Brian Elbel

More than one-third of adults consume fast-food daily, including sugar-sweetened beverages (SSBs) that contain more than the recommended daily allowance of calories from added sugars in one serving. Taxes on sweetened beverages are a promising solution to reduce the consumption of SSB and their potential contribution to obesity. However, these form of taxes must induce higher prices to reduce the demand for these products. This paper focuses on the passthrough of these taxes to prices of fast-food restaurants in five U.S. localities that implemented taxes between 2017-2018. Leveraging detailed national data from Taco Bell locations between 2015 and 2020 we estimate a synthetic control event-study design. Our results show an (almost) complete passthrough of the tax to single-serve beverages in cities taxing sugar- and artificially-sweetened beverages (Philadelphia, PA, and Cook County, IL). We find no significant price changes in locations taxing only sugar-sweetened beverages (Seattle, WA, Albany, CA, and Oakland, CA). Restaurant responses remained consistent into the second year post-tax in the four locations that retained the tax. These findings underscore the importance of the tax design of beverage to their potential success.

Importance  Despite recent growth in online redemption of Supplemental Nutrition Assistance Program (SNAP) benefits, no previous work has tested the impact of economic and behavioral economic strategies on food purchasing behaviors in an online grocery retail setting among adults with low income.

Objective  To examine the extent to which financial incentives and default shopping cart options influence fruit and vegetable purchases.

Design, Setting, and Participants  This randomized clinical trial used an experimental online grocery store for adults who currently or have ever received SNAP benefits. From October 7 to December 2, 2021, participants were instructed to shop for a week’s worth of groceries for their household, with a budget tailored to household size; no payment was taken.

Interventions  Random assignment to 1 of 4 conditions: no intervention, 50% discount on eligible fruits and vegetables, prefilled shopping carts with tailored fruit and vegetable items (ie, default options), or a combination of the discount and default options.

Main Outcomes and Measures  The primary outcome was the percentage of nondiscounted dollars spent on eligible fruit and vegetables per basket.

Results  Of 2744 participants, mean (SD) age was 46.7 (16.0) years, and 1447 (52.7%) identified as women. A total of 1842 participants (67.1%) reported currently receiving SNAP benefits and 1492 (54.4%) reported shopping online for groceries in the previous 12 months. Participants spent a mean (SD) 20.5% (23.5%) of total dollars on eligible fruits and vegetables. Compared with no intervention, those in the discount condition spent 4.7% (98.3% CI, 1.7%-7.7%) of more total dollars on eligible fruits and vegetables; those in the default condition, 7.8% (98.3% CI, 4.8%-10.7%) more; and those in the combination condition, 13.0% (98.3% CI, 10.0%-16.0%) more (P < .001 for all). There was no difference between the discount and the default conditions (P = .06), but the effect in the combination condition was significantly larger than both discount and default conditions (P < .001). Default shopping cart items were purchased by 679 participants (93.4%) in the default condition and 655 (95.5%) in the combination condition, whereas 297 (45.8%) in the control and 361 (52.9%) in the discount conditions purchased those items (P < .001). No variation was observed by age, sex, or race and ethnicity, and results were similar when those who reported never shopping online for groceries were excluded.

Conclusions and Relevance  In this randomized clinical trial, financial incentives for fruits and vegetables and default options, especially in combination, led to meaningful increases in online fruit and vegetable purchases among adults with low income.

Trial Registration  ClinicalTrials.gov Identifier: NCT04766034

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke (SHS) exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory infections (LRIs), and upper respiratory infections (URIs) in the early post-policy period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to policy) to children living in lots with other subsidized housing (unexposed to policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015 and December 31, 2019 (policy introduction was July 30, 2018). We also examined effect modification by baseline age group (0-2, 3-6, 7-15). In NYC, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early post-policy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient URI claims (IRR=1.05, 95% CI=1.01, 1.08), a result most pronounced among children ages 3-6. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

No studies have documented the prevalence of the food industry’s funding of academic programs, which is problematic because such funding can create conflicts of interest in research and clinical practice. We aimed to quantify the publicly available information on the food industry’s donations to academic programs by documenting the amount of donations given over time, categorizing the types of academic programs that receive food industry donations, cataloguing the source of the donation information, and identifying any stated reasons for donations. Researchers cataloged online data from publicly available sources (e.g., official press releases, news articles, tax documents) on the food industry’s donations to academic programs from 2000 to 2016. Companies included 26 food and beverage corporations from the 2016 Fortune 500 list in the United States. Researchers recorded the: (1) monetary value of the donations; (2) years the donations were distributed; (3) the name and type of recipient; (4) source of donation information; and (5) reasons for donations. Adjusting for inflation, we identified $366 million in food industry donations (N = 3274) to academic programs. Universities received 45.2% (n = 1480) of donations but accounted for 67.9% of total dollars given in the sample. Community colleges, schools (i.e., preschool, elementary, middle, and high schools), and academic nonprofits, institutes, foundations, and research hospitals collectively received 54.8% of the donations, but made up less than one-third of the monetary value of donations. Half of the donations (49.0%) did not include a stated reason for the donation. In our sample, donations grew from $3 million in 2000 to $24 million in 2016. Food companies in our sample donated millions of dollars to universities and other academic programs but disclosed little information on the purpose of the donations. Achieving transparency in donation practices may only be possible if federal policies begin to require disclosures or if companies voluntarily disclose information.

Crowdsourcing for Food Purchase Receipt Annotation via Amazon Mechanical Turk: A Feasibility Study

This study examines purchases at fruit and vegetable carts and evaluates the potential benefits of expanding the availability of electronic benefit transfer machines at Green Carts. Customers at 4 Green Carts in the Bronx, New York, were surveyed in 3 waves from June 2013 through July 2014. Customers who used Supplemental Nutrition Assistance Program benefits spent on average $3.86 more than customers who paid with cash. This finding suggests that there may be benefits to increasing the availability of electronic benefit transfer machines at Green Carts.

BACKGROUND:

Consuming a variety (vs. monotony) of energy-poor, nutrient-dense foods may help individuals adhere to dietary patterns favorably associated with weight control.

OBJECTIVE:

The objective of this study was to examine whether greater healthful food variety quantified using the US Healthy Food Diversity (HFD) index favorably influenced body adiposity.

METHODS:

Men and nonpregnant, nonlactating women aged ≥20 y with two 24-h recalls from the cross-sectional NHANES 2003-2006 (n = 7470) were included in this study. Dietary recalls were merged with the MyPyramid Equivalent database to generate the US HFD index, which ranges from 0 to ∼1, with higher scores indicative of diets with a higher number and proportion of healthful foods. Multiple indicators of adiposity including BMI, waist-to-height ratio, android-to-gynoid fat ratio, fat mass index (FMI), and percentage body fat were assessed across US HFD index quintiles. ORs and 95% CIs were computed with use of multivariable logistic regression (SAS v. 9.3).

RESULTS:

The US HFD index was inversely associated with most adiposity indicators in both sexes. After multivariable adjustment, the odds of obesity, android-to-gynoid ratio >1, and high FMI were 31-55% lower (P-trend < 0.01) among women in quintile 5 vs. quintile 1 of the US HFD index. Among men, the odds of obesity, waist-to-height ratio ≥0.5, and android-to-gynoid ratio >1 were 40-48% lower (P-trend ≤ 0.01) in quintile 5 vs. quintile 1 of the US HFD index.

CONCLUSIONS:

Higher US HFD index values were inversely associated with indicators of body adiposity in both sexes, indicating that greater healthful food variety may protect against excess adiposity. This study explicitly recognizes the potential benefits of dietary variety in obesity management and provides the foundation to support its ongoing evaluation.

Varied diets are diverse with respect to diet quality, and existing dietary variety indices do not capture this heterogeneity. We developed and evaluated the multidimensional US Healthy Food Diversity (HFD) index, which measures dietary variety, dietary quality and proportionality according to the 2010 Dietary Guidelines for Americans (DGA). In the present study, two 24 h dietary recalls from the 2003-6 National Health and Nutrition Examination Survey (NHANES) were used to estimate the intake of twenty-six food groups and health weights for each food group were informed by the 2010 DGA. The US HFD index can range between 0 (poor) and 1 - 1/n, where n is the number of foods; the score is maximised by consuming a variety of foods in proportions recommended by the 2010 DGA. Energy-adjusted Pearson's correlations were computed between the US HFD index and each food group and the probability of adequacy for fifteen nutrients. Linear regression was run to test whether the index differentiated between subpopulations with differences in dietary quality commonly reported in the literature. The observed mean index score was 0·36, indicating that participants did not consume a variety of healthful foods. The index positively correlated with nutrient-dense foods including whole grains, fruits, orange vegetables and low-fat dairy (r 0·12 to 0·64) and negatively correlated with added sugars and lean meats (r - 0·14 to - 0·23). The index also positively correlated with the mean probability of nutrient adequacy (r 0·41; P< 0·0001) and identified non-smokers, women and older adults as subpopulations with better dietary qualities. The US HFD index may be used to inform national dietary guidance and investigate whether healthful dietary variety promotes weight control.

We assessed purchases made, motivations for shopping, and frequency of shopping at four New York City corner stores (bodegas). Surveys and purchase inventories (n = 779) were collected from consumers at four bodegas in Bronx, NY. We use Chi square tests to compare types of consumers, items purchased and characteristics of purchases based on how frequently the consumer shops at the specific store and the time of day the purchase was made. Most consumers shopped at the bodega because it was close to their home (52 %). The majority (68 %) reported shopping at the bodega at least once per day. The five most commonly purchased items were sugary beverages, (29.27 %), sugary snacks (22.34 %), coffee, (13.99 %), sandwiches, (13.09 %) and non-baked potato chips (12.2 %). Nearly 60 % of bodega customers reported their purchase to be healthy. Most of the participants shopped at the bodega frequently, valued its convenient location, and purchased unhealthy items. Work is needed to discover ways to encourage healthier choices at these stores.

BACKGROUND:

Studies rarely find fewer calories purchased following calorie labeling implementation. However, few studies consider whether estimates of the number of calories purchased improved following calorie labeling legislation.

FINDINGS:

Researchers surveyed customers and collected purchase receipts at fast food restaurants in the United States cities of Philadelphia (which implemented calorie labeling policies) and Baltimore (a matched comparison city) in December 2009 (pre-implementation) and June 2010 (post-implementation). A difference-in-difference design was used to examine the difference between estimated and actual calories purchased, and the odds of underestimating calories.Participants in both cities, both pre- and post-calorie labeling, tended to underestimate calories purchased, by an average 216-409 calories. Adjusted difference-in-differences in estimated-actual calories were significant for individuals who ordered small meals and those with some college education (accuracy in Philadelphia improved by 78 and 231 calories, respectively, relative to Baltimore, p = 0.03-0.04). However, categorical accuracy was similar; the adjusted odds ratio [AOR] for underestimation by >100 calories was 0.90 (p = 0.48) in difference-in-difference models. Accuracy was most improved for subjects with a BA or higher education (AOR = 0.25, p < 0.001) and for individuals ordering small meals (AOR = 0.54, p = 0.001). Accuracy worsened for females (AOR = 1.38, p < 0.001) and for individuals ordering large meals (AOR = 1.27, p = 0.028).

CONCLUSIONS:

We concluded that the odds of underestimating calories varied by subgroup, suggesting that at some level, consumers may incorporate labeling information.

Objective: To assess the impact of a new government-subsidized supermarket in a

high-need area on household food availability and dietary habits in children.

Design: A difference-in-difference study design was utilized.

Setting: Two neighbourhoods in the Bronx, New York City. Outcomes were

collected in Morrisania, the target community where the new supermarket was

opened, and Highbridge, the comparison community.

Subjects: Parents/caregivers of a child aged 3–10 years residing in Morrisania

or Highbridge. Participants were recruited via street intercept at baseline (presupermarket

opening) and at two follow-up periods (five weeks and one year

post-supermarket opening).

Results: Analysis is based on 2172 street-intercept surveys and 363 dietary recalls

from a sample of predominantly low-income minorities. While there were small,

inconsistent changes over the time periods, there were no appreciable differences

in availability of healthful or unhealthful foods at home, or in children’s dietary

intake as a result of the supermarket.

Conclusions: The introduction of a government-subsidized supermarket into an

underserved neighbourhood in the Bronx did not result in significant changes in

household food availability or children’s dietary intake. Given the lack of healthful

food options in underserved neighbourhoods and need for programmes that

promote access, further research is needed to determine whether healthy food

retail expansion, alone or with other strategies, can improve food choices of

children and their families.

Objectives. We determined the influence of “water jets” on observed water and milk taking and self-reported fluid consumption in New York City public schools.

Methods. From 2010 to 2011, before and 3 months after water jet installation in 9 schools, we observed water and milk taking in cafeterias (mean 1000 students per school) and surveyed students in grades 5, 8, and 11 (n = 2899) in the 9 schools that received water jets and 10 schools that did not. We performed an observation 1 year after implementation (2011–2012) with a subset of schools. We also interviewed cafeteria workers regarding the intervention.

Results. Three months after implementation we observed a 3-fold increase in water taking (increase of 21.63 events per 100 students; P < .001) and a much smaller decline in milk taking (-6.73 events per 100 students; P = .012), relative to comparison schools. At 1 year, relative to baseline, there was a similar increase in water taking and no decrease in milk taking. Cafeteria workers reported that the water jets were simple to clean and operate.

Conclusions. An environmental intervention in New York City public schools increased water taking and was simple to implement. (Am J Public Health. Published online ahead of print December 18, 2014: e1–e8. doi:10.2105/AJPH.2014.302221)

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.

OBJECTIVE:

Identify consumer characteristics that predict seeing and using calorie information on fast food menu boards.

METHODS:

Two separate data collection methods were used in Philadelphia during June 2010, several weeks after calorie labeling legislation went into effect: (1) point-of-purchase survey and receipt collection conducted outside fast food restaurants (N = 669) and (2) a random digit dial telephone survey (N = 702). Logistic regressions were used to predict the odds of reporting seeing, and of reporting seeing and being influenced by posted calorie information.

RESULTS:

Approximately 35.1% of point-of-purchase and 65.7% of telephone survey respondents reported seeing posted calorie information, 11.8% and 41.7%, respectively, reported that the labels influenced their purchasing decisions, and 8.4% and 17% reported they were influenced in a healthful direction. BMI, education, income, gender, consumer preferences, restaurant chain, and frequency of visiting fast food restaurants were associated with heterogeneity in the likelihood of reporting seeing and reporting seeing and using calorie labels.

CONCLUSION:

Demographic characteristics and consumer preferences are important determinants in the use of posted calorie information. Future work should consider the types of consumers this information is intended for, and how to effectively reach them.

Obesity is a challenging public health problem that affects millions of Americans. Increasingly policy makers are seeking environmental and policy-based solutions to combat and prevent its serious health effects. Calorie labeling mandates, including the provision in the 2010 Patient Protection and Affordable Care Act that is set to begin in 2014, have been one of the most popular and most studied approaches. This review examines 31 studies published from January 1, 2007 through July 19, 2013. It builds on Harnack and French's 2008 review and assesses the evidence on the effectiveness of calorie labeling at the point of purchase. We find that, while there are some positive results reported from studies examining the effects of calorie labeling, overall the best designed studies (real world studies, with a comparison group) show that calorie labels do not have the desired effect in reducing total calories ordered at the population level. Moving forward, researchers should consider novel, more effective ways of presenting nutrition information, while keeping a focus on particular subgroups that may be differentially affected by nutrition policies.

In March 2013 a state judge invalidated New York City's proposal to ban sales of sugar-sweetened beverages larger than 16 ounces; the case is under appeal. This setback was attributable in part to opposition from the beverage industry and racial/ethnic minority organizations they support. We provide lessons from similar tobacco industry efforts to block policies that reduced smoking prevalence. We offer recommendations that draw on the tobacco control movement's success in thwarting industry influence and promoting public health policies that hold promise to improve population health.

OBJECTIVES:

Despite the increased focus on health care consumers' active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or 'nudges'.

METHODS:

We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, 'nudging' consumers toward particular choices. We hypothesized that these 'nudges' might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept 'nudges'.

RESULTS:

We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were 'nudged' towards.

CONCLUSIONS:

Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.

Background
To induce consumers to purchase healthier foods and beverages, some policymakers have suggested special taxes or labels on unhealthy products. The potential of such policies is unknown.

Purpose
In a controlled field experiment, researchers tested whether consumers were more likely to purchase healthy products under such policies.

Methods
From October to December 2011, researchers opened a store at a large hospital that sold a variety of healthier and less-healthy foods and beverages. Purchases (N=3680) were analyzed under five conditions: a baseline with no special labeling or taxation, a 30% tax, highlighting the phrase “less healthy” on the price tag, and combinations of taxation and labeling. Purchases were analyzed in January–July 2012, at the single-item and transaction levels.

Results
There was no significant difference between the various taxation conditions. Consumers were 11 percentage points more likely to purchase a healthier item under a 30% tax (95% CI=7%, 16%, p<0.001) and 6 percentage points more likely under labeling (95% CI=0%, 12%, p=0.04). By product type, consumers switched away from the purchase of less-healthy food under taxation (9 percentage point decrease, p<0.001) and into healthier beverages (6 percentage point increase, p=0.001); there were no effects for labeling. Conditions were associated with the purchase of 11–14 fewer calories (9%–11% in relative terms) and 2 fewer grams of sugar. Results remained significant controlling for all items purchased in a single transaction.

Conclusions
Taxation may induce consumers to purchase healthier foods and beverages. However, it is unclear whether the 15%–20% tax rates proposed in public policy discussions would be more effective than labeling products as less healthy.

Objective
Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits.

Design and Methods
Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits.

Results
The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time.

Conclusions
While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Background
This paper describes an innovative protocol for a type-II hybrid effectiveness-implementation trial that is evaluating a smoking cessation telephone care coordination program for Veterans Health Administration (VA) mental-health clinic patients. As a hybrid trial, the protocol combines implementation science and clinical trial methods and outcomes that can inform future cessation studies and the implementation of tobacco cessation programs into routine care. The primary objectives of the trial are (1) to evaluate the process of adapting, implementing, and sustaining a smoking cessation telephone care coordination program in VA mental health clinics, (2) to determine the effectiveness of the program in promoting long-term abstinence from smoking among mental health patients, and (3) to compare the effectiveness of telephone counseling delivered by VA staff with that delivered by state quitlines.

Methods/design
The care coordination program is being implemented at six VA facilities. VA mental health providers refer patients to the program via an electronic medical record consult. Program staff call referred patients to offer enrollment. All patients who enroll receive a self-help booklet, mailed smoking cessation medications, and proactive multi-call telephone counseling. Participants are randomized to receive this counseling from VA staff or their state’s quitline. Four primary implementation strategies are being used to optimize program implementation and sustainability: blended facilitation, provider training, informatics support, and provider feedback. A three-phase formative evaluation is being conducted to identify barriers to, and facilitators for, program implementation and sustainability. A mixed-methods approach is being used to collect quantitative clinical effectiveness data (e.g., self-reported abstinence at six months) and both quantitative and qualitative implementation data (e.g., provider referral rates, coded interviews with providers). Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.

Discussion
This paper describes the rationale and methods of a trial designed to simultaneously study the clinical effectiveness and implementation of a telephone smoking cessation program for smokers using VA mental health clinics. Such hybrid designs are an important methodological design that can shorten the time between the development of an intervention and its translation into routine clinical care.

Obesity is a prominent public health concern that disproportionally affects low-income and minority populations. Recent policies mandating the posting of calories on menus in fast-food chain restaurants have not proven to uniformly influence food choice. This qualitative research study used focus groups to study individual and environmental factors affecting the use of these menu labels among low-income minority populations. Ten focus groups targeting low-income residents (n=105) were held at various community organizations throughout New York City over a 9-month period in 2011. The focus groups were conducted in Spanish, English, or a combination of both languages. In late 2011 and early 2012, transcripts were coded through the process of thematic analysis using Atlas.ti for naturally emerging themes, influences, and determinants of food choice. Few participants used menu labels, despite awareness. The most frequently cited as barriers to menu label use included: price and time constraints, confusion and lack of understanding about caloric values, as well as the priority of preference, hunger, and habitual ordering habits. Based on the individual and external influences on food choice that often take priority over calorie consideration, a modified approach may be necessary to make menu labels more effective and user-friendly.

Because traditional Medicare leaves substantial gaps in coverage, many people obtain supplemental coverage to limit their exposure to out-of-pocket costs. However, some Medicare beneficiaries may not be well equipped to navigate the complex supplemental coverage landscape successfully because of their lower cognitive ability or numeracy—that is, the ability to work with numbers. We found that people in the lower third of the cognitive ability and numeracy distributions were at least eleven percentage points less likely than those in the upper third to enroll in a supplemental Medicare insurance plan. This result means that many Medicare beneficiaries do not have the financial protections and other benefits that would be available to them if they were enrolled in a supplemental insurance plan. Our findings suggest that policy makers may want to consider alternatives tailored to these high-need groups, such as enhanced education and enrollment programs, simpler sets of plan choices, or even some type of automatic enrollment with an option to decline coverage.

The obesity epidemic has transformed children's healthcare, such that diabetes, hypertension and the metabolic syndrome are phrases more commonly used by child health providers than ever before. This article reviews the economic consequences of this epidemic for healthcare delivery systems, both in the short term when obesity has been associated with increased utilization, and in the long term where increased likelihood of adult obesity and cardiovascular disease is well documented. Large investments through research and prevention are needed and are likely to provide strong returns in cost savings, and would optimally emerge through a cooperative effort between private and government payers alike. 

Policies that mandate calorie labeling in fast-food and chain restaurants have had little or no observable impact on calorie consumption to date. In three field experiments, we tested an alternative approach: activating consumers’ self-control by having servers ask customers if they wanted to downsize portions of three starchy side dishes at a Chinese fast-food restaurant. We consistently found that 14–33 percent of customers accepted the downsizing offer, and they did so whether or not they were given a nominal twenty-five-cent discount. Overall, those who accepted smaller portions did not compensate by ordering more calories in their entrées, and the total calories served to them were, on average, reduced by more than 200. We also found that accepting the downsizing offer did not change the amount of uneaten food left at the end of the meal, so the calorie savings during purchasing translated into calorie savings during consumption. Labeling the calorie content of food during one of the experiments had no measurable impact on ordering behavior. If anything, the downsizing offer was less effective in changing customers’ ordering patterns with the calorie labeling present. These findings highlight the potential importance of portion-control interventions that specifically activate consumers’ self-control.

Background. Little is known about how patients served by safety-net hospitals utilize and respond to hospital quality data. Objective. To understand how vulnerable, lower income patients make health care decisions and define quality of care and whether hospital quality data factor into such decisions and definitions. Methods. Mixed quantitative and qualitative methods were used to gather primary data from patients at an urban, tertiary-care safety-net hospital. The study hospital is a member of the first public hospital system to voluntarily post hospital quality data online for public access. Patients were recruited from outpatient and inpatient clinics. Surveys were used to collect data on participants’ sociodemographic characteristics, health literacy, health care experiences, and satisfaction variables. Focus groups were used to explore a representative sample of 24 patients’ health care decision making and views of quality. Data from focus group transcripts were iteratively coded and analyzed by the authors. Results. Focus group participants were similar to the broader diverse, low-income clinic population. Participants reported exercising choice in making decisions about where to seek health care. Multiple sources influenced decision-making processes including participants’ own beliefs and values, social influences, and prior experiences. Hospital quality data were notably absent as a source of influence in health care decision making for this population largely because participants were unaware of its existence. Participants’ views of hospital quality were influenced by the quality and efficiency of services provided (with an emphasis on the doctor-patient relationship) and patient centeredness. When presented with it, patients appreciated the hospital quality data and, with guidance, were interested in incorporating it into health care decision making. Conclusions. Results suggest directions for optimizing the presentation, content, and availability of hospital quality data. Future research will explore how similar populations form and make choices based on presentation of hospital quality data.

Background

A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.

Methods

Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.

Results

Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.

Conclusions

A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.

Objective To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes.

Design A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database.

Setting OECD countries (n=30) from 1995 to 2005.

Main outcomes Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost.

Results Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.

Conclusion Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.

Objective:Obesity is an enormous public health problem and children have been particularly highlighted for intervention. Of notable concern is the fast-food consumption of children. However, we know very little about how children or their parents make fast-food choices, including how they respond to mandatory calorie labeling. We examined children's and adolescents' fast-food choice and the influence of calorie labels in low-income communities in New York City (NYC) and in a comparison city (Newark, NJ).
Design:Natural experiment: Survey and receipt data were collected from low-income areas in NYC, and Newark, NJ (as a comparison city), before and after mandatory labeling began in NYC. Study restaurants included four of the largest chains located in NYC and Newark: McDonald's, Burger King, Wendy's and Kentucky Fried Chicken.Subjects:A total of 349 children and adolescents aged 1-17 years who visited the restaurants with their parents (69%) or alone (31%) before or after labeling was introduced. In total, 90% were from racial or ethnic minority groups.
Results:We found no statistically significant differences in calories purchased before and after labeling; many adolescents reported noticing calorie labels after their introduction (57% in NYC) and a few considered the information when ordering (9%). Approximately 35% of adolescents ate fast food six or more times per week and 72% of adolescents reported that taste was the most important factor in their meal selection. Adolescents in our sample reported that parents have some influence on their meal selection.
Conclusions:Adolescents in low-income communities notice calorie information at similar rates as adults, although they report being slightly less responsive to it than adults. We did not find evidence that labeling influenced adolescent food choice or parental food choices for children in this population.

Recently, localities across the United States have passed laws requiring the mandatory labeling of calories in all chain restaurants, including fast food restaurants. This policy is set to be implemented at the federal level. Early studies have found these policies to be at best minimally effective in altering food choice at a population level. This paper uses receipt and survey data collected from consumers outside fast food restaurants in low-income communities in New York City (NYC) (which implemented labeling) and a comparison community (which did not) to examine two fundamental assumptions necessary (though not sufficient) for calorie labeling to be effective: that consumers know how many calories they should be eating throughout the course of a day and that currently customers improperly estimate the number of calories in their fast food order. Then, we examine whether mandatory menu labeling influences either of these assumptions. We find that approximately one-third of consumers properly estimate that the number of calories an adult should consume daily. Few (8% on average) believe adults should be eating over 2,500 calories daily, and approximately one-third believe adults should eat lesser than 1,500 calories daily. Mandatory labeling in NYC did not change these findings. However, labeling did increase the number of low-income consumers who correctly estimated (within 100 calories) the number of calories in their fast food meal, from 15% before labeling in NYC increasing to 24% after labeling. Overall knowledge remains low even with labeling. Additional public policies likely need to be considered to influence obesity on a large scale.

Understanding the complex factors contributing to the growing childhood obesity epidemic is vital not only for the improved health of the world's future generations, but for the healthcare system. The impact of childhood obesity reaches beyond the individual family and into the public arenas of social systems and government policy and programs. Global Perspectives on Childhood Obesity explores these with an approach that considers the current state of childhood obesity around the world as well as future projections, the most highly cited factors contributing to childhood obesity, what it means for the future both for children and society, and suggestions for steps to address and potentially prevent childhood obesity.

We examined the influence of menu calorie labels on fast food choices in the wake of New York City's labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.

CONTEXT:

American health policy is increasingly relying on consumerism to improve its performance. This article examines a neglected aspect of medical consumerism: the extent to which consumers respond to problems with their health plans.

METHODS:

Using a telephone survey of five thousand consumers conducted in 2002, this article assesses how frequently consumers voice formal grievances or exit from their health plan in response to problems of differing severity. This article also examines the potential impact of this responsiveness on both individuals and the market. In addition, using cross-group comparisons of means and regressions, it looks at how the responses of "empowered" consumers compared with those who are "less empowered."

FINDINGS:

The vast majority of consumers do not formally voice their complaints or exit health plans, even in response to problems with significant consequences. "Empowered" consumers are only minimally more likely to formally voice and no more likely to leave their plan. Moreover, given the greater prevalence of trivial problems, consumers are much more likely to complain or leave their plans because of problems that are not severe. Greater empowerment does not alleviate this.

CONCLUSIONS:

While much of the attention on consumerism has focused on prospective choice, understanding how consumers respond to problems is equally, if not more, important. Relying on consumers' responses as a means to protect individual consumers or influence the market forhealth plans is unlikely to be successful in its current form.

Aims To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse.

Design Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial.

Setting Two community-based treatment centers.

Participants Patients (n = 120) enrolled in out-patient treatment for cocaine abuse.

Intervention Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won.

Measurements Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence; (2) percentage completing treatment; and (3) percentage of samples drug-free.

Findings The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis.

Conclusions Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.

Substantial national attention is being directed at enhancing the competency levels of early careerists in healthcare management. In this study, we examined preceptors' ratings of administrative resident/fellow competencies in multiple domains, and we compared those to our previous results of self-rated competency by residents/fellows. In this national sample of preceptors (n=61) of administrative residency/fellowship program listed with the American College of Healthcare Executives, competency in the information management domain was ranked highest, with more than half of preceptors (55.7%) giving their residents/fellows an "A" rating. Fewer preceptors (between 30.0% and 39.2%) gave their residents/fellows an "A" rating in domains of interpersonal and emotional intelligence, analytic and conceptual reasoning, and clinical operations. Less than 20% of preceptors rated competencies as "A" level in the domains of human resources/marketing/public affairs, financial management, fund raising, and facilities management. There were significant differences in preceptor ratings compared with resident/fellow self-ratings, with preceptors often providing lower ratings than provided by resident/fellows. The findings highlight the need not only to enhance competency levels of graduates but also to address the potential mismatch in early careerists' and preceptors' views about required and attained competency levels.

Context The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.

Objective To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.

Design, Setting, and Participants We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.

Main Outcome Measures Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.

Results We found moderately strong correlations (correlation coefficients ≥0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

Conclusions The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

OBJECTIVES:

The purpose of this study was to determine the least expensive strategy for device selection in patients receiving implantable cardioverter-defibrillators (ICDs).

BACKGROUND:

Device cost for a single-chamber ICD is less than an atrioventricular (dual-chamber) ICD (AV-ICD); however, some patients without clinical need for AV-ICD at implantation might require a later upgrade, potentially offsetting the initial cost advantage of the single-chamber device.

METHODS:

Decision analysis was used to estimate expected resource utilization costs of three alternative implantation strategies: 1) single-chamber device in all, with later upgrade to AV-ICD if needed; 2) initial implantation of an AV-ICD in all; and 3) targeted device selection on the basis of results of electrophysiologic testing (presence or absence of induced bradyarrhythmias or atrial arrhythmias). Clinical base estimates were obtained from retrospective review of all patients receiving ICDs between June 1997 and July 2001 at a single university hospital. Economic inputs were collected from national and single-center sources.

RESULTS:

In patients without other indications for electrophysiologic study (EPS), the expected per-person cost was least with the strategy of universal initial AV-ICD implantation (36,232 dollars) compared with initial single-chamber ICD/upgrade as needed (39,230 dollars) or EPS-guided selection (41,130 dollars). Sensitivity analyses demonstrated that universal AV-ICD implantation remained least expensive with upgrade rates as low as 10%. At a 5% upgrade rate, AV-ICD remained cheapest if the device cost-differential narrowed to 1,568 dollars. For patients undergoing EPS for risk assessment, EP-guided selection was least expensive.

CONCLUSIONS:

The strategy of universal AV-ICD implantation, which provides the benefits of dual-chamber capability while obviating any potential need for future upgrade, is the least costly strategy for most patient populations receiving ICDs.

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.

The states have implemented the State Children's Health Insurance Program (SCHIP) in a variety of ways. We describe these choices and estimate the resulting enrollment impacts. Many widely adopted policies, including mail-in applications and twelve- month continuous eligibility, have had limited impacts. Other policies that increase enrollment, including presumptive eligibility and self-declaration of income, have not been widely adopted. SCHIP programs administered as Medicaid expansions have been more successful in enrolling children than either separate SCHIP plans or combination programs. Waiting periods, premiums, and welfare reform have had important negative impacts on children's program enrollment.

Consumers dissatisfied with their health plan can either "exit" (switch service providers) or "voice" (complain to the current provider). Policymakers' efforts to help consumers voice their dissatisfaction to health plans or external mediators have been disappointing, in part because little is known about the determinants of voice. This article represents the first comprehensive assessment of voicing in response to problematic experiences with health plans. A national consumer survey from 1999 is used to test hypotheses about characteristics of problems, patients, and settings that might inhibit voice and assess state regulations intended to enhance voice. Although problems associated with plans led to more voice than exit, voice is circumscribed by several factors: certain groups, such as racial minorities, do not express their grievances as often; episodes with severe health consequences for patients are not reported as regularly. The findings suggest that even though regulatory initiatives have not increased the frequency of voice, they have made grievances more effective, at least in jurisdictions where citizens know about the laws.

Objectives: The purpose of this study was to determine the least expensive strategy for device selection in patients receiving implantable cardioverter-defibrillators (ICDs).

Background: Device cost for a single-chamber ICD is less than an atrioventricular (dual-chamber) ICD (AV-ICD); however, some patients without clinical need for AV-ICD at implantation might require a later upgrade, potentially offsetting the initial cost advantage of the single-chamber device.

Methods: Decision analysis was used to estimate expected resource utilization costs of three alternative implantation strategies: 1) single-chamber device in all, with later upgrade to AV-ICD if needed; 2) initial implantation of an AV-ICD in all; and 3) targeted device selection on the basis of results of electrophysiologic testing (presence or absence of induced bradyarrhythmias or atrial arrhythmias). Clinical base estimates were obtained from retrospective review of all patients receiving ICDs between June 1997 and July 2001 at a single university hospital. Economic inputs were collected from national and single-center sources.

Results: In patients without other indications for electrophysiologic study (EPS), the expected per-person cost was least with the strategy of universal initial AV-ICD implantation ($36,232) compared with initial single-chamber ICD/upgrade as needed ($39,230) or EPS-guided selection ($41,130). Sensitivity analyses demonstrated that universal AV-ICD implantation remained least expensive with upgrade rates as low as 10%. At a 5% upgrade rate, AV-ICD remained cheapest if the device cost-differential narrowed to $1,568. For patients undergoing EPS for risk assessment, EP-guided selection was least expensive.

Conclusions: The strategy of universal AV-ICD implantation, which provides the benefits of dual-chamber capability while obviating any potential need for future upgrade, is the least costly strategy for most patient populations receiving ICDs.