at Point-of-Service: Affect = sc Bid Programs on Foodborne IIIness Outcomes ADVANCEMENT OF THE SCIENCE Disclosing Inspection Results of Characteristics of Food Establishment Inspection A b St ra ct The significant proportion of foodborne illnesses attributed to restaurants highlights the importance of food establishment inspections. The objectives of this cross-sectional study were to characterize local inspection programs and evaluate the effects of programmatic characteristics, such as active public disclosure of inspection results, on select operational and foodborne illness outcomes. Between January 7 and April 6, 2020, an online 36-question survey was administered to 790 government-run food establishment inspection programs at state and local levels. Of 149 survey respondents, 127 (85%) represented local food establishment inspection agencies. Agencies that disclosed at the point-of- service reported fewer mean numbers of re-inspections by 15%, foodborne illness complaints by 38%, outbreaks by 55% (p = .03), and Salmonella cases by 12% than agencies that disclosed online only. Agencies that used some type of grading method for inspection results reported fewer mean numbers of re-inspections by 37%, complaints by 22%, outbreaks by 61%, and Salmonella cases by 25% than agencies that did not grade inspections. Programmatic characteristics appear to be associated with foodborne illness outcomes. These results warrant future research to improve the effectiveness of food establishment inspection programs. Introduction Approximately 51% of each consumer dollar dedicated to food spending in 2019 was spent in the food service industry, specifically in restaurants, compared with just 25% in 1955 (National Restaurant Association, 2020). Coincidentally, there is growing evidence that restaurants are an important source of spo- radic and outbreak-associated foodborne dis- 8 Volume 83 ¢ Number 6 ease in the U.S. Jones & Angulo, 2006). In 2017, there were 841 foodborne illness out- breaks resulting in 14,481 illnesses, 827 hos- pitalizations, 20 deaths, and 14 food recalls in the U.S., including Puerto Rico and Wash- ington, DC (Centers for Disease Control and Prevention [CDC], 2019). Among the illnesses and outbreaks for which a single location was identified, 44% Thuy N. Kim, MPH, CFOI Melanie J. Firestone, MPH, PhD University of Minnesota School of Public Health Natasha DeJarnett, MPH, PhD Laura Wildey, CP-FS Jesse C. Bliss, MPH David T. Dyjack, DrPH, CIH National Environmental Health Association Jennifer Edwards, PhD National Network of Public Health Institutes Harlan Stueven, MD Dining Safety Alliance Craig W. Hedberg, PhD University of Minnesota School of Public Health and 64%, respectively, were attributed to foods prepared in a restaurant setting (CDC, 2019). The rise in expenditure on foods eaten away from the home and the sig- nificant proportion of foodborne illnesses attributed to restaurants have highlighted the importance of food establishment inspections, as they could flag the existence of food safety hazards and mitigate their public health impact. Public disclosure of inspection results from food establishments enables consum- ers to make informed decisions about where they choose to eat (Fung et al., 2007). Con- sumer priority of hygienic food preparation practices, in turn, incentivizes food estab- lishments to improve hygiene practices—a proxy for better sanitary conditions—within their facility. Improved and maintained san- itary conditions, theoretically, lead to fewer foodborne illnesses. From a programmatic standpoint, however, disclosure of inspec- tion results can create more work for the environmental health workforce tasked with putting the information into a present- able format. In a survey of the environmen- tal health workforce, 76% of workers sur- veyed indicated working in food safety and protection programs; however, 17% of all respondents performed public health duties outside of environmental health, and of those, 37% spent >50% of their time work- ing in nonenvironmental health programs (Gerding et al., 2019). The value of actively disclosing inspec- tion results to the public has been dem- Vr... 1 Summary Statistics for Local Agency Respondents (n = 124) a aaa Sa Active disclosure 82 (66) Active disclosure methods Online 75 (91) Point-of-service 24 (29) Other 4 (5) No active disclosure 42 (27) Grading methods Numerical score 53 (43) Letter grade 20 (16) Other 34 (27) No grading 30 (24) Inspection violation schemes (n =75) P-PF-C 24 (32) C/NC 21 (28) RF-GRP* 23 (31) P-PF-C 10 (43) C/NC 4 (17) Major/minor 3 (13) Other 7 (9) P-PF-C = Priority-Priority Foundations-Core; C/NC = Critical/Noncritical; RF-GRP = Risk Factor-Good Retail Practices. *Of the 23 agencies that indicated using RF-GRP, 6 agencies used RF-GRP only. The other 17 agencies used RF-GRP in combination with the other schemes listed below. onstrated in several settings throughout the U.S. The debate about the best mode to convey inspection results to the public, however, is still ongoing. A study of people at the Minnesota State Fair found increased interest in public access to inspection results. Furthermore, fairgoers expressed interest in disclosure methods of posting online and at the point-of-service, that is, at a food establishment (Firestone & Hedberg, 2020). For local inspection agencies that disclose inspection results, the most com- mon method is through online disclosure only, typically accessed via departmental websites. Drawbacks of this method include difficulty in navigating these websites and lengthy reports that are confusing to the general public. Moreover, this method might not be accessible to those who are most vul- nerable to foodborne illness, such as older adults (Fleetwood, 2019). Disclosure at the point-of-service elimi- nates a barrier to using inspection data in the decision-making process, as this approach does not require a person to have online access to check a website for inspec- tion results. With the introduction of pub- lic disclosure by means of a color-coded inspection sticker placed at or near restau- rant entrances, Columbus Public Health (Ohio), saw inspection scores improve by 1.14 points out of a possible 100 points (Choi & Scharff, 2017). In New York City, New York, implementation of public disclo- sure at the point-of-service in the form of letter grades was associated with improve- ments in sanitary conditions (Wong et al., 2015) and a 5.3% decrease in Salmonella cases per year (Firestone & Hedberg, 2018). Furthermore, in Los Angeles County, Cali- fornia, public disclosure of letter grades at the establishment led to a 13% decline in hospitalizations due to foodborne illness (Simon et al., 2005). While the act of disclosure is important, what information is disclosed and how the public interprets it is also important. Famil- iarity with the symbols used to represent inspection results lends to easier interpreta- tion by the general public. Grading practices can include letter grading and/or numerical grading, similar to most grading methods in a school system (e.g., A, B, C grades or 100%, 90%, 80%) or other ordinal methods (e.g., stoplight colors, emoticons). During inspections, a labeling system is used to classify different types of violations and convey severity of the violations. These violation schemes often correlate with the version of the Food and Drug Administration (FDA) Food Code an agency has adopted and can be used in combination at the agency's discretion. For example, in Food Code ver- sions before 2009, violations that were more likely “to contribute to food contamination, illness, or environmental health hazard” were classified as critical. In 2009, FDA revised the Food Code to distinguish critical items as priority if the item includes a quantifiable measure to show control (e.g., cooking), or priority foundation if the item requires the purposeful incorporation of specific actions (e.g., training) (Food and Drug Administra- tion [FDA], 2015). The categorization of risk factor or good retail practices corresponds to the organization of the FDA Food Establish- ment Inspection Report. Current inspection practices and methods of disclosure vary widely across jurisdictions in the U.S. and present unique challenges to evaluating program effectiveness. The objec- tives of this cross-sectional study were to 1) characterize local inspection programs and 2) evaluate the effects of programmatic char- acteristics, such as active public disclosure methods, on select operational and food- borne illness outcomes. Methods An online 36-question survey was adminis- tered via Qualtrics to 790 government-run food establishment inspection programs at state, county, city, district, and territorial lev- els. Recipients were chosen based on avail- ability of program inspection data online or participation in FDAs Voluntary National Retail Food Regulatory Program Standards January/February 2021 e Journal of Environmental Health 9 ADVANCEMENT OF THE SCIENCE TABLE 2 Mean, Standard Deviation, and Median Estimates for Outcomes by Disclosure Methods, Grading Methods, and Inspection Violation Schemes Average # of Re- Average # of Average # of Average # of Salmonella Inspections/Establishment/ Complaints/1,000 Outbreaks/1,000 Cases/100,000 Population Year Establishments/Year Establishments/Year Served/Year (m= 109) (nm = 100) (n= 101) (n= 48) Mean (SD) Median Mean (SD) Median Mean (SD) Median Mean (SD) Median Disclosure methods Online 0.40 (0.55) 0.24 44.2 (49.6) 27.3 1.7 (2.4) 0.84 14.4 (7.2) 14.0 Point-of-service 0.35 (0.46) 0.17 30.3 (45.3) 22.2 0.9 (1.4) 0.25 12.9 (6.5) 14.0 None 0.53 (0.46) 0.50 31.3 (36.0) 18.5 7.0 (24) 0.00 9.9 (9.9) 6.7 Other* 0.36 (0.43) 0.17 74.5 (86.4) 42.7 3.7 (4.7) 2.39 - - Grading methods Numerical score 0.32 (0.37) 0.17 40.6 (54.6) 22.2 3.0 (10.7) 0.35 12.4 (6.8) 13.6 Letter grade 0.31 (0.48) 0.13 34.9 (41.7) 24.6 1.3 (1.6) 0.71 13.0 (7.0) 14.2 None 0.59 (0.64) 0.50 49.1 (49.2) 29.2 6.5 (25.0) 0.82 15.9 (12.2) 13.1 Other 0.46 (0.57) 0.27 36.4 (35.0) 27.6 1.9 (2.7) 0.95 12.0 (6.2) 12.7 Inspection violation schemes P-PF-C 0.39 (0.45) 0.18 47.2 (53.3) 29.0 1.5 (1.7) 0.95 15.7 (7.4) 16.4 C/NC 0.38 (0.49) 0.25 48.7 (45.2) 42.7 1.1 (1.4) 0.85 12.7 (8.8) 13.1 RF-GRP 0.32 (0.39) 0.17 38.1 (51.1) 22.8 2.4 (2.2) 1.97 16.8 (8.1) eal Other 0.29 (0.37) 0.19 57.9 (73.9)* 11.8% 0.77 (0.78)* 0.62* 10.9 (7.8)* 11.7* P-PF-C = Priority-Priority Foundations-Core; C/NC = Critical/Noncritical; RF-GRP = Risk Factor-Good Retail Practices. *Contains data from <5 respondents. (Retail Program Standards). The Retail Pro- gram Standards provide recommendations aimed at facilitating inspections that are more effective and implementing foodborne illness prevention strategies. Enrollees in this pro- gram intend to actively use these standards as a tool to assess and improve their regulatory programs (FDA, 2019). We administered the survey in two rounds. The first round consisted of 151 recipients whose inspection data were publicly available online, resulting in a 40% response rate (n = 60 respondents). The second round included 639 recipients who participated in the Retail Program Standards, resulting in a response rate of 19% (n = 122 respondents). Via the survey, we obtained information on general program characteristics such as size of popu- lation served; number of routine inspections conducted; number of licensed establish- ments within the inspection jurisdiction; and 10 Volume 83 ¢ Number 6 operational characteristics such as public dis- closure method, grading method, and FDA Food Code version in use. The time period for the survey was chosen to match the availability of inspection data from the agencies. Three geographically diverse local inspection agencies piloted the survey to ensure appropriateness and relevancy of questions and answer choices. The data col- lection period was January 7—April 6, 2020. We paused data collection in April due to the COVID-19 pandemic response taking prec- edent at state and local health departments. We categorized inspection agencies into two main types, state and local. A state agency was defined as an inspection program that oversees the inspection of food establish- ments at the state government level, includ- ing U.S. territories and Washington, DC. A local agency differs in that the oversight of the inspection programs is at the county, city, city-county, or district government level. One survey respondent represented a univer- sity and thus was excluded from this analy- sis, as there could be significant policy dif- ferences between government agencies and universities. Local agencies were the primary focus of this analysis, as most food establish- ment inspection programs are operated at the local government level. Four operational and foodborne illness out- comes were calculated as rates from a combi- nation of variables obtained from the survey and expressed as an average number of: 1. Re-inspections/establishment/year (calcu- lated as the quotient of average number of re-inspections and number of licensed food establishments within the jurisdiction of the agency). 2. Foodborne illness complaints/1,000 licensed food establishments/year (2016-2018; most recent years included in data set). TABLE 3 Mean, Standard Deviation, and Median Estimates for Outcomes by Point-of-Service (POS) Disclosure Versus Online (no POS) Disclosure Average # of Re-Inspections/ Establishment/Year (n= 71) Average # of Complaints/1,000 Establishments/Year (n = 62) Average # of Outbreaks/1,000 Establishments/Year (n= 63) Average # of Salmonella Cases/100,000 Population Served/Year (n= 31) p-value 65 .16 44 POS disclosure Mean (SD) 0.35 (0.46) 30.3 (45.3) 0.92 (1.4) 11.7 (6.6) Median 0.17 22.17 0.25 12.5 Online (no POS) disclosure Mean (SD) 0.41 (0.57) 48.6 (50.0) 2.04 (2.69) 13.3 (8.5) Median 0.24 29.0 0.95 12.7 3. Foodborne outbreaks/1,000 licensed food establishments/year (2016-2018). 4. Salmonella cases reported/100,000 popula- tion served/year (2016-2018). In addition to the survey data, we were able to obtain some Salmonella case counts using departmental websites for jurisdictions that reported these data online. For the purposes of this study, active dis- closure was defined as agencies that volun- tarily and preemptively publicize some or all inspection data to the public. Inspection violation scheme was not included in the survey, but was determined by searching online for inspection data from the respond- ing agencies. Predictors were classified into three categories: 1. Disclosure method consisting of online, point-of-service, no disclosure, and other disclosure methods. 2. Grading method consisting of numerical score, letter grade, no grading, and other grading methods. 3. Inspection violation scheme used for rou- tine inspections consisting of subcatego- ries Priority-Priority Foundations-Core; Critical/Noncritical; Risk Factor-Good Retail Practices; and other schemes. The Risk Factor-Good Retail Practices sub- category relates to the inspection report form and therefore can be used in combination with other violation schemes. The mean and median values of outcomes for each combi- nation of schemes were assessed in addition to the nonmutually exclusive scheme catego- ries previously stated. One respondent used a combination of three schemes: Risk Factor- Good Retail Practices, Critical/Noncritical, and Red/Blue. Of note, Red/Blue is similar and is sometimes used in reference to Criti- cal/Noncritical; therefore, this respondent's jurisdiction was included in the Risk Factor- Good Retail Practices and Critical/Noncriti- cal scheme combination. Mean and median values were calculated to identify trends in outcomes based on each subcategory. The means were compared using t-tests; p-values were reported assum- ing unequal variance. The analysis was con- ducted using SAS 9.4m6 University Edition. Linear regression was used to determine associations between the outcome variables reported by the local responding agencies. The level of statistical significance was set at o = .05. Results Of the 149 survey respondents, 127 (85%) represented a local food establishment inspection agency. More than one half of agencies (66%) actively disclosed inspection scores to the public and most (91%) did so by posting online; only some (30%) posted at the point-of-service. Approximately 43% of the agencies used numerical scores as a grading method, 24% used no grading method, and 16% used letter grades (Table 1). Frequently used inspection violation schemes included Priority-Priority Foun- dations-Core (32%) and Critical/Noncriti- cal (28%). The scheme Risk Factor-Good Retail Practices (31%) was used in combina- tion with other violation schemes. Of the 23 agencies that used Risk Factor-Good Retail Practices with another scheme, 43% used Priority-Priority Foundations-Core, 22% used Critical/Noncritical, and 13% used Major/Minor schemes. Violation schemes for 53 respondents could not be determined using online searching. Agencies disclosing at the point-of-service had lower mean values for all outcome mea- sures than did agencies disclosing online (Table 2). Of the 24 agencies disclosing inspection results at the point-of-service, however, 21 (88%) also disclosed inspection results online (Table 1). Due to this overlap, we made further comparisons of agencies dis- closing at the point-of-service and agencies disclosing online only (Table 3). Agencies that disclosed inspection results at the point- of-service reported fewer mean numbers of re-inspections by 15%, complaints by 38%, outbreaks by 55% (p = .03), and Salmonella cases by 12% than did agencies that disclosed online only. Agencies that used some type of grading method for inspection results reported fewer mean numbers of re-inspections by 37%, complaints by 22%, outbreaks by 61%, and Salmonella cases by 25% than did agencies that did not grade inspection results. Agen- cies using letter grades had lower mean values for complaints by 14% and outbreaks by 43% January/February 2021 e Journal of Environmental Health 11 ADVANCEMENT OF THE SCIENCE TABLE 4 Linear Regression Comparisons of Outcomes Average # of Average # of Complaints/1,000 Average # of Outbreaks/1,000 Average # of Salmonella Cases/100,000 Population Re-Inspections/ Establishment/Year Establishments/Year Establishments/Year Served/Year Parameter | p-Value | # Parameter | p-Value| # Parameter | p-Value| # Parameter | p-Value| # Estimate Estimate Estimate Estimate (SE) (SE) (SE) (SE) Average # of re-inspections/ - 11.49 306 91 | 0.943 (3.44) 784 92 | -0.18 (3.21) .956 44 establishment/year (11.16) Average # of 0.001 .306 91 - 0.058 .079 93 | 0.06 (0.031) .051 48 complaints/1,000 (0.000995) (0.033) establishments/year Average # of outbreaks/1,000 | 0.00089 78 92 0.579 .079 93 - 0.40 (0.50) A3 47 establishments/year (0.00323) (0.326) Average # of Salmonella -0.00042 96 44 1.305 .051 48 0.035 43 47 - cases/100,000 population (0.0074) (0.652) (0.044) served/year than agencies using numerical scores, but 5% more Salmonella cases (Table 2). Almost one third of agencies, however, using numerical scores also used letter grades (Table 1). Agencies that used a Critical/Noncritical violation scheme reported 3% more mean complaints but 3% fewer mean re-inspec- tions, 27% fewer outbreaks, and 19% fewer Salmonella cases than those using Priority- Priority Foundations-Core schemes. Agencies that used Risk Factor-Good Retail Practices schemes tended to have fewer re-inspections and complaints but more outbreaks and Sal- monella cases than did agencies not using these schemes (Table 2). Although most of these findings are not statistically different from each other, the overall pattern of results is noteworthy. Regarding associations between outcome measures, we observed an almost statistically significant relationship between reported number of complaints/1,000 establishments/ year and number of Salmonella cases/100,000 population/year. Every unit of increase in reported Salmonella cases/100,000 popula- tion/year was associated with an increase in 1.03 complaints/1,000 establishments (p = .051) (Table 4). Discussion The trends observed in this study comple- ment the existing literature that supports the value of transparency in the disclosure of 12 Volume 83 * Number 6 food establishment inspection data. Disclo- sure at the point-of-service was associated with fewer mean numbers of re-inspections, complaints, outbreaks, and Salmonella cases than disclosure online only, with a signifi- cant difference (p = .03) in the number of outbreaks between the two disclosure methods. These findings are consistent with previous studies in New York City and Los Angeles that demonstrated benefits to dis- closure at the point-of-service. In this study, disclosure at the point-of-service included posting of inspection results inside and outside of the food establishment. It was not the goal of this study to parse the out- comes resulting from disclosures of inspec- tion results posted inside or outside of food establishments. Future studies might be warranted to evaluate the effectiveness of the nuance of disclosure location at food establishments. Letter grading methods were associated with fewer complaints and outbreaks than numerical scoring methods but both meth- ods had better outcomes than for inspections in the absence of a grading system. The Criti- cal/Noncritical inspection violation scheme was associated with fewer outbreaks and Sal- monella cases than Priority-Priority Founda- tions-Core or Risk Factor-Good Retail Prac- tices schemes. These results suggest that how local agencies conduct and score food estab- lishment inspections and disclose results to the public likely affect the success of the programs to control and prevent foodborne illnesses and food safety hazards. A strength of this study is that use of the Retail Program Standards listserv allowed for direct contact and survey dissemination to managers or primary contacts of food establishment inspection programs. The use of this listserv also enabled access to a wide geographic range of potential respondents, as this program includes agencies from all 50 states and Washington, DC, as well as five U.S. territories: American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin Islands. Additionally, given the variations in inspection practices, many survey questions included an open- text option for “Other” answers that were not listed as potential answer choices. This feature allowed for the capture of unique or less common practices. There are several limitations to this study. First, the presence of selection bias cannot be understated given the use of a convenience sample of survey recipients and online recruitment, which limits the representativeness of the results to those who participated in the FDA Retail Food Program. Second, Salmonella cases were self-reported. Many inspection agencies do not track the number of Salmonella cases, as that is typically the duty of epidemiol- ogy divisions. As such, the number of cases reported by survey respondents might not reflect true case counts. Third, missing data and an abbreviated collection period weak- ened the survey data analysis; the data col- lection period was truncated by local and state health departments needing to focus on the COVID-19 pandemic response. This necessity limited the ability to obtain miss- ing data points and limited the ability of agencies to respond. Fourth, the survey did not collect information about the number and types of triggers for re-inspection of an establishment, which vary across agen- cies. A potential confounder might be the size of the inspection agency or the num- ber of inspectors, as agencies with more inspectors or more aggressive practices could potentially be able to conduct more re-inspections or to detect more violations, illnesses, and outbreaks than smaller agen- cies. Fifth, the survey did not allow for cap- ture of programmatic changes that occurred between 2016 and 2018 (e.g., if a jurisdic- tion updated its food code during this time). "SS References Although most findings were not statisti- cally significant on an individual basis due to limitations in sample size, the overall pattern of results supports and enhances the existing literature on the performance of food estab- lishment inspection programs. For example, for every unit increase in complaints, there was a corresponding increase in the number of re-inspections. There was a similar rela- tionship with reported foodborne outbreaks. Future research should include a larger num- ber of agencies by a factor of 2 or 3 to clarify several of these relationships. Conclusion Overall, characteristics of food establishment inspection programs appear to be associated with foodborne illness and outcomes. These results warrant future research efforts to improve the effectiveness of these programs. This study suggests that agencies that disclose at the point-of-service reported 55% fewer average number of outbreaks compared with those using online disclosure only. Similarly, applying a grading scheme as a summary measure of inspection results was associated with improved foodborne illness outcomes. Policy makers should consider these findings when evaluating program effectiveness mea- sures and when considering changes to exist- ing food inspection programs. “39M Acknowledgements: This study was funded through cooperative agreement 6NU380T 000300 between the Centers for Disease Con- trol and Prevention (CDC) and the National Environmental Health Association (NEHA). The findings and conclusions are solely the responsibility of the authors and do not nec- essarily represent the official views of CDC and NEHA. Corresponding Author: Thuy N. Kim, Divi- sion of Environmental Health Sciences, Uni- versity of Minnesota School of Public Health, 420 Delaware Street SE, MMC 807, Minne- apolis, MN 55455. E-mail: kim00977@umn.edu. Centers for Disease Control and Prevention. (2019). Surveillance for foodborne disease outbreaks, United States, 2017: Annual report. 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