to ensure renovations benefit all neighborhoods.

Psychosocial Moderators and Outcomes of a Randomized Effectiveness Trial for Child Asthma.

OBJECTIVE: Psychosocial factors play a role in child asthma morbidity and disparities, but their impact on asthma intervention effectiveness is less understood. This study examined how child, parent, and family psychosocial factors moderated asthma response to, and changed in response to, 2 community asthma interventions among urban minority youth. METHODS: Asthma Action at Erie was a randomized comparative effectiveness trial examining a community health worker (CHW) home intervention versus certified asthma educator (AE-C) services for children aged 5-16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was assessed via the Asthma Control Test (ACT)/childhood ACT and activity limitation. Baseline child/parent depression and posttraumatic stress disorder (PTSD) symptoms, family chaos, and social support were examined as treatment moderators. We also tested intervention effects on psychosocial outcomes. RESULTS: For parents with higher baseline depression symptoms, youth in the CHW group had greater ACT improvement by 24 months (7.49 points) versus AE-C (4.76 points) and 51% reduction in days of limitation by 6 months versus AE-C (ß = -0.118; p = .0145). For higher parent PTSD symptoms, youth in CHW had 68% fewer days of limitation at 24 months versus AE-C (ß = -0.091; p = .0102). Psychosocial outcomes did not vary by group, but parent depression, parent and child PTSD symptoms, and social support improved for all. CONCLUSIONS: CHW intervention was associated with improved asthma control among families with higher parent strain. Findings have implications for utilizing tailored CHW home interventions to optimize asthma outcomes in at-risk families.

Longer-term impacts of sugar-sweetened beverage taxes on fast-food beverage prices: evidence from Oakland, California, 2-year post-tax.

OBJECTIVE: To evaluate the effect of a sugar-sweetened beverage (SSB) tax implemented in Oakland, California, in July 2017, on prices of beverages sold in fast-food restaurants 2-year post-tax. DESIGN: Using a difference-in-differences (DID) approach, we analysed beverage price data collected from fast-food restaurants 1-month pre-tax and 2-year post-tax in Oakland (intervention site) and Sacramento, California (comparison site). Separate linear regression models were used to estimate the impact of the tax on prices of bottled regular soda, bottled diet soda, bottled unsweetened beverages and fountain drinks. SETTING: Oakland and Sacramento, California, USA. PARTICIPANTS: Chain and non-chain fast-food restaurants (n 85). RESULTS: DID estimates indicate that in fast-food restaurants, on average, the price of bottled regular soda increased by 1·44 cents/oz (95 % CI 0·50, 2·73) (tax pass-through rate of 144 %) and the price of bottled diet soda increased by 1·17 cents/oz (95 % CI 0·07, 2·13). No statistically significant differences were found between bottled regular and diet soda price increases. Price effects for unsweetened beverages and fountain drinks were not statistically significant. Further, the estimated price change for fountain drinks was nearly zero. CONCLUSIONS: Findings suggest that the effectiveness of SSB taxes in discouraging SSB consumption may be limited in fast-food restaurants in Oakland, California, because there were similar price increases in taxed and untaxed bottled soda and no changes in fountain drink prices.

Oral Health Behaviors in Very Young Children in Low-Income Urban Areas in Chicago, Illinois, 2018-2019.

INTRODUCTION: Because most data on oral health do not include infants and toddlers, we aimed to describe the oral health behaviors of low-income children younger than 3 years and determine factors associated with child tooth brushing. METHODS: We obtained data from the Coordinated Oral Health Promotion Chicago study, which included 420 families with children aged 6 to 36 months and their caregivers in Cook County, Illinois. We assessed child frequency of brushing from caregiver reports and objectively determined child dental plaque scores. Significant factors associated with tooth brushing frequency and dental plaque score were identified using the Least Absolute Shrinkage and Selection Operator variable selection. RESULTS: Mean child age was 21.5 (SD, 6.9) months, and only 45% of caregivers brushed their children's teeth twice per day or more. The mean plaque score was 1.9 (SD, 0.6), indicating high levels of plaque. Child brushing frequency was higher when children were older; used the correct toothpaste amount; brushed for a longer duration; and when caregivers brushed their own teeth more frequently, had more help with the overall care of the child's teeth, and had family to help. Child brushing frequency was lower for caregivers with more interference from activities of daily life. Children whose caregivers had more adult help with child brushing had better plaque scores; worse plaque scores were seen in children with higher sugary beverage and food consumption and lower household incomes. CONCLUSION: The tooth brushing behaviors of young children are strongly associated with those of their parents and with the level of family support for brushing. Interventions to improve brushing in young children should focus on the entire family.

What really happens in the home: a comparison of parent-reported and observed tooth brushing behaviors for young children.

BACKGROUND: Most studies of tooth brushing behaviors rely on self-report or demonstrations of behaviors conducted in clinical settings. This study aimed to determine the feasibility of objective assessment of tooth brushing behaviors in the homes of high-risk children under three years old. We compared parent self-report to observations to determine the accuracy of self-report in this population. METHODS: Forty-five families were recruited from dental and medical clinics and a community social service agency. Research staff asked questions about oral health behaviors and observed tooth brushing in the homes. Brushing was also video-recorded. Video-recordings were coded for brushing behaviors by staff that did not collect the primary data; these abstracted data were compared to those directly observed in homes. RESULTS: Most families were Hispanic (76%) or Black (16%) race/ethnicity. The majority of parents had a high school education (42%) or less (24%). The mean age of children was 21 months. About half of parents reported brushing their child's teeth twice a day (58%). All parents tried to have their children brush, but three children refused. For brushing duration, 70% of parents reported differently than was observed. The average duration of brushing was 62.4 s. Parent report of fluoride in toothpaste frequently did not match observations; 39% said they used toothpaste with fluoride while 71% actually did. Sixty-eight percent of parents reported using a smear of toothpaste, while 61% actually did. Brushing occurred in a variety of locations and routines varied. Abstracted data from videos were high in agreement for some behaviors (rinse with water, floss used, brushing location, and parent involvement: Kappa 0.74-1.0). Behaviors related to type of brushing equipment (brushes and toothpaste), equipment storage, and bathroom organization and clutter had poor to no agreement. CONCLUSIONS: Observation and video-recording of brushing routines and equipment are feasible and acceptable to families. Observed behaviors are more accurate than self-report for most components of brushing and serve to highlight some of the knowledge issues facing parents, such as the role of fluoride.

A geographic information system-based method for estimating cancer rates in non-census defined geographical areas.

PURPOSE: To address locally relevant cancer-related health issues, health departments frequently need data beyond that contained in standard census area-based statistics. We describe a geographic information system-based method for calculating age-standardized cancer incidence rates in non-census defined geographical areas using publically available data. METHODS: Aggregated records of cancer cases diagnosed from 2009 through 2013 in each of Chicago's 77 census-defined community areas were obtained from the Illinois State Cancer Registry. Areal interpolation through dasymetric mapping of census blocks was used to redistribute populations and case counts from community areas to Chicago's 50 politically defined aldermanic wards, and ward-level age-standardized 5-year cumulative incidence rates were calculated. RESULTS: Potential errors in redistributing populations between geographies were limited to <1.5% of the total population, and agreement between our ward population estimates and those from a frequently cited reference set of estimates was high (Pearson correlation r = 0.99, mean difference = -4 persons). A map overlay of safety-net primary care clinic locations and ward-level incidence rates for advanced-staged cancers revealed potential pathways for prevention. CONCLUSIONS: Areal interpolation through dasymetric mapping can estimate cancer rates in non-census defined geographies. This can address gaps in local cancer-related health data, inform health resource advocacy, and guide community-centered cancer prevention and control.

Classification Tree Analysis as a Method for Uncovering Relations Between CHRNA5A3B4 and CHRNB3A6 in Predicting Smoking Progression in Adolescent Smokers.

INTRODUCTION: Prior research suggests the CHRNA5A3B4 and CHRNB3A6 gene clusters have independent effects on smoking progression in young smokers. Here classification tree analysis uncovers conditional relations between these genes. METHODS: Conditional classification tree and random forest analyses were employed to predict daily smoking at 6-year follow-up in a longitudinal sample of young smokers (N = 480) who had smoked at least one puff at baseline and were of European ancestry. Potential predictors included gender, lifetime smoking, Nicotine Dependence Syndrome Scale (NDSS), and five single nucleotide polymorphisms (SNPs) tagging CHRNB3A6 and CHRNA5A3B4 Haplotypes A, B, and C. Conditional random forest analysis was used to calculate variable importance. RESULTS: The classification tree identified NDSS, the CHRNB3A6 SNP rs2304297, and the CHRNA5A3B4 Haplotype C SNP rs6495308 as predictive of year 6 daily smoking with the baseline NDSS identified as the strongest predictor. The CHRNB3A6 protective effect was contingent on a lower level of baseline NDSS, whereas the CHRNA5A3B4 Haplotype C protective effect was seen at a higher level of baseline NDSS. A CHRNA5A3B4 Haplotype C protective effect also was observed in participants with low baseline NDSS who had no CHRNB3A6 rs2304297 minor allele. CONCLUSIONS: The protective effects of CHRNA5A3B4 Haplotype C and CHRNB3A6 on smoking progression are conditional on different levels of baseline cigarette use. Also, duplicate dominant epistasis between SNPs indicated the minor allele of either SNP afforded comparable protective effects in the absence of a minor allele at the other locus. Possible mechanisms underlying these conditional relations are discussed. IMPLICATIONS: The substantive contributions of this paper are the demonstration of a difference in the protective effects of CHRNB3A6 and CHRNA5A3B4 Haplotype C in young smokers attributable to level of cigarette use, as well as observation of duplicate dominant epistasis between the two markers. The methodological contribution is demonstrating that classification tree and random forest statistical methods can uncover conditional relations among genetic effects not detected with more common regression methods.

CYP2A6 Effects on Subjective Reactions to Initial Smoking Attempt.

INTRODUCTION: In very novice smokers, CYP2A6 genotypes that reduce nicotine metabolism to an intermediate rate may increase smoking risk, relative to both normal and slow rates. The present study examined the hypothesis that intermediate metabolism variants are associated with greater pleasurable effects of the initial smoking attempt than either normal or slow metabolism variants. METHODS: Participants were novice smokers (N = 261, 65% female) of European descent. Predicted nicotine metabolic rate based on CYP2A6 diplotypes (CYP2A6 Diplotype Predicted Rate [CDPR]) was partitioned into Normal, Intermediate, and Slow categories using a metabolism metric. Subjective reactions to the initial smoking attempt were assessed by the Pleasurable Smoking Experiences (PSE) scale, which was collected within 3 years of the initial smoking attempt. The effect of CDPR on PSE was tested using a generalized linear model in which CDPR was dummy coded and Intermediate CDPR was the reference condition. Gender was included in the model as a control for higher PSE scores by males. RESULTS: Lower PSE scores were associated with Normal CDPR, ß = -0.34, P = .008, and Slow CDPR, ß = -0.52, P = .001, relative to Intermediate CDPR. CONCLUSIONS: Intermediate CDPR-enhanced pleasurable effects of the initial smoking attempt relative to other CYP2A6 variants. This finding is consistent with the hypothesis that the risk effect of Intermediate CDPR on early smoking is a function of optimal pleasurable effects. IMPLICATIONS: This study supports our recent hypothesis that CYP2A6 diplotypes that encode intermediate nicotine metabolism rate are associated with enhanced pleasurable events following the initial smoking attempt, compared with diplotypes that encode either normal or slow metabolism. This hypothesis was offered to account for our unexpected previous finding of enhanced smoking risk in very novice smokers associated with intermediate metabolism rate. Our new finding encourages further investigation of time-dependent relations between CYP2A6 effects and smoking motives, and it encourages laboratory study of the mechanisms underlying the initial smoking enhancement in novice smokers associated with intermediate metabolism.

Modeling mood variation and covariation among adolescent smokers: application of a bivariate location-scale mixed-effects model.

INTRODUCTION: Ecological momentary assessments (EMAs) are useful for understanding both between- and within-subject dynamic changes in smoking and mood. Modeling 2 moods (positive affect [PA] and negative affect [NA], PA and NA) simultaneously will better enable researchers to explore the association between mood variables and what influences them at both the momentary and subject level. METHODS: The EMA component of a natural history study of adolescent smoking was analyzed with a bivariate location-scale mixed-effects model. The proposed model separately estimates the between- and within-subject variances and jointly models the 2 mood constructs. A total of 461 adolescents completed the baseline EMA wave, which resulted in 14,105 random prompts. Smoking level, represented by the number of smoking events on EMA, entered the model as 2 predictors: one that compared nonsmokers during the EMA week to 1-cigarette smokers, and the second one that estimated the effect of smoking level on mood among smokers. RESULTS: Results suggest that nonsmokers had more consistent positive and negative moods compared to 1-cigarette smokers. Among those who smoked, both moods were more consistent at higher smoking levels. The effects of smoking level were greater for NA than for PA. The within-subject association between mood constructs was negative and strongest among 1-cigarette smokers; the within-subject association between positive and negative moods was negatively associated with smoking. CONCLUSIONS: Mood variation and association between mood constructs varied across smoking levels. The most infrequent smokers were characterized with more inconsistent moods, whereas mood was more consistent for subjects with higher smoking levels.

Changes in Retail Tobacco Product Availability Following a Chicago City Ordinance Restricting Sales of Menthol and Other Flavored Tobacco Products Near Schools.

BACKGROUND: In April 2016, the City of Chicago implemented an ordinance restricting the sale of all flavored (including menthol) tobacco products (FTPs), including electronic cigarettes, at retailers located within 500 feet of any public, private, or alternative elementary, middle ("primary"), or high ("secondary") school. We examined changes in retail availability of FTPs from before to after policy implementation among policy-affected retailers compared with retailers not subject to the policy. METHOD: Observational data were collected in June to September 2015 (Wave 1; pre-policy) and November to December 2016 (Wave 2; post-policy) from a panel of 194 randomly selected policy-area stores (located within 500 feet of a school), and a panel of 199 randomly selected comparison-area stores (located more than 500 feet from a school). Using generalized estimation equation regression, we assessed differences in FTP availability changes across study areas. RESULTS: We observed a statistically significant policy effect on FTP availability (Area × Wave interaction, p < .05); however, more than half of policy-area retailers continued to display at least one FTP after policy implementation (87.11% at Wave 1, 57.73% at Wave 2, p < .05). Similar reductions were seen for the availability of flavored cigarillos/little cigars and menthol cigarettes, while policy effects varied across store types. DISCUSSION: FTP availability reductions appear to be associated with policy implementation, but FTPs remained readily available at retailers subject to the policy. This study contributes to the evidence base indicating that policies with exclusions or exemptions for certain flavors, products, store types, or retailer locations have a limited effect on retail availability of FTPs.

A brief pre-visit educational video improved patient engagement after telehealth visits; results from a randomized controlled trial.

Objective: To test an intervention designed to improve patient engagement in telehealth visits by encouraging patients to use active communication behaviors. Methods: US Veterans with type 2 diabetes mellitus receiving primary care using telehealth were randomized 1:1 to receive both a pre-visit educational video and pamphlet (intervention) or pamphlet alone (control) prior to their scheduled telehealth visit. Data were collected before and after the intervention from the medical record and at telephone interviews (questionnaires). Analyses compared the intervention and control groups using bivariate statistics and multiple regression. Results: There were no statistically significant differences in baseline Hemoglobin A1c (HbA1c) between intervention and control groups (P > 0.05). Patient's ratings of physicians' communication and post-visit empathy were higher (P ≤ 0.05) in the intervention group than control group and after adjusting for baseline values the intervention group reported higher scores on post-visit therapeutic alliance with the provider and higher patient engagement, compared with the control group, P = 0.01 and P = 0.04, respectively, but post-visit HbA1c was not statistically different. Conclusions: The educational video was useful as pre-visit preparation for patients prior to a primary care telehealth visit. Innovation: This study showed the efficacy of a pre-visit video to improve patient engagement and therapeutic alliance after telehealth visits.ClinicalTrials.govIdentifier: NCT02522494.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers.

BACKGROUND: The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children. OBJECTIVES: Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention. METHODS: Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes. RESULTS: Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms. CONCLUSIONS: The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

Active living-oriented zoning codes and cardiometabolic conditions across the lifespan.

Environments that make it easier for people to incorporate physical activity into their daily life may help to reduce high rates of cardiometabolic conditions. Local zoning codes are a policy and planning tool to create more walkable and bikeable environments. This study evaluated relationships between active living-oriented zoning code environments and cardiometabolic conditions (body mass index, hyperlipidemia, hypertension). The study used county identifiers to link electronic health record and other administrative data for a sample of patients utilizing primary care services between 2012 and 2016 with county-aggregated zoning code data and built environment data. The analytic sample included 7,441,991 patients living in 292 counties in 44 states. Latent class analysis was used to summarize municipal- and unincorporated county-level data on seven zoning provisions (e.g., sidewalks, trails, street connectivity, mixed land use), resulting in classes that differed in strength of the zoning provisions. Based on the probability of class membership, counties were categorized as one of four classes. Linear and logistic regression models estimated cross-sectional associations with each cardiometabolic condition. Models were fit separately for youth (aged 5-19), adults (aged 20-59), and older adults (aged 60+). Little evidence was found that body mass index in youth, adults, or older adults or the odds of hyperlipidemia or hypertension in adults or older adults differed according to the strength of active living-oriented zoning. More research is needed to identify the health impacts of zoning codes and whether alterations to these codes would improve population health over the long term.

A clinical diabetes risk prediction model for prediabetic women with prior gestational diabetes.

INTRODUCTION: Without treatment, prediabetic women with a history of gestational diabetes mellitus (GDM) are at greater risk for developing type 2 diabetes compared with women without a history of GDM. Both intensive lifestyle intervention and metformin can reduce risk. To predict risk and treatment response, we developed a risk prediction model specifically for women with prior GDM. METHODS: The Diabetes Prevention Program was a randomized controlled trial to evaluate the effectiveness of intensive lifestyle intervention, metformin (850mg twice daily), and placebo in preventing diabetes. Data from the Diabetes Prevention Program (DPP) was used to conduct a secondary analysis to evaluate 11 baseline clinical variables of 317 women with prediabetes and a self-reported history of GDM to develop a 3-year diabetes risk prediction model using Cox proportional hazards regression. Reduced models were explored and compared with the main model. RESULTS: Within three years, 82 (25.9%) women developed diabetes. In our parsimonious model using 4 of 11 clinical variables, higher fasting glucose and hemoglobin A1C were each associated with greater risk for diabetes (each hazard ratio approximately 1.4), and there was an interaction between treatment arm and BMI suggesting that metformin was more effective relative to no treatment for BMI ≥ 35kg/m2 than BMI < 30kg/m2. The model had fair discrimination (bias corrected C index = 0.68) and was not significantly different from our main model using 11 clinical variables. The estimated incidence of diabetes without treatment was 37.4%, compared to 20.0% with intensive lifestyle intervention or metformin treatment for women with a prior GDM. CONCLUSIONS: A clinical prediction model was developed for individualized decision making for prediabetes treatment in women with prior GDM.

The impact of the Philadelphia beverage tax on employment: A synthetic control analysis.

Prevalence of obesity and other diet-related non-communicable diseases (NCDs) have continued to rise for decades in the United States. In addition to adverse health consequences, these diseases have led to substantial economic costs in the form of medical expenses and productivity losses. To address the rise in NCDs, excise taxes on sugar-sweetened beverages (SSBs) are increasingly proposed and implemented as a policy tool for improving dietary intake and population health. To date, few empirical studies have evaluated the potential unintended economic effects of these taxes. In this paper, we examine the impact of the Philadelphia, PA, sweetened beverage tax (applied to both SSBs and artificially sweetened beverages) on employment in key industries that sell sweetened beverages as well as on net total employment. Drawing on monthly employment count data from the Bureau of Labor Statistics from January 2012 through June 2019, we conducted a synthetic control analysis of total, private sector, limited-service restaurant, and convenience store employment. The synthetic controls reproduced nearly identical pre-tax employment trends to Philadelphia and had similar values of important predictors. In the post-tax period, Philadelphia employment was not lower, on average, than the synthetic control employment for each outcome. Placebo tests suggested a null effect of the tax, and the results were robust to changes in predictors and control site criteria. Overall, we did not find that the sweetened beverage tax resulted in job losses up to two and a half years after the tax was implemented. These findings are consistent with other peer-reviewed modeling and empirical papers on the employment and unemployment effects of sweetened beverage taxes.

Sex differences in outcomes for out-of-hospital cardiac arrest in the United States.

BACKGROUND: Approximately 1000 out-of-hospital cardiac arrest (OHCA) occur each day in the United States. Although sex differences exist for other cardiovascular conditions such as stroke and acute myocardial infarction, they are less well understood for OHCA. Specifically, the extent to which neurological and survival outcomes after OHCA differ between men and women remains poorly characterized in the U.S. METHODS AND RESULTS: Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 326,138 adults with an OHCA from 2013 to 2019. Using multivariable logistic regression, we evaluated for sex differences in rates of survival to hospital admission, survival to hospital discharge, and favorable neurological survival (i.e., without severe neurological disability), adjusted for demographics, cardiac arrest characteristics and bystander interventions. Overall, 117,281 (36%) patients were women. Median age was 62 and 65 years for men and women, respectively. An initial shockable rhythm (25.1% vs 14.7%, standardized difference of 0.26) and an arrest in a public location (22.2% vs. 11.3%; standardized difference of 0.30) were more common in men, but there were no meaningful sex differences in rates of witnessed arrests, bystander cardiopulmonary resuscitation, intra-venous access, or use of mechanical devices for delivering cardiopulmonary resuscitation. Overall, the unadjusted rates of all survival outcomes were similar between men and women: survival to hospital admission (27.0% for men vs. 27.9% for women, standardized difference of -0.02), survival to hospital discharge (10.5% for men vs. 8.6% for women, standardized difference of 0.07), and favorable neurological survival (9.0% for men vs. 6.6% for women, standardized difference of 0.09). After multivariable adjustment, however, men were less likely to survive to hospital admission (adjusted OR = 0.75, 95% CI: 0.73, 0.77), survive to hospital discharge (adjusted OR = 0.83, 95% CI: 0.80, 0.85), or have favorable neurological survival (adjusted OR = 0.88, 95% CI: 0.85, 0.91). CONCLUSIONS: Compared to women, men with OHCA have more favorable cardiac arrest characteristics but were less likely to survive to hospital admission, survive to discharge, nor have favorable neurological survival.

Changes in Child and Adult Care Food Program (CACFP) Practices at Participating Childcare and Education Centers in the United States Following Updated National Standards, 2017-2019.

The U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) updated meal pattern standards took effect in October 2017. The aim of this quasi-experimental, pre-post study is to identify changes in food and beverage practices of CACFP-participating centers due to implementation of updated CACFP meal patterns over a 21-month period. Eight hundred and fifty-eight centers located in 47 states and the District of Columbia completed a survey (primarily electronic) at both time points (67.6% follow-up response rate). Multivariable logistic regressions with robust standard errors assessed changes over time, accounting for repeated observations within each site. From baseline to follow-up, centers reported the increased familiarity and implementation, albeit with time, money, and staffing-related challenges. Significant improvements were seen in not serving sugary cereals or flavored milk, in serving 100% whole grains, and serving processed meats less than once a week. While CACFP-participating centers reported making significant progress in meeting the updated meal pattern standards and suggested best practices within 15-19 months of their effective date, reported compliance and adherence to the standards and best practices was not universal. USDA, state agencies, and technical assistance providers should work to provide centers with additional guidance to help them with implementation.

The impact of the Oakland sugar-sweetened beverage tax on bottled soda and fountain drink prices in fast-food restaurants.

Beverage taxes are increasingly being implemented as an intervention aimed at reducing the consumption of sugar-sweetened beverages (SSBs) and their associated adverse health outcomes. Whether these taxes achieve public health objectives depends, in part, on the extent to which beverage prices increase, known as tax pass-through. Fast-food restaurants are a significant source of SSBs and an environment where the effect of beverage taxes is less understood. This study evaluates the impact of an SSB tax on prices of beverage products sold in fast-food restaurants in Oakland, CA, which implemented a 1-cent per ounce excise tax on SSBs containing 25 or more calories per 12 fluid ounces in 2017. A pre-post intervention difference-in-differences (DID) research design with Sacramento, CA, serving as a comparison site was used to estimate the effect of the tax on fast-food restaurant beverage prices. A panel of fast-food restaurants were audited 1-month pre-tax and 6- and 12-months post-tax. DID regression models with restaurant and product fixed effects were used to estimate tax pass-through to prices of bottled regular (N = 150 observations from 39 restaurants) and diet (N = 106 observations from 32 restaurants) soda and fountain drinks (N = 501 observations from 73 restaurants). Statistically significant (p < 0.05) pass-through of 82% was found for bottled regular soda one year after the tax was implemented. This effect represents an 8% increase in prices from baseline. No statistically significant changes in prices were found in either time period for taxed and untaxed fountain drinks and untaxed bottled diet soda.