Outcomes Following Taxation of Sugar-Sweetened Beverages: A Systematic Review and Meta-analysis.

Importance: More than 45 countries and several local jurisdictions have implemented sugar-sweetened beverage (SSB) taxes to improve nutrition and population health, and evidence on their outcomes to date is essential to inform policy discussions. Responding to this need, the World Health Organization commissioned a systematic literature review on the outcomes of fiscal policies, including SSB taxes. Objective: To assess the associations of implemented SSB taxes with prices, sales, consumption, diet, body weight, product changes, unintended consequences, health, and pregnancy outcomes. Data Sources: Searches of 8 bibliographic databases (Business Source Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, EconLit, PsycINFO, PubMed, and Scopus) were performed from database inception through June 1, 2020, with no language or setting restrictions. Grey literature was assessed using 14 sources and government websites. Study Selection: The review included primary studies of implemented SSB taxes. Data Extraction and Synthesis: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. For prices, sales and consumption, results were meta-analyzed using a 3-level random-effects model. Study quality was assessed at the outcome level. Main Outcomes and Measures: Tax pass-through rate for prices, percentage reduction in SSB demand, and price elasticity of demand for sales and consumption. Heterogeneity was assessed using τ2 and the I2 statistic. Results: A total of 86 articles were eligible, with 62 studies contributing to the meta-analysis. The overall tax pass-through rate was 82% (95% CI, 66% to 98%; P < .001, I2 = 99%), suggesting tax undershifting. The demand for SSBs was highly sensitive to tax-induced price increases, with the price elasticity of demand of -1.59 (95% CI, -2.11 to -1.08; P < .001; I2 = 100%) and a mean reduction in SSB sales of 15% (95% CI, -20% to -9%; P < .001; I2 = 100%). There was no evidence of substitution to untaxed beverages, and changes in SSB consumption were not significant. The narrative synthesis found reformulation and reduced sugar content of taxed beverages for tiered taxes, cross-border shopping in most studies of local-level taxes, and no negative changes in employment. Data on the heterogeneity of SSB tax outcomes across subpopulations were limited. Conclusions and Relevance: In this systematic review and meta-analysis of implemented SSB taxes worldwide, SSB taxes were associated with higher prices and lower sales of taxed beverages.

Evaluation of Economic and Health Outcomes Associated With Food Taxes and Subsidies: A Systematic Review and Meta-analysis.

Importance: Fiscal policy is a promising approach to incentivizing better food choices and reducing the burden of chronic disease. To inform guidelines on using fiscal policies, including taxes and subsidies, to promote health, the World Health Organization commissioned a systematic review and meta-analysis of the worldwide literature on the outcomes of such policies for food products. Objective: To assess the outcomes of implemented food taxes and subsidies for prices, sales, consumption, and population-level diet and health. Data Sources: Eight bibliographic databases were searched for peer-reviewed literature and 14 data sources along with governmental websites were searched for grey literature that were published from database inception through June 1, 2020. There were no language and setting restrictions. Study Selection: Only primary studies of implemented food taxes and subsidies were considered for inclusion. Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. A 3-level random-effects model was used to conduct a meta-analysis of sales and consumption outcomes of fruit and vegetable subsidies. Other outcomes were analyzed in a narrative synthesis. Main Outcomes and Measures: Study estimates in the meta-analysis were combined using a price elasticity measure for sales and consumption outcomes. Heterogeneity was assessed using the I2 statistic and τ2. Studies varied in how diet and health were measured. Results: A total of 54 articles were included in the systematic review, of which 15 studies were included in the meta-analysis. Most food subsidies targeted fruits and vegetables and populations with low income, whereas the evidence on food taxes was primarily from the nonessential energy-dense food tax in Mexico. Sales of subsidized fruits and vegetables increased significantly, with an estimated price elasticity of demand of -0.59 (95% CI, -1.04 to -0.13 [P = .02]; 95% prediction interval, -2.07 to 0.90; I2 = 92.4% [95% CI, 89.0%-94.8%; P < .001]), suggesting inelastic demand. There was no significant change in the consumption of subsidized fruits and vegetables, with an estimated price elasticity of demand of -0.17 (95% CI, -0.49 to 0.15 [P = .26]; 95% prediction interval, -1.01 to 0.67; I2 = 76.2% [95% CI, 54.3%-87.6%; P < .001]). Food excise taxes were associated with higher prices and reduced sales. Evidence was limited on the differential outcomes of food taxes and subsidies across subpopulations. Conclusions and Relevance: Results of this systematic review and meta-analysis indicated that fruit and vegetable subsidies were associated with a moderate increase in fruit and vegetable sales. Further research is warranted to understand the implications of food taxes and subsidies for population-level consumption, diet, and health outcomes.

Universal Free Meals Associated with Lower Meal Costs While Maintaining Nutritional Quality.

The Community Eligibility Provision (CEP) of the Healthy, Hunger-Free Kids Act of 2010 allows the provision of universal free meals (UFMs) in high-poverty school areas. Participation in UFM programs, including through CEP, could reduce meal costs due to economies of scale and a lower administrative burden. We analyzed the School Nutrition and Meal Cost Study (SNMCS) data from 508 UFM-eligible schools (103 UFMs) to evaluate whether meal costs varied by UFM status. We used school-level data to address the non-random selection to UFMs with inverse probability of treatment weighting (IPTW). We estimated a generalized linear model with a log link and gamma distribution to predict meal costs by UFM status and school size. Full costs among medium and large schools were marginally lower in UFM schools for lunch (-$0.673; 95% CI: -1.395, 0.0499; p = 0.068) and significantly lower for breakfast (-$0.575; 95% CI: -1.077, -0.074; p = 0.025). UFM was not associated with meal costs among smaller schools. Healthy Eating Index scores did not vary significantly by UFMs, suggesting that lower costs could be achieved without an adverse effect on nutritional quality. This analysis is limited by the lack of identified student percentage (ISP) data needed to definitively identify CEP eligibility, although results were robust to sensitivity analyses addressing the lack of ISP data. The potential policy impact of these findings emphasizes the need for future studies that assess ISP and cost with more recent data and longitudinal designs.

Setting quality and safety priorities in a target-rich environment: an academic medical center's challenge.

Hospitals are continually challenged to provide safer and higher-quality patient care despite resource constraints. With an ever-increasing range of quality and safety targets at the national, state, and local levels, prioritization is crucial in effective institutional quality goal setting and resource allocation.Organizational goal-setting theory is a performance improvement methodology with strong results across many industries. The authors describe a structured goal-setting process they have established at Massachusetts General Hospital for setting annual institutional quality and safety goals. Begun in 2008, this process has been conducted on an annual basis. Quality and safety data are gathered from many sources, both internal and external to the hospital. These data are collated and classified, and multiple approaches are used to identify the most pressing quality issues facing the institution. The conclusions are subject to stringent internal review, and then the top quality goals of the institution are chosen. Specific tactical initiatives and executive owners are assigned to each goal, and metrics are selected to track performance. A reporting tool based on these tactics and metrics is used to deliver progress updates to senior hospital leadership.The hospital has experienced excellent results and strong organizational buy-in using this effective, low-cost, and replicable goal-setting process. It has led to improvements in structural, process, and outcomes aspects of quality.