Publications by authors named "Jonathan Cantor"

42 Publications

Assessing the Association Between Social Gatherings and COVID-19 Risk Using Birthdays.

JAMA Intern Med 2021 Jun 21. Epub 2021 Jun 21.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Many policies designed to stop the spread of COVID-19 address formal gatherings, such as workplaces and dining locations. Informal social gatherings are a potentially important mode of SARS-CoV-2 transmission, but studying their role in transmission is challenged by data and methodological limitations; birthdays offer an opportunity to empirically quantify the potential role of small social gatherings in COVID-19 spread.

Objective: To assess the association between social gatherings and SARS-CoV-2 transmission by studying whether COVID-19 rates increase after birthdays in a household.

Design, Setting, And Participants: This cross-sectional study used nationwide data from January 1 to November 8, 2020, from 2.9 million US households with private insurance to compare COVID-19 infections between households with and without a birthday in the preceding 2 weeks, stratified according to county-level COVID-19 prevalence in that week and adjusting for household size and both week- and county-specific differences. The study also compared how birthday-associated infection rates differed by type of birthday (eg, child vs adult birthday, or a milestone birthday such as a 50th birthday), county-level precipitation on the Saturday of each week (which could move gatherings indoors), political leanings in the county, and state shelter-in-place policies.

Main Outcomes And Measures: Household-level COVID-19 infection.

Results: Among the 2.9 million households in the study, in the top decile of counties in COVID-19 prevalence, households with a birthday in the 2 weeks prior had 8.6 more diagnoses per 10 000 individuals (95% CI, 6.6-10.7 per 10 000 individuals) compared with households without a birthday in the 2 weeks prior, a relative increase of 31% above the county-level prevalence of 27.8 cases per 10 000 individuals, vs 0.9 more diagnoses per 10 000 individuals (95% CI, 0.6-1.3 per 10 000 individuals) in the fifth decile (P < .001 for interaction). Households in the tenth decile of COVID-19 prevalence had an increase in COVID-19 diagnoses of 15.8 per 10 000 persons (95% CI, 11.7-19.9 per 10 000 persons) after a child birthday, compared with an increase of 5.8 per 10 000 persons (95% CI, 3.7-7.9 per 10 000 persons) among households with an adult birthday (P < .001 in a test of interactions). No differences were found by milestone birthdays, county political leaning, precipitation, or shelter-in-place policies.

Conclusions And Relevance: This cross-sectional study suggests that birthdays, which likely correspond with social gatherings and celebrations, were associated with increased rates of diagnosed COVID-19 infection within households in counties with high COVID-19 prevalence.
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http://dx.doi.org/10.1001/jamainternmed.2021.2915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8218234PMC
June 2021

Trends in visits to substance use disorder treatment facilities in 2020.

J Subst Abuse Treat 2021 08 11;127:108462. Epub 2021 May 11.

RAND Corporation, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, USA. Electronic address:

Objective: To describe weekly changes in the number of substance use disorder treatment (SUDT) facility visits in 2020 compared to 2019 using cell phone location data.

Methods: We calculated the percentage weekly change in visits to SUDT facilities from the week of January 5 through the week of October 11, 2020, relative to the week of January 6 through the week of October 13, 2019. We stratified facilities by county COVID-19 incidence per 10,000 residents in each week and by 2018 fatal drug overdose rate. Finally, we conducted a multivariable linear regression analysis examining percent change in visits per week as a function of county-level COVID-19 tercile, a series of calendar month indicators, and the interaction of county-level COVID-19 tercile and month. We repeated the regression analysis replacing COVID-19 tercile with overdose tercile.

Results: Beginning the eleventh week of 2020, the number of visits to SUDT facilities declined substantially, reaching a nadir of 48% of 2019 visits in early July. In contrast to January, there were significantly fewer visits in 2020 compared to 2019 in all subsequent months (p < 0.01 in all months). Multivariable regression results found that facilities in the tercile of counties experiencing the most COVID-19 cases had a significantly greater reduction in the number of SUDT visits in 2020 for the months of June through August than facilities in counties with the fewest COVID-19 rates (p < 0.05). The study found no statistically significant difference in the change in the number of visits by facilities in counties with historically different overdose rates.

Discussion: Our findings support the hypothesis that a reduction has occurred in the average weekly number of visits to SUDT facilities. The size of the effect differs based on the number of COVID-19 cases but not on historical overdose rate.
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http://dx.doi.org/10.1016/j.jsat.2021.108462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217724PMC
August 2021

Where are US outpatient mental health facilities that serve children with autism spectrum disorder? A national snapshot of geographic disparities.

Autism 2021 Jun 12:13623613211024046. Epub 2021 Jun 12.

Harvard Medical School, USA.

Lay Abstract: There has been a rise in the observed prevalence of autism spectrum disorder among children. Existing studies show the share of counties with a treatment facility that offers care for children with autism spectrum disorder. However, no estimates exist of the share of US outpatient mental health treatment facilities that provide services for children with autism spectrum disorder. We identified key facility-level characteristics in offering mental health care for children with autism spectrum disorder. We used a telephone survey to contact almost all outpatient mental health treatment facilities in the contiguous United States. We asked the facilities if they provided mental health care for children with autism spectrum disorder. We took the results of this survey and estimated multivariable regressions to examine county- and facility-level predictors of offering services. We found that over half (50.3%) of the 6156 outpatient facilities reported offering care for children with autism spectrum disorder. Non-metro counties, counties with a lower percentage of non-White residents, counties with a higher percentage of uninsured residents, and counties with a higher poverty rate had fewer outpatient mental health treatment facilities providing care for children with autism spectrum disorder. Facilities accepting Medicaid as a form of payment, offering telehealth, and private for-profit facilities were more likely to provide services for children with autism spectrum disorder. Because only half of outpatient mental health treatment facilities offer care for children with autism spectrum disorder, public health officials and policymakers should do more to ensure that this vulnerable population has access to mental health services.
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http://dx.doi.org/10.1177/13623613211024046DOI Listing
June 2021

Where did the specialty behavioral health workforce grow between 2011 and 2019? Evidence from census data.

J Subst Abuse Treat 2021 May 19;130:108482. Epub 2021 May 19.

Indiana University, Bloomington, IN, USA; National Bureau of Economic Research, Cambridge, MA, USA.

Importance: Given that mental health and substance use conditions are ongoing major public health problems in the United States, it is important for researchers to understand the behavioral health treatment workforce landscape and to assess whether increases in treatment capacity exist in areas with public health needs.

Objectives: This study quantified national and county-level changes in specialty behavioral health (SBH) workforce outcomes and assessed associations between these measures and age-adjusted drug mortality rate.

Design: Using a novel longitudinal dataset from the U.S. Census Bureau, this study described SBH workforce outcomes in 3130 U.S. counties between 2011 and 2019. The study stratified workforce outcomes, including the number of establishments, likelihood of having establishments, mean number of workers, and average wage of workers per county, by service settings: outpatient, residential, and hospital. The study fitted outcome data at the county level to ordinary least squares regression models as a function of the country's previous year age-adjusted drug mortality rate and county sociodemographic characteristics.

Results: The number of SBH establishments, their workforce, and their wages have increased steadily between 2011 and 2019, with the largest increases occurring in the following settings: outpatient (number of establishments and employment) and residential (average wage). County-level growth of residential SBH establishments was positively and significantly associated with the county's previous year county age-adjusted drug mortality rate. We did not observe a similar positive association between either employment or wages and the mortality rate.

Conclusions: The increase in the number of SBH establishments in recent years may indicate that the SBH workforce is responding to increased need for treatment; however, more work needs to be done to close behavioral health workforce gaps in areas with an elevated drug overdose mortality rate.
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http://dx.doi.org/10.1016/j.jsat.2021.108482DOI Listing
May 2021

The new services that opioid treatment programs have adopted in response to COVID-19.

J Subst Abuse Treat 2021 Apr 9;130:108393. Epub 2021 Apr 9.

Department of Public Administration, University of Illinois at Chicago, 412 S. Peoria St., 136, Chicago, IL 60607 (MC 278), USA. Electronic address:

COVID-19 has exacerbated the opioid epidemic and transformed how programs treat opioid use disorder. In response to the pandemic, the federal government modified guidelines to allow opioid treatment programs (OTPs) greater flexibility in the provision of medication for opioid use disorder. We conducted a telephone survey of 31.10% of OTPs in the contiguous United States between June and July 2020. We contacted a random sample of 477 facilities and obtained responses from 373. The survey asked questions about new patient intake, screening for COVID-19, social distancing measures, as well as new treatments offered due to changes in federal government policy. We calculated percentages of positive and nonpositive responses to each survey question. We estimated logistic regressions of facility-, county- and state-level predictors of each treatment approach. Most OTPs are taking new patients (91%). Roughly 83% of them screen for COVID-19 symptoms for in-person visits and about 92% use social distancing measures. More than half of OTPs provide curbside treatment (83%) or telehealth (81%). Less than a quarter of OTPs offer medication drop off (21%) or pick up by a trusted person (32%) when patients need to quarantine due to COVID-19. Results from multivariable logistic regressions show that OTPs in states that had a shelter-in-place policy are more likely to socially distance for in-person visits than those in states without such a policy.
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http://dx.doi.org/10.1016/j.jsat.2021.108393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032476PMC
April 2021

Use of buprenorphine for those with employer-sponsored insurance during the initial phase of the COVID-19 pandemic.

J Subst Abuse Treat 2021 Apr 8;129:108384. Epub 2021 Apr 8.

RAND Corporation, Santa Monica, CA, United States of America.

Objective: To quantify weekly rates of use of buprenorphine for those with employer-based insurance and whether the rate differs based on county-level measures of race, historical fatal drug overdose rate, and COVID-19 case rate.

Methods: We used 2020 pharmaceutical claims for 4.8 million adults from a privately insured population to examine changes in the use of buprenorphine to treat opioid use disorder in 2020 during the onset of the COVID-19 pandemic. We quantified variation by examining changes in use rates across counties based on their fatal drug overdose rate in 2018, number of COVID-19 cases per capita, and percent nonwhite.

Results: Weekly use of buprenorphine was relatively stable between the first week of January (0.6 per 10,000 enrollees, 95%CI = 0.2 to 1.1) and the last week of August (0.8 per 10,000 enrollees, 95%CI = 0.4 to 1.3). We did not find evidence of any consistent change in use of buprenorphine by county-level terciles for COVID-19 rate as of August 31, 2020, age-adjusted fatal drug overdose rate, and percent nonwhite. Use was consistently higher for counties in the highest tercile of county age-adjusted fatal drug overdose rate when compared to counties in the lowest tercile of county age-adjusted fatal drug overdose rate.

Discussion: Our results provide early evidence that new federal- and state-level policies may have steadied the rate of using buprenorphine for those with employer-based insurance during the pandemic.
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http://dx.doi.org/10.1016/j.jsat.2021.108384DOI Listing
April 2021

Brief Report: Medicaid Expansion and Growth in the Workforce for Autism Spectrum Disorder.

J Autism Dev Disord 2021 May 20. Epub 2021 May 20.

Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.

Over 700,000 children throughout the U.S. have received insurance coverage through welcome mat effects of Medicaid expansion, including children with autism spectrum disorder (ASD). Utilizing health workforce data from the Health Resources and Services Administration, we examined workforce growth (2008-2017) among three types of health providers for children with ASD as a result of Medicaid expansion: child psychiatrists, board-certified behavioral analysts (BCBAs) and pediatricians. We found that state Medicaid expansion was associated with a 9% increase in BCBAs per 100,000 children one year after enactment, a 5% increase in child psychiatrists, and was not associated with growth in pediatricians. Results indicate the importance of new policies that directly address a shortage of providers for children with ASD.
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http://dx.doi.org/10.1007/s10803-021-05044-2DOI Listing
May 2021

SNAP Participants and High Levels of Food Insecurity in the Early Stages of the COVID-19 Pandemic.

Public Health Rep 2021 Jul-Aug;136(4):457-465. Epub 2021 Mar 31.

Division of Social and Economic Wellbeing, RAND Corporation, Pittsburgh, PA, USA.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately strained households experiencing poverty, particularly Black and Latino households. Food insecurity, which entails having limited or uncertain access to a sufficient quantity of nutritious food, is a key pandemic-related consequence. We examined how people enrolled in the Supplemental Nutrition Assistance Program (SNAP) have been affected by the pandemic, particularly Black participants and participants residing in food deserts.

Methods: Using survey data from a longitudinal cohort study of predominantly Black low-income adults aged ≥18 residing in urban food deserts in Pittsburgh, Pennsylvania, we examined changes in food insecurity and SNAP participation before COVID-19 (2018) and early in the COVID-19 pandemic (March-May 2020). We modeled changes in food insecurity from 2018 to 2020 via covariate-adjusted logistic regression.

Results: Food insecurity increased significantly among participants enrolled in SNAP and surveyed in both 2018 and 2020 (from 25.9% in 2018 to 46.9% in 2020; < .001). Compared with cohort participants not enrolled in SNAP at both points, cohort participants enrolled in SNAP in 2018 and 2020 had the highest rates of using a food bank in 2020 (44.4%) and being newly food insecure in 2020 (28.9%) (ie, they were food insecure in 2020 but not in 2018).

Conclusions: Food insecurity during the COVID-19 pandemic increased among low-income Black households enrolled in SNAP and residing in a food desert. Public health recovery efforts might focus on modifying SNAP to improve the food security of people experiencing poverty.
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http://dx.doi.org/10.1177/00333549211007152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203047PMC
June 2021

Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic.

Am J Prev Med 2021 Mar 6. Epub 2021 Mar 6.

RAND Corporation, Santa Monica, California.

Introduction: The COVID-19 pandemic has forced telehealth to be the primary means through which patients interact with their providers. There is a concern that the pandemic will exacerbate the existing disparities in overall healthcare utilization and telehealth utilization. Few national studies have examined the changes in telehealth use during the COVID-19 pandemic.

Methods: Data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019, respectively, were collected in 2020. Unadjusted rates were compared both before and after the week of the declaration of the COVID-19 pandemic as a national emergency. Trends in weekly utilization were also examined using a difference-in-differences regression framework to quantify the changes in telemedicine and office-based care utilization while controlling for the patient's demographic and county-level sociodemographic measures. All analyses were conducted in 2020.

Results: More than a 20-fold increase in the incidence of telemedicine utilization after March 13, 2020 was observed. Conversely, the incidence of office-based encounters declined by almost 50% and was not fully offset by the increase in telemedicine. The increase in telemedicine was greatest among patients in counties with low poverty levels (β=31.70, 95% CI=15.17, 48.23), among patients in metropolitan areas (β=40.60, 95% CI=30.86, 50.34), and among adults than among children aged 0-12 years (β=57.91, 95% CI=50.32, 65.49).

Conclusions: The COVID-19 pandemic has affected telehealth utilization disproportionately on the basis of patient age and both the county-level poverty rate and urbanicity.
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http://dx.doi.org/10.1016/j.amepre.2021.01.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7936544PMC
March 2021

Availability of Outpatient Telemental Health Services in the United States at the Outset of the COVID-19 Pandemic.

Med Care 2021 04;59(4):319-323

Department of Population Medicine, Harvard Medical School.

Background: Since coronavirus disease 2019 (COVID-19) has caused dramatic changes in everyday life, a major concern is whether patients have adequate access to mental health care despite shelter-in-place ordinances, school closures, and social distancing practices.

Objectives: The aim was to examine the availability of telehealth services at outpatient mental health treatment facilities in the United States at the outset of the COVID-19 pandemic, and to identify facility-level characteristics and state-level policies associated with the availability.

Research Design: Observational cross-sectional study.

Subjects: All outpatient mental health treatment facilities (N=8860) listed in the Behavioral Health Treatment Services Locator of the Substance Abuse and Mental Health Services Administration on April 16, 2020.

Measures: Primary outcome is whether an outpatient mental health treatment facility reported offering telehealth services.

Results: Approximately 43% of outpatient mental health facilities in the United States reported telehealth availability at the outset of the pandemic. Facilities located in the United States South and nonmetropolitan counties were more likely to offer services, as were facilities with public sector ownership, those providing care for both children and adults, and those accepting Medicaid as a form of payment. Outpatient mental health treatment facilities located in states with state-wide shelter-in-place laws were less likely to offer telehealth, as well as facilities in counties with more COVID-19 cases per 10,000 population.

Conclusions: At the onset of the COVID-19 pandemic, fewer than half of outpatient mental health treatment facilities were providing telehealth services. Our results suggest that additional policies to promote telehealth may be warranted to increase availability over the course of the COVID-19 pandemic.
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http://dx.doi.org/10.1097/MLR.0000000000001512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954880PMC
April 2021

Food Insecurity in a Low-Income, Predominantly African American Cohort Following the COVID-19 Pandemic.

Am J Public Health 2021 03 21;111(3):494-497. Epub 2021 Jan 21.

The authors are with the RAND Corporation, and this work was performed in the Division of Social and Economic Well-Being.

To examine the impact of COVID-19 shutdowns on food insecurity among a predominantly African American cohort residing in low-income racially isolated neighborhoods. Residents of 2 low-income African American food desert neighborhoods in Pittsburgh, Pennsylvania, were surveyed from March 23 to May 22, 2020, drawing on a longitudinal cohort (n = 605) previously followed from 2011 to 2018. We examined longitudinal trends in food insecurity from 2011 to 2020 and compared them with national trends. We also assessed use of food assistance in our sample in 2018 versus 2020. From 2018 to 2020, food insecurity increased from 20.7% to 36.9% ( = 7.63;  < .001) after steady declines since 2011. As a result of COVID-19, the United States has experienced a 60% increase in food insecurity, whereas this sample showed a nearly 80% increase, widening a preexisting disparity. Participation in the Supplemental Nutrition Assistance Program (52.2%) and food bank use (35.9%) did not change significantly during the early weeks of the pandemic. Longitudinal data highlight profound inequities that have been exacerbated by COVID-19. Existing policies appear inadequate to address the widening gap.
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http://dx.doi.org/10.2105/AJPH.2020.306041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893363PMC
March 2021

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder.

Autism 2021 05 4;25(4):921-931. Epub 2020 Dec 4.

Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.

Lay Abstract: To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.
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http://dx.doi.org/10.1177/1362361320976744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089032PMC
May 2021

Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic.

JAMA Netw Open 2020 11 2;3(11):e2024984. Epub 2020 Nov 2.

Castlight Health, San Francisco, California.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented strain on patients and health care professionals and institutions, but the association of the pandemic with use of preventive, elective, and nonelective care, as well as potential disparities in use of health care, remain unknown.

Objective: To examine changes in health care use during the first 2 months of the COVID-19 pandemic in March and April of 2020 relative to March and April of 2019 and 2018, and to examine whether changes in use differ by patient's zip code-level race/ethnicity or income.

Design, Setting, And Participants: This cross-sectional study analyzed health insurance claims for patients from all 50 US states who receive health insurance through their employers. Changes in use of preventive services, nonelective care, elective procedures, prescription drugs, in-person office visits, and telemedicine visits were examined during the first 2 months of the COVID-19 pandemic in 2020 relative to existing trends in 2019 and 2018. Disparities in the association of the pandemic with health care use based on patient's zip code-level race and income were also examined.

Results: Data from 5.6, 6.4, and 6.8 million US individuals with employer-sponsored insurance in 2018, 2019, and 2020, respectively, were analyzed. Patient demographics were similar in all 3 years (mean [SD] age, 34.3 [18.6] years in 2018, 34.3 [18.5] years in 2019, and 34.5 [18.5] years in 2020); 50.0% women in 2018, 49.5% women in 2019, and 49.5% women in 2020). In March and April 2020, regression-adjusted use rate per 10 000 persons changed by -28.2 (95% CI, -30.5 to -25.9) and -64.5 (95% CI, -66.8 to -62.2) for colonoscopies; -149.1 (95% CI, -162.0 to -16.2) and -342.1 (95% CI, -355.0 to -329.2) for mammograms; -60.0 (95% CI, -63.3 to -54.7) and -118.1 (95% CI, -112.4 to -113.9) for hemoglobin A1c tests; -300.5 (95% CI, -346.5 to -254.5) and -369.0 (95% CI, -414.7 to -323.4) for child vaccines; -4.6 (95% CI, -5.3 to -3.9) and -10.9 (95% CI, -11.6 to -10.2) for musculoskeletal surgery; -1.1 (95% CI, -1.4 to -0.7) and -3.4 (95% CI, -3.8 to -3.0) for cataract surgery; -13.4 (95% CI, -14.6 to -12.2) and -31.4 (95% CI, -32.6 to -30.2) for magnetic resonance imaging; and -581.1 (95% CI, -612.9 to -549.3) and -1465 (95% CI, -1496 to -1433) for in-person office visits. Use of telemedicine services increased by 227.9 (95% CI, 221.7 to 234.1) per 10 000 persons and 641.6 (95% CI, 635.5 to 647.8) per 10 000 persons. Patients living in zip codes with lower-income or majority racial/ethnic minority populations experienced smaller reductions in in-person visits (≥80% racial/ethnic minority zip code: 200.0 per 10 000 [95% CI, 128.9-270.1]; 79%-21% racial/ethnic minority zip code: 54.2 per 10 000 [95% CI, 33.6-74.9]) but also had lower rates of adoption of telemedicine (≥80% racial/ethnic minority zip code: -71.6 per 10 000 [95% CI, -87.6 to -55.5]; 79%-21% racial/ethnic minority zip code: -15.1 per 10 000 [95% CI, -19.8 to -10.4]).

Conclusions And Relevance: In this cross-sectional study of a large US population with employer-sponsored insurance, the first 2 months of the COVID-19 pandemic were associated with dramatic reductions in the use of preventive and elective care. Use of telemedicine increased rapidly but not enough to account for reductions in in-person primary care visits. Race and income disparities at the zip code level exist in use of telemedicine.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.24984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645698PMC
November 2020

Telehealth Capability Among Substance Use Disorder Treatment Facilities in Counties With High Versus Low COVID-19 Social Distancing.

J Addict Med 2020 12;14(6):e366-e368

RAND Corporation, Santa Monica, CA (JC), RAND Corporation, Pittsburgh, PA (BDS), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (BS).

Objective: To quantify the availability of telehealth services at substance use treatment facilities in the U.S. at the beginning of the COVID-19 pandemic, and determine whether telehealth is available at facilities in counties with the greatest amount of social distancing.

Methods: We merged county-level measures of social distancing through April 18, 2020 to detailed administrative data on substance use treatment facilities. We then calculated the number and share of treatment facilities that offered telehealth services by whether residents of the county social distanced or not. Finally, we estimated a logistic regression that predicted the offering of telehealth services using both county- and facility-level characteristics.

Results: Approximately 27% of substance use facilities in the U.S. reported telehealth availability at the outset of the pandemic. Treatment facilities in counties with a greater social distancing were less likely to possess telemedicine capability. Similarly, nonopioid treatment programs that offered buprenorphine or vivitrol in counties with a greater burden of COVID-19 were less likely to offer telemedicine when compared to similar facilities in counties with a lower burden of COVID-19.

Conclusions: Relatively few substance use treatment facilities offered telehealth services at the onset of the COVID-19 pandemic. Policymakers and public health officials should do more to support facilities in offering telehealth services.
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http://dx.doi.org/10.1097/ADM.0000000000000744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869724PMC
December 2020

State Insurance Mandates and the Workforce for Children With Autism.

Pediatrics 2020 10 8;146(4). Epub 2020 Sep 8.

Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts.

Background: State mandates have required insurance companies to provide coverage for autism-related child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs).

Methods: We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017.

Results: From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: -0.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply.

Conclusions: State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.
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http://dx.doi.org/10.1542/peds.2020-0836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546088PMC
October 2020

Adoption of telemedicine services by substance abuse treatment facilities in the U.S.

J Subst Abuse Treat 2020 10 23;117:108060. Epub 2020 Jun 23.

Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America.

Objective: To describe trends in licensed substance use treatment facilities' adoption of telemedicine and how adoption varies across local factors, including county-level drug overdose rates, urbanicity measures, and state policy laws.

Methods: We analyzed data (2016-2019) from the National Directory of Drug and Alcohol Abuse Treatment Facilities. Our main outcome was telemedicine use by a treatment facility. We also captured independent variables from other datasets, including estimated county-level drug poisoning deaths and state-level telemedicine policies. We estimated a multivariable logistic regression model to determine which facility characteristics were associated with offering telemedicine.

Results: From 2016 to 2019, an average of 12,334 treatment facilities were included. During this period, the unadjusted proportion of facilities offering telemedicine grew from 13.5% to 17.4% (p < 0.001). In adjusted models, rural location; offering multiple treatment settings; offering pharmacotherapy; and serving both adult and pediatric patients were associated with greater telemedicine adoption (p < 0.05 for all comparisons).

Discussion: Use of telemedicine is increasing steadily among substance use disorder (SUD) treatment facilities; however, uptake is uneven and relatively low. As such, telemedicine may be an underutilized tool to expand access to care for patients with SUDs.
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http://dx.doi.org/10.1016/j.jsat.2020.108060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308749PMC
October 2020

The effects of soda taxes on adolescent sugar intake and blood sugar.

Health Econ 2020 11 6;29(11):1422-1434. Epub 2020 Aug 6.

RAND Corporation, Santa Monica, California, USA.

Intake of added sugars is high in the US adolescent population, with sugar-sweetened beverages being the primary source. We contribute to the literature by providing the first estimates of the impacts of soda sales taxes, which are commonly levied in the US states, on the total daily sugar intake and blood sugar of adolescents aged 12-19 years. Using a restricted-use version of the 1999-2014 National Health and Nutrition Examination Survey (NHANES) and exploiting within-state variation in soda sales tax rates over time, our results indicate that adolescent soft drink demand is tax-sensitive. Consistent with prior research using NHANES data, we find that adolescents reduce calories consumed from soft drinks when faced with a rise in soda sales taxes, but they offset this reduction with an increase in calorie intake from milk drinks. In accordance with this substitution behavior, we find that soda sales taxes cause small and insignificant changes in the total daily calorie intake, total daily sugar intake, or blood sugar levels of adolescents.
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http://dx.doi.org/10.1002/hec.4142DOI Listing
November 2020

SNAP Participants Improved Food Security And Diet After A Full-Service Supermarket Opened In An Urban Food Desert.

Health Aff (Millwood) 2020 08;39(8):1386-1394

Tamara Dubowitz is a senior policy researcher in the Department of Behavioral and Policy Sciences, RAND Corporation, in Pittsburgh.

The Supplemental Nutrition Assistance Program (SNAP) is the largest US food and nutrition assistance program, tasked with improving food security among low-income households. Another federal effort to improve food access is the Healthy Food Financing Initiative (HFFI), which invested tens of millions of dollars to incentivize healthy food retail outlets in areas lacking access to nutritious, fresh food. We explore the intersection of these programs, testing the impact of a new, HFFI-financed full-service supermarket on SNAP participants in an urban food desert. After the supermarket's opening, SNAP participants' food security improved and intake of added sugars declined in the intervention neighborhood, but both were unchanged in a comparison neighborhood without a new supermarket. Intervention neighborhood participants also experienced relative declines in the percentage of daily calories from solid fats, alcoholic beverages, and added sugars. Our findings suggest that HFFI amplifies the effects of SNAP participation on improving food security and dietary quality in food deserts.
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http://dx.doi.org/10.1377/hlthaff.2019.01309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237564PMC
August 2020

Fewer Than Half Of US Mental Health Treatment Facilities Provide Services For Children With Autism Spectrum Disorder.

Health Aff (Millwood) 2020 06;39(6):968-974

Hao Yu is an associate professor of population medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute, both in Boston.

Despite estimates of rising prevalence of children with autism spectrum disorder (ASD) in the US, there is little research on the availability of behavioral health care services for this vulnerable population. To fill the gap, we surveyed 8,184 mental health treatment facilities in the contiguous US. As of August 2019, 43.0 percent of facilities reported providing behavioral health care for children with ASD, and 36.6 percent were accepting such children as new patients. Only 12.7 percent reported having a clinician with specialized training, and 4.3 percent reported having a specialized treatment program. Multivariable regression results indicated that there was poorer access to specialized ASD care in rural and lower-income communities. New policies are needed to increase the availability of behavioral health care for children with ASD.
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http://dx.doi.org/10.1377/hlthaff.2019.01557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773216PMC
June 2020

Neighborhood Environments, SNAP-Ed Eligibility, and Health Behaviors: An Analysis of the California Health Interview Survey (CHIS).

J Urban Health 2020 08;97(4):543-551

Division of Chronic Disease and Injury Prevention, Los Angeles County Department of Public Health, Los Angeles, CA, USA.

Neighborhood conditions are associated with health outcomes, but whether individual health behaviors are independent of or associated with the settings are not clear. We analyzed the California Health Interview Survey (CHIS) (N = 11,152) data to determine if the perceptions and behaviors of similar individuals with an income low enough to be eligible for SNAP-Ed services differed based on whether they lived in high- or low-income neighborhoods. We found that SNAP-Ed eligible individuals living in low-income neighborhoods walked for transportation more frequently (3.04 times versus 2.38 times, p = 0.001), drank sugary beverages more frequently in the past month (2.93 times versus 1.69 times, p = 0.000), and had a higher risk of obesity than similar low-income individuals living in high-income neighborhoods (0.34 versus 0.26, p = 0.012).
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http://dx.doi.org/10.1007/s11524-020-00433-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392966PMC
August 2020

Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome.

JAMA Netw Open 2019 11 1;2(11):e1914078. Epub 2019 Nov 1.

RAND Corporation, Pittsburgh, Pennsylvania.

Importance: Despite the rapidly changing policy environment regarding substance use during pregnancy, information is lacking on the association of state policies with neonatal abstinence syndrome (NAS).

Objective: To determine if punitive or reporting state policies related to substance use during pregnancy are associated with NAS rates.

Design, Setting, And Participants: This repeated cross-sectional study used retrospective, difference-in-difference analysis of live births in the State Inpatient Databases from 8 US states in varying years between January 1, 2003, and December 31, 2014. States without punitive or reporting policies were compared with states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and state and year fixed effects. Analyses were conducted from April 10, 2019, to July 30, 2019.

Exposures: Time since enactment of state policies related to substance use in pregnancy, county-level rurality and unemployment, and presence of specialized treatment programs for pregnant and postpartum women in a county.

Main Outcome And Measures: Rates of NAS.

Results: Among 4 567 963 live births, 23 377 neonates (0.5%) received a diagnosis of NAS. Among neonates with NAS, 3394 (14.5%) lived in counties without any treatment programs specifically for pregnant and postpartum women, 20 323 (86.9%) lived in metropolitan counties, and 8135 (34.8%) lived in counties in the highest unemployment quartile. In adjusted analyses among neonates in states with punitive policies, odds of NAS were significantly greater during the first full calendar year after enactment (adjusted odds ratio, 1.25; 95% CI, 1.06-1.46; P = .007) and more than 1 full year after enactment (adjusted odds ratio, 1.33; 95% CI, 1.17-1.51; P < .001). After regression adjustment, the annual NAS rate was 46 (95% CI, 43-48) neonates with NAS per 10 000 live births in states without punitive policies; 57 (95% CI, 48-65) neonates with NAS per 10 000 live births in states with punitive policies during the first full year after enactment; and 60 (95% CI, 56-65) neonates with NAS per 10 000 live births in states with punitive policies in effect for more than 1 full year. There was no association between reporting policies and odds of NAS.

Conclusions And Relevance: In this repeated cross-sectional analysis of 8 states, states with punitive policies were associated with greater odds of NAS immediately and in the longer term, but there was no association between NAS and states with reporting policies.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.14078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902764PMC
November 2019

Growth and Distribution of Child Psychiatrists in the United States: 2007-2016.

Pediatrics 2019 12 4;144(6). Epub 2019 Nov 4.

Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.

Background: Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade.

Methods: Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models.

Results: From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by >50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in both 2007 and 2016. Child psychiatrists were significantly more likely to practice in high-income counties ( < .001), counties with higher levels of postsecondary education ( < .001), and metropolitan counties compared with those adjacent to metropolitan regions ( < .05).

Conclusions: Despite the increased ratio of child psychiatrists per 100 000 children in the United States over the past decade, there remains a dearth of child psychiatrists, particularly in parts of the United States with lower levels of income and education.
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http://dx.doi.org/10.1542/peds.2019-1576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889947PMC
December 2019

Systematic Review: United States Workforce for Autism-Related Child Healthcare Services.

J Am Acad Child Adolesc Psychiatry 2020 01 29;59(1):113-139. Epub 2019 May 29.

RAND Corporation, Pittsburgh, PA.

Objective: A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies' strength of evidence.

Method: We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research.

Results: Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples.

Conclusion: There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability.
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http://dx.doi.org/10.1016/j.jaac.2019.04.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883168PMC
January 2020

Food environment does not predict self-reported SSB consumption in New York City: A cross sectional study.

PLoS One 2018 24;13(10):e0196689. Epub 2018 Oct 24.

Department of Population Health, New York University School of Medicine, New York City, New York, United States of America.

The purpose of this research was to examine whether the local food environment, specifically the distance to the nearest sugar sweetened beverage (SSB) vendor, a measure of SSB availability and accessibility, was correlated with the likelihood of self-reported SSB consumption among a sample of fast food consumers. As part of a broader SSB behavior study in 2013-2014, respondents were surveyed outside of major chain fast food restaurants in New York City (NYC). Respondents were asked for the intersection closest to their home and how frequently they consume SSBs. Comprehensive, administrative food outlet databases were used to geo-locate the SSB vendor closest to the respondents' home intersections. We then used a logistic regression model to estimate the association between the distance to the nearest SSB vendor (overall and by type) and the likelihood of daily SSB consumption. Our results show that proximity to the nearest SSB vendor was not statistically significantly associated with the likelihood of daily SSB consumption, regardless of type of vendor. Our results are robust to alternative model specifications, including replacing the linear minimum distance measure with count of the total number of SSB vendors or presence of a SSB vendor within a buffer around respondents' home intersections. We conclude that there is not a strong relationship between proximity to nearest SSB vendor, or proximity to a specific type of SSB vendor, and frequency of self-reported SSB consumption among fast food consumers in NYC. This suggests that policymakers focus on alternative strategies to curtail SSB consumption, such as improving the within-store food environment or taxing SSBs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0196689PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200180PMC
March 2019

The response of substance use disorder treatment providers to changes in macroeconomic conditions.

J Subst Abuse Treat 2017 10 8;81:59-65. Epub 2017 Jul 8.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 344, Baltimore, MD 21205, USA. Electronic address:

Objective: To study how substance use disorder (SUD) treatment providers respond to changes in economic conditions.

Data Sources: 2000-2012 National Survey of Substance Abuse Treatment Services (N-SSATS) which contains detailed information on specialty SUD facilities in the United States.

Study Design: We use fixed-effects regression to study how changes in economic conditions, proxied by state unemployment rates, impact treatment setting, accepted payment forms, charity care, offered services, special programs, and use of pharmacotherapies by specialty SUD treatment providers.

Data Collection: Secondary data analysis in the N-SSATS.

Principal Findings: Our findings suggest a one percentage point increase in the state unemployment rate is associated with a 2.5% reduction in outpatient clients by non-profit providers and a 1.8% increase in the acceptance of private insurance as a form of payment overall. We find no evidence that inpatient treatment, the provision of charity care, offered services, or special programs are impacted by changes in the state unemployment rate. However, a one percentage point increase in the state unemployment rate leads to a 2.5% increase in the probability that a provider uses pharmacotherapies to treat addiction.

Conclusions: Deteriorating economic conditions may increase financial pressures on treatment providers, prompting them to seek new sources of revenue or to change their care delivery models.
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http://dx.doi.org/10.1016/j.jsat.2017.07.005DOI Listing
October 2017

Measuring Micro-Level Effects of a New Supermarket: Do Residents Within 0.5 Mile Have Improved Dietary Behaviors?

J Acad Nutr Diet 2018 06 8;118(6):1037-1046. Epub 2017 Aug 8.

Background: Local and national policies to encourage supermarket opening or expansion are popular strategies for improving access to healthy food for residents in neighborhoods lacking these types of stores, yet few evaluations of such initiatives exist.

Objective: Our aim was to test whether a newly opened supermarket in the Bronx, NY, changed household availability of healthy and unhealthy food items and reported daily consumption of these items among respondents residing in close proximity (≤0.5 mile) to the new supermarket.

Design: This quasi-experimental study evaluated changes in purchasing and consumption habits of residents within 0.5 mile of the new supermarket as compared to residents living more than 0.5 mile from the supermarket. Data were collected through street intercept surveys at three different times: once before the store opened (March to August 2011) and in two follow-up periods (1 to 5 months and 13 to 17 months after the store opened). This study analyzed a subset of successfully geocoded resident intersections from the larger study.

Participants/setting: We surveyed 3,998 residents older than the age of 18 years in two Bronx neighborhoods about their food-purchasing behaviors before the store opened and in two follow-up periods. Responses from residents whose intersections were successfully geocoded (N=3,378) were analyzed to examine the consumption and purchasing behaviors of those in close proximity to the new store.

Intervention: A new supermarket opened in a low-access neighborhood in the Bronx with the help of financial incentives through New York City's Food Retail Expansion to Support Health (FRESH) program.

Main Outcome Measures: The primary outcome evaluated was the change in percent of respondents reporting that the following food items were "always available" in the home: milk, fruit juice, soda, pastries, packaged snacks, fruits, and vegetables. As a secondary outcome, we explored changes in self-reported daily servings of these items.

Statistical Analysis Performed: A difference-in-difference analysis was performed, controlling for age, education, marital status, income, sex, race, and ethnicity.

Results: Residents within 0.5 mile of the store had increased household availability of both healthy and unhealthy foods. After the introduction of the supermarket, the percent of residents in close proximity to the store who reported always having produce available in the home increased by 8.8% compared to those living >0.5 mile from the store in the first post-period and by 10.6% compared to those living >0.5 mile from the store in the second post-period. A similar positive increase in household availability of salty snacks and pastries was observed. Residents living in close proximity also reported greater consumption of healthy foods like produce and water, and lower intake of soft drinks and pastries.

Conclusions: Given the financial support at the national and local levels to encourage supermarket development and expansion in high-need communities, it is imperative to evaluate the impact of such initiatives. Although the findings have so far been equivocal, our findings give weight to the argument that, at a micro-level, the siting of a new supermarket can indeed impact local purchasing and consumption behavior. Although purchasing for both healthy and unhealthy food items increased, reported consumption showed an increase in servings of healthy items (water, vegetables, and fruit) and a decrease in servings of unhealthy foods (soft drinks, salty snacks, and pastries).
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http://dx.doi.org/10.1016/j.jand.2017.06.360DOI Listing
June 2018

Vitamin panacea: Is advertising fueling demand for products with uncertain scientific benefit?

J Health Econ 2017 09 17;55:30-44. Epub 2017 Jun 17.

Wagner School of Public Service, New York University, United States; Department of Population Health, New York University School of Medicine, New York, NY, United States.

This study examines the effect of advertising on demand for vitamins-products with spiraling sales despite little evidence of efficacy. We merge seven years (2003-2009) of advertising data from Kantar Media with the Simmons National Consumer Survey to estimate individual-level vitamin print and television ad exposure effects. Identification relies on exploiting exogenous variation in year-to-year advertising exposure by controlling for each individual's unique media consumption. We find that increasing advertising exposure from zero to the mean number of ads increases the probability of consumption by 1.2 and 0.8% points (or 2 and 1.4%) in print and television respectively. Stratifications by the presence of health conditions suggests that in print demand is being driven by both healthy and sick individuals.
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http://dx.doi.org/10.1016/j.jhealeco.2017.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599169PMC
September 2017

Energy contribution of sugar-sweetened beverage refills at fast-food restaurants.

Public Health Nutr 2017 Sep 9;20(13):2349-2354. Epub 2017 May 9.

1New York University Robert F. Wagner School of Public Service,295 Lafayette Street,2nd Floor,New York,NY 10012,USA.

Objective: To identify demographic and consumer characteristics associated with refilling a soft drink at fast-food restaurants and the estimated energy content and volume of those refills.

Design: Logistic and linear regression with cross-sectional survey data.

Setting: Data include fast-food restaurant receipts and consumer surveys collected from restaurants in New York City (all boroughs except Staten Island), and Newark and Jersey City, New Jersey, during 2013 and 2014.

Subjects: Fast-food restaurant customers (n 11795) from ninety-eight restaurants.

Results: Thirty per cent of fast-food customers ordered a refillable soft drink. Nine per cent of fast-food customers with a refillable soft drink reported refilling their beverage (3 % of entire sample). Odds of having a beverage refill were higher among respondents with a refillable soft drink at restaurants with a self-serve refill kiosk (adjusted OR (aOR)=7·37, P<0·001) or who ate in the restaurant (aOR=4·45, P<0·001). KFC (aOR=2·18, P<0·001) and Wendy's (aOR=0·41, P<0·001) customers had higher and lower odds, respectively, of obtaining a refill, compared with Burger King customers. Respondents from New Jersey (aOR=1·47, P<0·001) also had higher odds of refilling their beverage than New York City customers. Customers who got a refill obtained on average 29 more 'beverage ounces' (858 ml) and 250 more 'beverage calories' (1046 kJ) than customers who did not get a refill.

Conclusions: Refilling a beverage was associated with having obtained more beverage calories and beverage ounces. Environmental cues, such as the placement and availability of self-serve beverage refills, may influence consumer beverage choice.
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http://dx.doi.org/10.1017/S1368980017000611DOI Listing
September 2017
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