OBJECTIVES: Our objective was to use national data to produce a comprehensive description of trends in childhood asthma prevalence, health care utilization, and mortality to assess changes in the disease burden among U.S. children. METHODS: Five data sources from the National Center for Health Statistics were used to describe trends in asthma for children aged 0 to 17 years from 1980 to the most recent year for which data were available. These included the National Health Interview Survey (NHIS), the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the National Hospital Discharge Survey, and the Mortality Component of the National Vital Statistics System. RESULTS:   Asthma prevalence increased by an average of 4.3% per year from 1980 to 1996, from 3.6% to 6.2%. The peak prevalence was 7.5% in 1995. In 1997, asthma attack prevalence was 5.4%, but changes in the NHIS design in 1997 preclude comparison to previous estimates. Asthma attack prevalence remained level from 1997 to 2000. After a decrease between 1980 and 1989, the asthma office visit rate increased by an average of 3.8% per year from 1989 to 1999. The asthma hospitalization rate grew by 1.4% per year from 1980 to 1999. Although childhood asthma deaths are rare, the asthma death rate increased by 3.4% per year from 1980 to 1998. Children aged 0 to 4 years had the largest increase in prevalence and had greater health care use, but adolescents had the highest mortality. The asthma burden was borne disproportionately by black children throughout the period. Racial disparities were largest for asthma hospitalizations and mortality: compared with white children, in 1998-99, black children were more than three times as likely to be hospitalized and in 1997-98 more than four times as likely to die from asthma. CONCLUSIONS: Recent data suggest that the burden from childhood asthma may have recently plateaued after several years of increasing, although additional years of data collection are necessary to confirm a change in trend. Racial and ethnic disparities remain large for asthma health care utilization and mortality.

Akinbami LJ, LaFleur BJ, Schoendorf KC.  
Racial and income disparities in childhood asthma in the United States. 
Ambulatory Pediatrics 2002 Sep-Oct;2(5):382-7.

OBJECTIVE: To examine racial and income disparities in asthma prevalence in U.S. children, and disparities in morbidity and ambulatory health care use among children with asthma. METHODS: Using 1993-96 National Health Interview Survey data, we measured asthma prevalence and morbidity in children aged 3 to 17 years (n = 14,211) stratifying by race and poverty status. Measures of morbidity included asthma-related activity limitation and number of bed days. We used the ratio of asthma-related doctor contacts to number of bed days in the past 2 weeks to measure health care use adjusted for severity of illness. RESULTS:  An annual average of 7.4% of children aged 3 to 17 years had asthma. There were no significant differences in asthma prevalence between race and poverty groups. In contrast, asthma-related morbidity was higher among black and poor children. Black poor children were most likely to have activity limitations due to asthma: 49% were limited compared with about 20% of black nonpoor, white poor, and white nonpoor children. Among children with activity limitations, black children and white poor children were more likely to have severe limitations, and white nonpoor children were least likely. Finally, white nonpoor children had the highest level of ambulatory care use for asthma after accounting for disease severity, and black poor children had the lowest level. CONCLUSIONS: We found no significant racial or income disparities in asthma prevalence among children in the United States. However, black children and poor children are at higher risk for activity limitation, more severe activity limitation, and relative underuse of ambulatory health care. Black children living in poverty are at highest risk. Targeted interventions to reduce the burden of asthma morbidity in this population are likely to reduce disparities in asthma morbidity as well as reduce overall childhood asthma morbidity.

Auchincloss AH, Hadden W. 
The health effects of rural-urban residence and concentrated poverty.
Journal of Rural Health 2002 Spring;18(2):319-36. 

This research quantifies the extent to which excess morbidity in rural areas is associated with individual characteristics, county income, and neighborhood poverty. Census geographic codes were assigned to people 25 to 64 years old (n = 176,930) from the National Health Interview Survey, 1989-91, in order to link individuals to the U.S. Department of Agriculture's county urban-rural classification scheme and to 1990 county per capita income and poverty concentration in Census tracts. General health status and limitation of activity were analyzed in logistic and multinomial logit models. Residents of rural counties were at greater risk for health problems compared with residents of metropolitan and central core counties. In adjusted models, the health disadvantage of rural areas was partly explained by differences in population composition. The residual rural disadvantage was concentrated in people with less than a high school education. Tract poverty and county per capita income were also important independent predictors of morbidity. The results of this study suggest that special attention should be paid to improving education in disadvantaged places and to better understanding the ways in which economic growth and its benefits are distributed.

Balgobin Nandram, Jai Won Choi. 

A Bayesian analysis of a proportion under nonignorable nonresponse.

Statistics in Medicine 2002 May 15;21(9):1189-212.

The National Health Interview Survey (NHIS) is one of the surveys used to assess one aspect of the health status of the U.S. population. One indicator of the nation's health is the total number of doctor visits made by the household members in the past year. We study the binary variable of at least one doctor visit versus no doctor visit by all household members to each of the 50 States and the District of Columbia. The proportion of households with at least one doctor visit is an indicator of the status of health of the U.S. population. There is a substantial number of nonrespondents among the sampled households. The main issue we address here is that the nonresponse mechanism should not be ignored because respondents and nonrespondents differ. The purpose of this work is to estimate the proportion of households with at least one doctor visit, and to investigate what adjustment needs to be made for nonignorable nonresponse. We consider a nonignorable nonresponse model that expresses uncertainty about ignorability through the ratio of odds of a household doctor visit among respondents to the odds of doctor visit among all households, and this ratio varies from State to State. We use a hierarchical Bayesian selection model to accommodate this nonresponse mechanism. Because of the weak identifiability of the parameters, it is necessary to 'borrow strength' across States as in small area estimation. We also perform a simulation study to compare the expansion model with an alternative expansion model, an ignorable model and a nonignorable model. Inference for the probability of a doctor visit is generally similar across the models. Our main result is that for some of the States the nonresponse mechanism can be considered nonignorable, and that 95 per cent credible intervals of the probability for a household doctor visit and the probability that a household responds shed important light on the NHIS data. Copyright 2002 Copyright John Wiley & Sons, Ltd.

Barell V, Aharonson-Daniel L, Fingerhut LA, Mackenzie EJ, Ziv A, Boyko V, Abargel A, Avitzour M, Heruti R.
An introduction to the Barell body region by nature of injury diagnosis matrix. 
Injury Prevention 2002 Jun;8(2):91-6.

INTRODUCTION:  The Barell body region by nature of injury diagnosis matrix standardizes data selection and reports, using a two dimensional array (matrix) that includes all International Classification of Diseases (ICD)-9-CM codes describing trauma. AIM: To provide a standard format for reports from trauma registries, hospital discharge data systems, emergency department data systems, or other sources of nonfatal injury data. This tool could also be used to characterize the patterns of injury using a manageable number of clinically meaningful diagnostic categories and to serve as a standard for case mix comparison across time and place. CONCEPT:  The matrix displays 12 nature of injury columns and 36 body region rows placing each ICD-9-CM code in the range from 800 to 995 in a unique cell location in the matrix. Each cell includes the codes associated with a given injury. The matrix rows and columns can easily be collapsed to get broader groupings or expanded if more specific sites are required. The current matrix offers three standard levels of detail through predefined collapsing of body regions from 36 rows to 9 rows to 5 rows. MATRIX DEVELOPMENT: This paper presents stages in the development and the major concepts and properties of the matrix, using data from the Israeli national trauma registry, and from the U.S. National Hospital Discharge Survey. The matrix introduces new ideas such as the separation of traumatic brain injury (TBI), into three types. Injuries to the eye have been separated from other facial injuries. Other head injuries such as open wounds and burns were categorized separately. Injuries to the spinal cord and spinal column were also separated as are the abdomen and pelvis. Extremities have been divided into upper and lower with a further subdivision into more specific regions. Hip fractures were separated from other lower extremity fractures. FORTHCOMING DEVELOPMENTS: The matrix will be used for the development of standard methods for the analysis of multiple injuries and the creation of patient injury profiles. To meet the growing use of ICD-10 and to be applicable to a wider range of countries, the matrix will be translated to ICD-10 and eventually to ICD-10-CM. CONCLUSION: The Barell injury diagnosis matrix has the potential to serve as a basic tool in epidemiological and clinical analyses of injury data.

Barfield WD, Rhodes JC, Kohn MA, Hedberg K, Schoendorf KC.
Releasing pre-adoption birth records: Evaluation of the experience of the Oregon health division.
Public Health Reports 2002 Sep-Oct;117(5):472-8. 

OBJECTIVE: In November 1998, Oregon voters passed Ballot Measure 58, which allowed Oregon adoptees 21 years of age and over access to their original birth records, which are sealed at adoption. The objective of this study was to evaluate the impact of the measure on the Oregon Health Division (since renamed Oregon Health Services) by assessing procedures used and resources needed after implementation of Measure 58. METHODS: Vital records employees were interviewed about processing, storage, and archive retrieval procedures for pre-adoption birth records before, during, and after the implementation of Measure 58 and the effect on their usual workload. Personnel time, space, and fiscal resources used to process requests for pre-adoption records were also calculated. RESULTS:  The Oregon Health Division began to receive requests from adoptees immediately following the passage of Measure 58 in November 1998, but due to legal challenges, they could not be processed until May 31, 2000. From June 2, 2000, through October 20, 2000, 12 staff members and 2 supervisors issued more than 4,700 pre-adoption birth records while also processing their normal workload, which averages more than 135,400 vital record orders annually. Due to the need for retrieval from archives, requests for pre-adoption birth records were estimated to take 75 hours to process vs. 2-3 minutes for standard requests. Each batch of approximately 75 pre-adoption birth records required approximately 12.5 person-hours from vital records staff and 3-4 person-hours from archive personnel; in addition, supervisors spent time responding to incomplete orders, informing the public and the media, and responding to concerns of adoptees, birth parents, and adoptive parents. Fewer than 1% of requests went unfilled. CONCLUSIONS: Implementation of Measure 58 utilized substantial resources of the Oregon Health Division. States contemplating similar legislation should consider increasing personnel and resources, preparing for intense public and media interest, and reorganizing the storage of adoptees' original birth records so they are easily retrieved.

Bethell CD, Read D, Neff J, Blumberg SJ, Stein RE, Sharp V, Newacheck PW. 
Comparison of the children with special health care needs screener to the questionnaire for identifying children with chronic conditions--revised.
Ambulatory Pediatrics 2002 Jan-Feb;2(1):49-57.

BACKGROUND: The Children with Special Health Care Needs (CSHCN) Screener is an instrument to identify CSHCN, one that is based on parent-reported consequences experienced by children with ongoing health conditions. Information about how this instrument compares with other methods for identifying CSHCN is important for current and future uses of the CSHCN Screener. RESEARCH OBJECTIVES: The goal of this study was to assess the level of agreement between the CSHCN Screener and the Questionnaire for Identifying Children With Chronic Conditions--Revised (QuICCC-R) and to describe the characteristics of children in whom these methods do not agree. METHODS: The CSHCN Screener and the QuICCC-R were administered to two samples: a random sample of parents of children under age 18 years through the first pretest of the National CSHCN Survey (n = 2,420) and a random sample of children under age 14 years enrolled in a managed care health plan (n = 497). Information on specific conditions and needs for health services were collected for children identified by one or both instruments in the national sample. Data from the administrative data-based Clinical Risk Groups (CRGs) were collected for all children in the health plan sample. The proportions of children identified with the CSHCN Screener and the QuICCC-R were compared, the level of agreement between these two methods was assessed, and the health service needs of children identified by the QuICCC-R but not the CSHCN Screener were evaluated. RESULTS:  In both study samples, the CSHCN Screener agreed with the QuICCC-R approximately 9 out of 10 times on whether or not a child was identified as having a special health care need. Compared with the CSHCN Screener, the QuICCC-R identified an additional 7.6% and 8.5% of children as having special health care needs in the national and health plan samples, respectively. Compared with children identified by the QuICCC-R only, the odds were 12 times greater that children identified by both the CSHCN Screener and the QuICCC-R needed health care services, six times greater that parents named a specific chronic health condition, and nine times greater that children were identified with a chronic condition using the CRG algorithm. Study design and purposeful differences in question design or content account for most cases in which children are not identified by the CSHCN Screener but are identified using the QuICCC-R. CONCLUSIONS: The brief CSHCN Screener exhibits a high level of agreement with the longer QuICCC-R instrument. Whereas, nearly all children identified by the CSHCN Screener are also identified by the QuICCC-R, the QuICCC-R classifies a higher proportion of children as having special health care needs.

Bethell CD, Read D, Stein RE, Blumberg SJ, Wells N, Newacheck PW. 
Identifying children with special health care needs: Development and evaluation of a short screening instrument. 
Ambulatory Pediatrics 2002 Jan-Feb;2(1):38-48. 

BACKGROUND: Public agencies, health care plans, providers, and consumer organizations share the need to monitor the health care needs and quality of care for children with special health care needs (CSHCN). Doing so requires a definition of CSHCN and a precise methodology for operationalizing that definition. RESEARCH: The purpose of this study was to develop an efficient and flexible consequence-based screening instrument that identifies CSHCN across populations with rates commensurate with other studies of CSHCN. METHODS: The CSHCN Screener was developed using the Federal Maternal and Child Health Bureau (MCHB) definition of CSHCN and building on the conceptual and empirical properties of the Questionnaire for Identifying Children with Chronic Conditions (QuICCC) and other consequence-based models for identifying CSHCN. The CSHCN Screener was administered to three samples: a national sample of households with children (n = 17,985), children enrolled in Medicaid managed care health plans (n = 3,894), and children receiving Supplemental Security Income (SSI) benefits in Washington State (n = 1550). The efficiency, impact of further item reduction, and flexibility of administration mode were evaluated. Rates and expected variation in rates across demographic groups of children positively identified by one or more of the five CSHCN Screener item sequences in each sample were examined and multinomial logistic regression analysis were conducted to evaluate the effect of child characteristics in predicting positive identification. RESULTS:  The CSHCN Screener took approximately 1 minute per child to administer by telephone and 2.1 minutes per household. During self-administration, over 98% of respondents completed each of the five CSHCN Screener item sequences, and respondents accurately followed each of the item skip patterns 94% of the time. Mailed surveys and telephone-administered surveys led to similar rates of positive identification in the same sample. Two Screener items would have identified 80%-90% of children positively identified as CSHCN across the study samples, although using only two items eliminates some children with more complex health needs. Rates of children identified by the CSHCN Screener varied according to age, sex, race/ethnicity, health status, and utilization of health services. CONCLUSIONS: Results of this study indicate that the CSHCN Screener requires minimal time to administer, is acceptable for use as both an interview-based and self-administered survey, and that rates of children positively identified by the CSHCN Screener vary according to child demographic, health, and health care-need characteristics. The CSHCN Screener provides a comprehensive yet parsimonious and flexible method for identifying CSHCN, making it more feasible than existing measures for standardized use across public agencies, health care plans, and other users.

Blackwell D, Tonthat L. 
Summary health statistics for the U.S. population: National Health Interview Survey, 1998.
Vital and Health Statistics 10 2002 Oct;(207):1-93. 

OBJECTIVES: This report presents health statistics from the 1998 National Health Interview Survey (NHIS) for the civilian, noninstitutionalized population of the United States, classified by age, sex, race and Hispanic origin, poverty status, family income, education, place of residence, region of residence, and where appropriate, health insurance coverage. The topics covered are health status and limitations of activity, injuries and poisonings, health care access and utilization, and health insurance coverage. Source of Data: NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the National Center for Health Statistics, Centers for Disease Control and Prevention, and is representative of the civilian noninstitutionalized U.S. population. Data are collected during face-to-face interviews with adults present at the time of interview. Information about children and absent adults is obtained from an adult proxy respondent. Highlights:  Nearly 40% of Americans reported having excellent health in 1998, while almost 9% reported having either fair or poor health. Fifteen percent of the U.S. population did not have any health insurance coverage in 1998. Nineteen percent of not Hispanic black persons and 33% of Hispanics were uninsured in 1998, as opposed to 11% of non-Hispanic white persons. Further, 46% of poor Hispanics and 44% of near-poor Hispanics under age 65 years were uninsured; percents of uninsurance among poor and near poor not Hispanic white and black persons under age 65 years had private health insurance coverage, as opposed to 55% of not Hispanic black persons and 49% of Hispanics in this same age category.

Blackwell D, Tonthat L.  
Summary health statistics for the U.S. population: National Health Interview Survey, 1998.
Vital and Health Statistics 10 2002 Oct;(208):1-46.  

OBJECTIVES: This report presents statistics from the 1998 National Health Interview Survey (NHIS) on selected health measures for children under 18 years of age, classified by sex, age, race/ethnicity, family structure, parent’s education, family income, poverty status, health insurance coverage, place of residence, region, and current health status. The topics covered are asthma, allergies, learning disabilities, Attention Deficit Disorder (ADD), use of medication, respondent-assessed health status, school-loss days, usual place of medical care, time since last contact with a health care professional, selected health care risk factors, and time since last dental contact. Source of Data: NHIS is multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the National Center for Health Statistics, Centers for Disease Control and Prevention, and is representative of the civilian noninstitutionalized population of the United States.  Data are collected during face-to-face interviews with adults present at the time of interview.  Information about children is collected for one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child’s health. Highlights:  In 1998 most U.S. children under 18 years of age enjoyed excellent or very good health (84%). However, 12% of children had no health insurance coverage, and 6% of children had no usual place of medical care. Twelve percent of children had ever been diagnosed with asthma. An estimated 8% of children 3-17 years of age had a learning disability, and an estimated 6% of children had ADD. Lastly, 11% of children in single mother families had two or more visits to an emergency room in the past year compared with 6% of children in two-parent or single-father families.

Blumberg SJ, Olson L, Osborn L, Srinath KP, Harrison H. 
Design and operation of the National Survey of Early Childhood Health, 2002.
Vital and Health Statistics 1 2002 Jun;(40):1-97. 

OBJECTIVES: This report presents the development, plan, and operation of the National Survey of Early Childhood Health, a module of the State and Local Area Integrated Telephone Survey, conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention. This survey was designed to assess parents' perceptions of their children's pediatric care. In addition, data were collected that can be used to examine relationships between the promotion of health in the pediatric office and promotion of health in the home. Funding for the survey was provided by The Gerber Foundation, the American Academy of Pediatrics, and the Maternal and Child Health Bureau, Health Resources and Services Administration. The UCLA Center for Healthier Children, Families, and Communities contributed to the design of the study and the questionnaire. METHODS: A national random-digit-dialed (RDD) sample of households with children 4-35 months of age was selected. The study included an oversample of households having an eligible black not Hispanic or Hispanic child. In households with more than one eligible child, one was randomly selected to be the subject of the interview. The respondent was the parent or guardian who was most responsible for the child's health care. A computer-assisted telephone interviewing (CATI) system was used to collect the data. RESULTS:  A total of 2,068 interviews were completed during the first half of 2000. The response rate was 65.6%. A data file has been released that contains demographic information on the focal child and respondent, substantive health and health-related data, and sampling weights. Estimates based on the sampling weights generalize to the entire U.S. population of children 4-35 months of age.

Branum AM, Schoendorf KC.
Changing patterns of low birthweight and preterm birth in the United States, 1981-98.
Pediatric and Perinatal Epidemiology 2002 Jan;16(1):8-15.

Low birthweight (LBW) and preterm birth are primary risk factors for infant morbidity and mortality in the United States. With increasing multiple births and delayed childbearing, it is important to examine the separate contributions of these characteristics to the increases in LBW and preterm birth rates. U.S. natality records from 1981, 1990, and 1998 were used to calculate LBW (percent births under 1,500, 1,500-2,499, and 2,500 grams and under) and preterm (percent births under 29, 29-32, 33-36, and 37 weeks gestation and under) rates. Data were stratified by maternal race (black or white) and plurality (singleton vs. multiple birth). LBW and preterm rates among singletons were adjusted for maternal age to examine the influence of demographic shifts on LBW trends. From 1981 to 1998, LBW increased 12% among white infants, but remained relatively stable among black infants. During the same time, preterm birth increased 23% among white infants compared with 3% among black infants. For both black and white infants, the increase in LBW and preterm births was greater among multiple births than among singletons. Adjustment for maternal age did not reduce the temporal increase in LBW or preterm birth among singletons. Black infants continue to experience a markedly higher incidence of LBW and preterm birth, but the racial gap in these outcomes has narrowed slightly in recent years as a result of increasing LBW and preterm birth among white births. The differing trends for white and black infants are the consequence of a disparate trend in the incidence and outcome of multiple births coupled with increases in LBW and preterm birth among white singletons. Understanding the differential patterns in birth outcomes among white and black infants is necessary to develop effective interventions designed to decrease racial disparities in pregnancy outcome.

Burt CW. 
National trends in use of medications in office-based practice, 1985-99. 
Health Affairs (Millwood) 2002 Jul-Aug;21(4):206-14.  

Increases in physician office visits involving the use or prescribing of a drug were observed between 1985 and 1999 using data from the National Ambulatory Medical Care Survey. The prescription rate increased from 109 to 146 prescriptions per 100 visits. Growth in drug mention rates for specific therapeutic classes varied by patients' age. The rate of multiple prescriptions per visit rose 39%. Similar-size increases were observed after differences in patients' age, number of comorbidities, source of payment, and physician specialty were controlled for.

Chumlea WC, Guo SS, Kuczmarski RJ, Flegal KM, Johnson CL, Heymsfield SB, Lukaski HC, Friedl K, Hubbard VS.

Body composition estimates from NHANES III bioelectrical impedance data.
International journal of obesity and related metabolic disorders: Journal of the International Association for the Study of Obesity 2002 Dec;26(12):1596-609. 

BACKGROUND: Body composition estimates for the U.S. population are important in order to analyze trends in obesity, sarcopenia, and other weight-related health conditions. National body composition estimates have not previously been available. OBJECTIVE: To use transformed bioelectrical impedance analysis (BIA) data in sex-specific, multicomponent model-derived prediction formulae, to estimate total body water (TBW), fat-free mass (FFM), total body fat (TBF), and percentage body fat (%BF) using a nationally representative sample of the U.S. population. DESIGN: Anthropometric and BIA data were from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1994). Sex-specific BIA prediction equations developed for this study were applied to the NHANES data, and mean values for TBW, FFM, TBF, and %BF were estimated for selected age, sex, and racial-ethnic groups. RESULTS:   Among the non-Hispanic white, non-Hispanic black, and Mexican-American participants aged 12-80 years examined in NHANES III, 15,912 had data available for weight, stature, and BIA resistance measures. Males had higher mean TBW and FFM than did females, regardless of age or racial-ethnic status. Mean TBW and FFM increased from the adolescent years to mid-adulthood and declined in older adult age groups. Females had higher mean TBF and %BF estimates than males at each age group. Mean TBF also increased with older age groups to approximately 60 years of age after which it decreased. CONCLUSIONS: These mean body composition estimates for TBW, FFM, TBF, and %BF based upon NHANES III BIA data provide a descriptive reference for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans in the U.S. population.

Coresh J, Astor BC, McQuillan G, Kusek J, Greene T, Van Lente F, Levey AS. 

Calibration and random variation of the serum creatinine assay as critical elements of using equations to estimate glomerular filtration rate.

American Journal of Kidney Disease 2002 May;39(5):920-9.

Equations using serum creatinine level, age, sex, and other patient characteristics often are used to estimate glomerular filtration rate (GFR) in both clinical practice and research studies. However, the critical dependence of these equations on serum creatinine assay calibration often is overlooked, and the reproducibility of estimated GFR is rarely discussed. We address these issues in frozen samples from 212 Modification of Diet in Renal Disease (MDRD) study participants and 342 Third National Health and Nutrition Examination Survey (NHANES III) participants assayed for serum creatinine level a second time during November 2000. Variation in serum creatinine level was assessed in 1,919 NHANES III participants who had serum creatinine measured on two visits a median of 17 days apart. Linear regression was used to compare estimates. Calibration of serum creatinine varied substantially across laboratories and time. Data indicate that serum creatinine assays on the same samples were 0.23 mg/dL higher in the NHANES III than MDRD study. Data from the College of American Pathologists suggest that a difference of this magnitude across laboratories is not unusual. Conversely, serum creatinine assays an average of 2 weeks apart have better precision (SD of percentage of difference in estimated GFR, 15%; 90% of estimates within 21%). Errors in calibration make little difference in estimating severely decreased GFR (less than 30 mL/min/1.73 m2), but result in progressively larger differences at higher GFRs. Both clinical and research use of serum creatinine or equations to estimate GFR require knowledge of the calibration of the serum creatinine assay. Copyright 2002 by the National Kidney Foundation, Inc.

Daumit GL, Pratt LA, Crum RM, Powe NR, Ford DE. Characteristics of primary care visits for individuals with severe mental illness in a national sample.

General Hospital Psychiatry 2002 Nov-Dec;24(6):391-5.  

Individuals with severe mental illness (SMI) are at risk for inadequate general medical and preventive care, but little is known about their visits for primary care. We performed a cross-sectional analysis of primary care physician visits from the National Ambulatory Medical Care Survey (NAMCS) 1993-1998 and compared visit characteristics for patients with and without SMI. SMI was defined from ICD-9 diagnoses and medications. Primary care visits for patients with SMI were more likely to be return visits, were longer, and were more likely to have scheduled follow-up than for patients without SMI. Obesity, diabetes, and smoking were reported approximately twice as frequently in visits for patients with SMI compared with patients without SMI. The percent of visits with preventive counseling and counseling targeted at chronic medical conditions was similar for both groups. Likely appropriate to their complex needs, patients with SMI using primary care tend to have more return visits, longer time with the physician, and are more often scheduled for follow-up care; their preventive counseling appears similar to non-SMI visits.

OBJECTIVE: To examine the association of intrapair birthweight discordance with fetal and neonatal mortality. METHODS: We used the United States (1995-1997) Matched Multiple Birth File (n = 297,155). RESULTS: Among twin live births and stillborn fetuses, 29.9% had less than 5% birth weight discordance, 24.2% had 5-9%, 29.6% had 10-19%, 11.1% had 20-29%, 3.4% had 30-39%, and 1.8% had 40% or more. The stillborn fetus rate increased progressively with increasing birth weight discordance for smaller and larger twins of the same sex. Compared with the less than 5% birth weight discordance category, the adjusted odds ratios (OR) (95% confidence intervals [CIs]) for stillborn fetus associated with 5-9%, 10-19%, 20-29%, 30-39%, and 40% or more birthweight discordance, respectively, were 0.81 (95% CI 0.58, 1.11), 1.41 (95% CI 1.07, 1.84), 1.74 (95% CI 1.28, 2.35), 3.06 (95% CI 2.21, 4.24), and 4.29 (95% CI 3.05, 6.04) for smaller twins. The corresponding ORs (95% CIs) for larger twins were 0.78 (95% CI 0.57, 1.08), 1.26 (95% CI 0.96, 1.66), 1.77 (95% CI 1.27, 2.46), 3.38 (95% CI 2.33, 4.92), and 2.91 (95% CI 1.89, 4.47). Similar associations were observed among smaller but not larger twins of opposite sex. Among larger but not smaller twins of the same sex, increasing birthweight discordance was associated with overall neonatal deaths. This association was not apparent among smaller and larger twins of opposite sex. However, increasing birthweight discordance was associated with neonatal deaths related to congenital malformations among smaller and larger twins. CONCLUSION: The results provide evidence that increased twin birth weight discordance was associated with increased risk of intrauterine death and malformation-related neonatal deaths.

Dillon C, Petersen M, Tanaka S. 
Self-reported hand and wrist arthritis and occupation: Data from the U.S. National Health Interview Survey-Occupational Health Supplement.
American Journal of Industrial Medicine 2002 Oct;42(4):318-27. 

BACKGROUND: There is a paucity of population-based studies examining occupational hand-wrist arthritis. We examined relationships between hand-wrist arthritis, occupation, and biomechanical exposures in the U.S. National Health Interview Survey-Occupational Health Supplement. METHODS: A randomized, multistage, and cross-sectional national prevalence survey was carried out. RESULTS:   Self-reported, medically attended hand-wrist arthritis was common among employed persons (period prevalence 1.58%; lifetime prevalence 3.58%). Highest prevalences occurred among technicians, machine operators, assemblers, and farmers, and in the mining, agriculture, and construction industries. Work requiring repetitive hand bending and twisting was associated with hand-wrist arthritis (Odds Ratio 1.43; 95%CI: 1.11-1.84; P = 0.005). Among workers with hand arthritis, 7.4% had made major changes in their work, 7.6% missed work, and 4.5% stopped working or changed jobs because of the problem. CONCLUSIONS: Our study links hand-wrist arthritis to occupation and potentially modifiable workplace ergonomic factors. The spectrum of hand-wrist "cumulative trauma" disorders may considerably exceed that of soft-tissue injuries like carpal tunnel syndrome and tendonitis, and may include arthritis, a widely prevalent, disabling condition. Copyright 2002 Wiley-Liss, Inc.

Dye BA, Hirsch R, Brody DJ.
The relationship between blood lead levels and periodontal bone loss in the United States, 1988-94. 
Environmental Health Perspectives 2002 Oct;110(10):997-1002. 

An association between bone disease and bone lead has been reported. Studies have suggested that lead stored in bone may adversely affect bone mineral metabolism and blood lead (PbB) levels. However, the relationship between PbB levels and bone loss attributed to periodontal disease has never been reported. In this study we examined the relationship between clinical parameters that characterize bone loss due to periodontal disease and PbB levels in the U.S. population. We used data from the Third National Health and Nutritional Examination Survey (NHANES III), 1988-1994, for the analyses. A total of 10,033 participants 20-69 years of age who completed a periodontal examination and had whole blood tested for lead were examined. Four types of periodontal disease measures were used to indicate oral bone loss: periodontal pocket depth, attachment loss extent, attachment loss severity, and the presence of dental furcations. We found that dental furcations were the best periodontal bone loss indicator for PbB levels (p = 0.005) in a multivariate linear regression model adjusting for sex, age, race/ethnicity, educational attainment, poverty status, smoking, and age of home. Furthermore, after additional modeling, we found a smoking and dental furcation interaction (p = 0.034). Subsequent stratified analyses indicated that current and past smoking is an effect modifier for dental furcations on PbB levels. These findings indicate that increased PbB levels may be associated with advanced periodontal bone loss, particularly among people with a history of smoking.

Dye BA, Kruszon-Moran D, McQuillan G.
The relationship between periodontal disease attributes and Helicobacter pylori infection among adults in the United States.
Am J Public Health 2002 Nov;92(11):1809-15. 

OBJECTIVES: We investigated the relationship between Helicobacter pylori infection and abnormal periodontal conditions. METHODS: Data from the first phase of the Third National Health and Nutrition Examination Survey were used. A total of 4,504 participants aged 20-59 years who completed a periodontal examination and tested positive for H. pylori antibodies were examined. RESULTS:   Periodontal pockets with a depth of 5 mm or more were associated with increased odds of H. pylori seropositivity (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.12, 1.94) after adjustment for sociodemographic factors. This association is comparable to the independent effects of poverty on H. pylori (OR = 1.54; 95% CI = 1.10, 2.16). CONCLUSIONS: Poor periodontal health, characterized by advanced periodontal pockets, may be associated with H. pylori infection in adults, independent of poverty status.

Dye BA, Vargas CM.
The use of a modified CPITN approach to estimate periodontal treatment needs among adults aged 20-79 years by sociodemographic characteristics in the United States, 1988-94.
Community Dental Health 2002 Dec;19(4):215-23. 

AIM: The aim of the study was to ascertain periodontal treatment needs and their sociodemographic determinants among adults in the United States by transforming nationally representative periodontal data into an index routinely used internationally. DESIGN: Data were abstracted from a complex, highly stratified, multistage probability cross-sectional study to create a modified Community Periodontal Index of Treatment Needs (CPITN). PARTICIPANTS: 11,339 persons aged 20-79 who participated in the Third National Health and Nutrition Examination Survey (NHANES III), 1988-94. RESULTS:   At least 3% of the adult U.S. population required complex periodontal treatment, 90% needed scaling and prophylaxis, and nearly 5% did not need periodontal treatment or oral hygiene instruction. A multivariate cumulative logistic model indicated that being older, male, non-Hispanic black, having lower education, smoking, or not having had a dental visit in the past year increased the likelihood of needing more complex periodontal treatment. The risk factors that indicated the greatest potential for increasing complexity of periodontal treatment, after controlling for all covariates, were being either non-Hispanic black (OR=2.51; 95% CI=1.98, 3.18), or not completing high school (OR=2.10: 95% CI=1.60, 2.77), or a current cigarette smoker (OR=2.02; 95% CI=1.76, 2.33). CONCLUSIONS: The need for increasingly complex periodontal treatment differs by sociodemographic factors. Most American adults need some type of periodontal treatment; however, the majority of periodontal treatment needs in the United States are within the clinical skill range of dental hygienists. There is significant disparity in the distribution of need for periodontal treatment; persons from socially disadvantaged groups are more likely to present with increasing complexity of periodontal treatment needs.

Ervin RB, Kennedy-Stephenson J.
Mineral intakes of elderly adult supplement and non-supplement users in the Third National Health and Nutrition Examination Survey.
Journal of Nutrition 2002 Nov;132(11):3422-7. 

Calcium, iron, and zinc are important in many of the body's functions. We report dietary and combined (diet + supplements) intakes for these minerals for elderly supplement and nonsupplement users in the United States and the prevalence of inadequate intakes. We calculated usual dietary intakes for adults 60 years and older from the Third National Health and Nutrition Examination Survey, 1988-94; mineral intakes from supplements and calcium-containing antacids were added to usual dietary intakes. We evaluated iron and zinc intakes using the dietary reference intakes, recommended dietary allowances and estimated average requirements for elderly adults, as well as calcium intakes using the Adequate Intake and the Healthy People 2010 objective. The highest prevalences of inadequate dietary intakes was for calcium (males, 70-75%; females, 87%) and zinc (males, 35-41%; females, 36-45%). Dietary supplements improved intakes, but nearly two-thirds of elderly adults had combined intakes below the calcium objective. Non-Hispanic blacks usually had lower intakes than non-Hispanic whites and higher prevalences of intakes below the standards. Supplement users had significantly higher mean dietary intakes than nonsupplement users for all three minerals for total females and non-Hispanic white females (P < 0.05 for each mineral). Many elderly adults had inadequate dietary zinc intakes, and calcium intakes fell below the Healthy People 2010 objective; dietary supplements improved intakes. Even with supplements most older adults still had intakes below the calcium objective, partly because the supplements they took usually contained low doses of calcium. Total female and non-Hispanic white female supplement users were the only groups that had higher dietary intakes than nonsupplement users for all three minerals.

Faucett CL, Schenker N, Taylor JM. 
Survival analysis using auxiliary variables via multiple imputation, with application to AIDS clinical trial data.
Biometrics 2002 Mar;58(1):37-47. 

We developed an approach, based on multiple imputation, to using auxiliary variables to recover information from censored observations in survival analysis. We applied the approach to data from an AIDS clinical trial comparing ZDV and placebo, in which CD4 count is the time-dependent auxiliary variable. To facilitate imputation, a joint model is developed for the data, which includes a hierarchical change-point model for CD4 counts and a time-dependent proportional hazards model for the time to AIDS. Markov chain Monte Carlo methods are used to multiply impute event times for censored cases. The augmented data are then analyzed and the results combined using standard multiple-imputation techniques. A comparison of our multiple-imputation approach to simply analyzing the observed data indicates that multiple imputation leads to a small change in the estimated effect of ZDV and smaller estimated standard errors. A sensitivity analysis suggests that the qualitative findings are reproducible under a variety of imputation models. A simulation study indicates that improved efficiency over standard analyses and partial corrections for dependent censoring can result. An issue that arises with our approach, however, is whether the analysis of primary interest and the imputation model are compatible.

Fingerhut LA, Christoffel KK.
Firearm-related death and injury among children and adolescents. 
Future Child 2002 Summer-Fall;12(2):24-37.

As the articles in this journal issue show, gun violence affects children and youth in many ways: psychologically, emotionally, financially, and legally. But first and foremost, gun violence affects children's physical safety. Therefore, this issue opens with an overview of the physical toll that firearms exact upon children and youth, reviewing the incidence of firearm-related injury and death among Americans under age 20. This article analyzes trends and current status in firearm death and injury, based on nationwide data collected by the Federal government. Several key findings emerge from the data: Firearm death rates among children and youth in the United States have declined dramatically since 1993, but remain high compared with historical rates in this country and rates in other developed nations. A majority of these deaths are homicides. Certain groups of children and youth, especially adolescents, boys, minority youth, and those residing outside the northeast, are particularly at risk for firearm death. The problem is most acute among black teenage males. Firearm injuries are much more likely to result in death than are other injuries for which children and youth visit emergency departments--a reflection of the extreme lethality of firearms. Given these findings, the authors call for a concerted effort to reduce youth firearm deaths to levels comparable with those of other industrialized nations, using a wide variety of approaches that span the public health, criminal justice, and educational spheres. They also recommend improved data systems to track firearm injury and death, so that researchers can better analyze these incidents and evaluate intervention strategies.

Flegal KM, Carroll MD, Ogden CL, Johnson CL. 
Prevalence and trends in obesity among U.S. adults, 1999-2000.
Journal of the American Medical Association 2002 Oct 9;288(14):1723-7. 

CONTEXT: The prevalence of obesity and overweight increased in the United States between 1978 and 1991. More recent reports have suggested continued increases but are based on self-reported data. OBJECTIVE: To examine trends and prevalences of overweight (body mass index [BMI] > or = 25) and obesity (BMI > or = 30), using measured height and weight data. DESIGN, SETTING, AND PARTICIPANTS: A survey of 4,115 adult men and women was conducted in 1999-2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the U.S. population. MAIN OUTCOME MEASURE: Age-adjusted prevalence of overweight, obesity, and extreme obesity compared with prior surveys, and sex-, age-, and race/ethnicity-specific estimates. RESULTS:  The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-94; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI > or = 40) also increased significantly in the population, from 2.9% to 4.7% (P =.002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalences were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight. CONCLUSIONS: The increases in the prevalences of obesity and overweight previously observed continued in 1999-2000. The potential health benefits from reduction in overweight and obesity are of considerable public health importance.

Flegal KM, Wei R, Ogden C. 

Weight-for-stature compared with body mass index-for-age growth charts for the United States from the Centers for Disease Control and Prevention.

American Journal of Clinical Nutrition 2002 Apr;75(4):761-6.  

BACKGROUND: The 2000 Centers for Disease Control and Prevention growth charts for the United States include population reference data for body mass index (BMI)-for-age (ages 2-19 years) and weight-for-stature (from 77 to 121 cm). For younger children, either set of reference data could be used. OBJECTIVE: The objective of this study was to compare BMI-for-age with weight-for-stature. DESIGN: We used data for 4,348 children (aged 2-5 years) from the Third National Health and Nutrition Examination Survey. Weight-for-stature and BMI-for-age percentiles were calculated for each child. The 10th and 85th percentiles of weight-for-stature at selected ages were also reexpressed as BMI-for-age percentiles. RESULTS:   More than 63% of children had lower weight-for-stature than BMI-for-age percentiles. Children were more likely to be classified as < or = 10th percentile by weight-for-stature than by BMI-for-age, but less likely to be classified as > or = 85th percentile. Differences in classification by the two measures varied with age and stature and were greater for shorter children. The 10th and 85th percentiles of weight-for-stature corresponded to BMI-for-age percentiles from the 3rd to the 21st percentile and from the 74th to the 92nd percentile, respectively, depending on age and stature. CONCLUSIONS: Weight-for-stature is easier to use than BMI-for-age. However, BMI-for-age captures changes in the weight-height relation with age and can be used continuously up to the age of 20 years. BMI-for-age is recommended in most situations. BMI-for-age and weight-for-stature will not give identical results and are not interchangeable.

Friedman SR, Flom PL, Kottiri BJ, Neaigus A, Sandoval M, Fuld J, Curtis R, Zenilman JM, Des Jarlais DC.
Consistent condom use among drug-using youth in a high HIV-risk neighbourhood. 
AIDS Care 2002 Aug;14(4):493-507.

OBJECTIVES:  of this study were to determine predictors of consistent condom use in heterosexual relationships of young adults who use hard drugs in a neighbourhood with widespread drug-use-connected HIV. We interviewed 196 18-24-year-olds who injected drugs or used heroin, cocaine, or crack in the prior year and lived in the Bushwick neighbourhood of New York City. Interviews covered sociodemographics, substance use, and sexual networks. The unit of analysis is the relationship; the dependent variable measures consistent condom use over the prior 30 days in a given relationship. Consistent condom use was reported in 26% of 377 noncommercial relationships and in all of 22 commercial relationships. Using multiple logistic regression, consistent condom use in noncommercial relationships was more likely in relationships that are not 'very close'; for men (but not women) with peers whose norms are more favourable to condom use; and for subjects who had concurrent sex partners in the last 12 months. In conclusion, we found that: (1) the lack of relationship between the peer norms of drug-using women and their condom use suggests they may have little control over condom use in their relationships-programmes should attempt to empower young women drug users and to develop ways for their peers to influence the men in their lives; (2) epidemiologically, the positive association of concurrency to consistent condom use suggests that condom use may be restricting HIV spread through the community-the presence of consistent condom use in all of the commercial sexual relationships also may restrict HIV spread; (3) prevention efforts should attempt to change peer cultures as a way to develop self-sustaining risk reduction. These changes should include changes in gender roles and power relations.

Gillum RF. 
New considerations in analyzing stroke and heart disease mortality trends: The Year 2000 Age Standard and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision.
Stroke 2002 Jun;33(6):1717-22.

BACKGROUND: Monitoring of trends and patterns of stroke mortality will be of utmost importance in the coming decade. Two innovations in vital statistics may complicate this task and must be brought to the attention of both researchers and readers of research reports: the new Year 2000 Age Standard and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). SUMMARY OF REVIEW: For cerebrovascular diseases, the age-adjusted death rate is 2.4 times higher with the use of the year 2000 standard than with the use of the old 1940 standard. However, if rates for all years are computed with the use of the same age standard, the percent change from 1979 to 1995 is similar according to the 1940 standard (-35.8%) or the year 2000 standard (-34.3%). Another important effect of the change to the year 2000 standard is to reduce black/white differentials in age-adjusted death rates. Major discontinuities are not observed for mortality trends in cerebrovascular disease or heart disease between International Classification of Diseases, Ninth Revision (ICD-9) (1979-1998) and ICD-10 (1999 and following years) classifications. CONCLUSIONS: All data users must exercise caution to specify the age standard used when assessing or presenting age-adjusted rates over time or between groups. The comparability of ICD codes chosen for years before 1999 versus 1999 or following years must be checked to distinguish changes due to coding from true changes in mortality levels.

Goodman DC, Fisher ES, Little GA, Stukel TA, Chang CH, Schoendorf KS.
The relation between the availability of neonatal intensive care and neonatal mortality.  
New England Journal of Medicine 2002 May 16;346(20):1538-44.

BACKGROUND: There is marked regional variation in the availability of neonatal intensive care in the United States. We conducted a study to determine whether a greater supply of neonatologists or neonatal intensive care beds is associated with lower neonatal mortality. METHODS: We used the 1996 master files of the American Medical Association and the American Osteopathic Association and 1998 and 1999 surveys of neonatal intensive care units to calculate the supply of neonatologists and neonatal intensive care beds in 246 neonatal intensive care regions. We used linked birth and death records from the 1995 U.S. birth cohort to assess associations between the supply of both neonatologists and neonatal intensive care beds per capita (in quintiles) and the risk of death within the first 27 days of life.  RESULTS:   Among 3,892,208 newborns with a birthweight of 500 grams or greater, the mortality rate was 3.4 per 1000 births. After adjustment for neonatal and maternal characteristics associated with an increased risk of neonatal death, the rate was lower in the regions with 4.3 neonatologists per 10,000 births than in those with 2.7 neonatologists per 10,000 births (odds ratio for death, 0.93; 95 percent confidence interval, 0.88 to 0.99). Further increases in the number of neonatologists were not associated with greater reductions in the risk of death. There was no consistent relation between the number of neonatal intensive care beds and neonatal mortality. CONCLUSIONS: A minority of regions in the United States may have inadequate neonatal intensive care resources, whereas many others may have more resources than are needed to prevent the death of high-risk newborns. The effect of the availability of neonatologists on other health outcomes is not known.

Harris MI, Cowie CC, Gu K, Francis ME, Flegal K, Eberhardt MS.
Higher fasting insulin but lower fasting C-peptide levels in African Americans in the U.S. population. 
Diabetes/Metabolism Research and Reviews 2002 Mar-Apr;18(2):149-55.

BACKGROUND: Fasting serum insulin and fasting serum C-peptide are risk factors for developing type 2 diabetes. Because of the higher incidence of type 2 diabetes in African Americans and Hispanic Americans, it is likely that these groups may differ from non-Hispanic whites in their levels of insulin and C-peptide. METHODS: We analyzed data from a nationally representative sample of adults in the U.S. population for whom sociodemographic, clinical, and laboratory information were obtained. The data were used to describe distributions of fasting insulin and fasting C-peptide in non-Hispanic white, non-Hispanic black, and Mexican American men and women aged >or= 20 years without a medical history of diabetes. RESULTS:   Among men, Mexican Americans had higher insulin values than non-Hispanic whites and blacks. Among women, both Mexican Americans and blacks had higher insulin values than whites. For C-peptide, differences by sex and race-ethnicity paralleled those seen for fasting insulin with the exception that black men had significantly lower C-peptide values than whites and Mexican Americans. After adjustment for age, fasting plasma glucose (FPG), body mass index (BMI), and waist-to-hip ratio (WHR), the higher levels for insulin in blacks and Mexican Americans remained; both black men and women had significantly lower C-peptide values than whites and Mexican Americans. The molar ratio of fasting C-peptide to fasting insulin was similar for men and women in each race-ethnic group. However, blacks had substantially lower ratios than whites and Mexican Americans. CONCLUSIONS: We found wide variations in fasting insulin and fasting C-peptide levels by race and ethnicity in U.S. adults that were not explained by confounding factors, primarily measures of obesity. Most notably, the higher fasting insulin and lower fasting C-peptide levels in blacks implies that there is a derangement in insulin clearance and an impairment in beta-cell function in blacks compared with whites and Mexican Americans.

Heck K, Parker J. 
Family structure, socioeconomic status, and access to health care for children.  
Health Services 2002 Feb;37(1):173-86.

OBJECTIVE: To test the hypothesis that among children of lower socioeconomic status (SES), children of single mothers would have relatively worse access to care than children in two-parent families, but there would be no access difference by family structure among children in higher SES families. DATA SOURCES: The National Health Interview Surveys of 1993-95, including 63,054 children. STUDY DESIGN: Logistic regression was used to examine the relationship between the child's family structure (single mother or two-parent family) and three measures of health care access and utilization: having no physician visits in the past year, having no usual source of health care, and having unmet health care needs. To examine how these relationships varied at different levels of SES, the models were stratified on maternal education level as the SES variable. The stratified models adjusted for maternal employment, child's health status, race and ethnicity, and child's age. Models were fit to examine the additional effects of health insurance coverage on the relationships between family structure, access to care, and SES. PRINCIPAL FINDINGS: Children of single mothers, compared with children living with two parents, were as likely to have had no physician visit in the past year; were slightly more likely to have no usual source of health care; and were more likely to have an unmet health care need. These relationships differed by mother's education. As expected, children of single mothers had similar access to care as children in two-parent families at high levels of maternal education, for the access measures of no physician visits in the past year and no usual source of care. However, at low levels of maternal education, children of single mothers appeared to have better access to care than children in two-parent families. Once health insurance was added to adjusted models, there was no significant socioeconomic variation in the relationships between family structure and physician visits or usual source of care, and there were no significant disparities by family structure at the highest levels of maternal education. There were no family structure differences in unmet needs at low maternal education, whereas children of single mothers had more unmet needs at high levels of maternal education, even after adjustment for insurance coverage. CONCLUSIONS: At high levels of maternal education, family structure did not influence physician visits or having a usual source of care, as expected. However, at low levels of maternal education, single mothers appeared to be better at accessing care for their children. Health insurance coverage explained some of the access differences by family structure. Medicaid is important for children of single mothers, but children in two-parent families whose mothers are less educated do not always have access to that resource. Public health insurance coverage is critical to ensure adequate health care access and utilization among children of less educated mothers, regardless of family structure.

Heck KE, Schoendorf KC, Chavez GF.
The influence of proximity of prenatal services on small-for-gestational-age birth.  
Journal of Community Health 2002 Feb;27(1):15-31.

Some studies suggest that prenatal services may decrease the risk of poor fetal growth for full-term infants, but have not examined the influence of the availability of community health and social services. The availability of prenatal services may have a stronger effect among women already at high risk of a small-for-gestational-age (SGA) birth. Singleton full-term (> or = 37 weeks gestation) California births for 1997-98 (n = 744,736) were geocoded to maternal Census tract of residence. Women were placed into one of three demographic risk groups utilizing combinations of maternal age, marital status, parity, and education. SGA was defined as birthweight less than the 10th percentile for gestational age. Locations of WIC sites, prenatal care providers, and perinatal outreach programs were geocoded. Multilevel logistic regression was used to model the influence of community health care services on SGA, adjusting for additional maternal and community factors. There was no association between SGA and community services available for either high- or low-risk women, in either unadjusted or adjusted models. The addition of maternal prenatal care utilization to models did not change the results. Maternal residence near prenatal services was not associated with SGA, regardless of demographic risk; other community factors may warrant consideration.

Hootman JM, Helmick CG, Schappert SM.
Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. 
Arthritis Care and Research 2002 Dec 15;47(6):571-81. 

OBJECTIVE: To describe ambulatory medical care utilization, defined to exclude injury-related visits, for persons with arthritis and other rheumatic conditions. METHODS: National estimates, rates, and other characteristics of ambulatory care visits were calculated from a national sample of patient visits to physician offices and acute care hospital outpatient and emergency departments. RESULTS:   An estimated 36.5 million ambulatory care visits were related to arthritis and other rheumatic conditions. Visit rates increased with age and, overall, were twice as high among women as men. Rates of visits by race varied by ambulatory care setting. Soft tissue disorders (9.3 million), osteoarthritis (7.1 million), nonspecific joint pain/effusion (7.0 million), and rheumatoid arthritis (3.9 million) were the most common diagnoses. CONCLUSIONS: Arthritis and other rheumatic conditions account for about as many ambulatory care visits as cardiovascular disease or essential hypertension. These visits serve as excellent opportunities to counsel patients regarding prevention messages for arthritis.

Hoyert DL, Martin JA.
Vital statistics as a data source.
Seminars in Perinatology 2002 Feb;26(1):12-6. 

A focus group convened at a National Institutes of Health (NIH) Stillbirth Conference discussed issues related to vital statistics as a data source on fetal mortality. Fetal death is a tragic occurrence and part of the continuum of pregnancy outcomes. A primary source of data is the National Vital Statistics System fetal death component, which is routinely used to track mortality trends and to provide the context for nonrepresentative investigations. The data are also used to examine differentials in mortality by characteristics and to evaluate data quality. Issues concerning how to improve the vital statistics data include culture and context; data instrument; persons providing information; what information is available to the information provider; processing issues; and use of data. Perhaps most important is to enhance recognition of fetal death both for the individual confronting a loss and to promote research. Other studies are needed to augment the information obtainable through vital records.

Hsu VP, Lukacs SL, Handzel T, Hayslett J, Harper S, Hales T, Semenova VA, Romero-Steiner S, Elie C, Quinn CP, Khabbaz R, Khan AS, Martin G, Eisold J, Schuchat A, Hajjeh RA.
Opening a bacillus anthracis-containing envelope, Capitol Hill, Washington, D.C.: The public health response.
Emerging Infectious Diseases 2002 Oct;8(10):1039-43.

On October 15, 2001, a U.S. Senate staff member opened an envelope containing Bacillus anthracis spores. Chemoprophylaxis was promptly initiated and nasal swabs obtained for all persons in the immediate area. An epidemiologic investigation was conducted to define exposure areas and identify persons who should receive prolonged chemoprophylaxis, based on their exposure risk. Persons immediately exposed to B. anthracis spores were interviewed; records were reviewed to identify additional persons in this area. Persons with positive nasal swabs had repeat swabs and serial serologic evaluation to measure antibodies to B. anthracis protective antigen (anti-PA). A total of 625 persons were identified as requiring prolonged chemoprophylaxis; 28 had positive nasal swabs. Repeat nasal swabs were negative at 7 days; none had developed anti-PA antibodies by 42 days after exposure. Early nasal swab testing is a useful epidemiologic tool to assess risk of exposure to aerosolized B. anthracis. Early, wide chemoprophylaxis may have averted an outbreak of anthrax in this population.

Jemal A, Graubard BI, Devesa SS, Flegal KM.
The association of blood lead level and cancer mortality among whites in the United States.
Environmental Health Perspectives  2002 Apr;110(4):325-9. 

Lead is classified as a possible carcinogen in humans. We studied the relationship of blood lead level and all cancer mortality in the general population of the United States using data from the National Health and Nutrition Examination Survey II (NHANES II) Mortality Study, 1992, consisting of a total of 203 cancer deaths (117 men and 86 women) among 3,592 whites (1,702 men and 1,890 women) with average of 13.3 years of follow-up. We used Cox proportional hazard regression models to estimate the dose-response relationship between blood lead and all cancer mortality. Log-transformed blood lead was either categorized into quartiles or treated as a continuous variable in a cubic regression spline. Relative risks (RRs) were estimated for site-specific cancers by categorizing lead above and below the median. Among men and women combined, dose-response relationship between quartile of blood lead and all cancer mortality was not significant (ptrend = 0.16), with RRs of 1.24 [95% percent confidence interval (CI), 0.66-2.33], 1.33 (95% CI, 0.57-3.09), and 1.50 (95% CI, 0.75-3.01) for the second, third, and fourth quartiles, respectively, compared with the first quartile. Spline analyses found no dose response (p = 0.29), and none of the site-specific cancer RRs were significant. Among men, no significant dose-response relationships were found for quartile or spline analyses (p trend = 0.57 and p = 0.38, respectively). Among women, no dose-response relationship was found for quartile analysis (ptrend = 0.22). However, the spline dose-response results were significant (p = 0.001), showing a threshold effect at the 94th percentile of blood lead or a lead concentration of 24 microg/dL, with an RR of 2.4 (95% CI, 1.1-5.2) compared with the risk at 12.5 percentile. Because the dose-response relationship found in women was not found in men, occurred at only the highest levels of lead, and has no clear biologic explanation, further replication of this relationship is needed before it can be considered believable. In conclusion, individuals with blood lead levels in the range of NHANES II do not appear to have increased risk of cancer mortality.

Jones CA, Francis ME, Eberhardt MS, Chavers B, Coresh J, Engelgau M, Kusek JW, Byrd-Holt D, Narayan KM, Herman WH, Jones CP, Salive M, Agodoa LY.
Microalbuminuria in the U.S. population: Third National Health and Nutrition Examination Survey.
American Journal of Kidney Disease 2002 Mar;39(3):445-59.

Microalbuminuria (MA) is associated with adverse health outcomes in diabetic and hypertensive adults. The prevalence and clinical significance of MA in nondiabetic populations is less clear. The purpose of this study was to generate national estimates of the prevalence of MA in the U.S. population. Untimed urinary albumin concentrations (UACs) and creatinine concentrations were evaluated in a nationally representative sample of 22,244 participants aged 6 years and older. Persons with hematuria and menstruating or pregnant women were excluded from analysis. The percent prevalence of clinical proteinuria (UAC > or = 300 mg/L) was similar for males and females. However, the prevalence of MA (urinary albumin-creatinine ratio [ACR], 30 to 299 mg/g) was significantly lower in males (6.1%) compared with females (9.7%). MA prevalence was greater in children than young adults and increased continuously starting at 40 years of age. MA prevalence was greater in non-Hispanic blacks and Mexican Americans aged 40-79 years compared with similar-aged non-Hispanic whites. MA prevalence was 28.8% in persons with previously diagnosed diabetes, 16.0% in those with hypertension, and 5.1% in those without diabetes, hypertension, cardiovascular disease, or elevated serum creatinine levels. In adults aged 40 years and over, after excluding persons with clinical proteinuria, albuminuria (defined as ACR > or = 30 mg/g) was independently associated with older age, non-Hispanic black and Mexican American ethnicity, diabetes, hypertension, and elevated serum creatinine concentration. MA is common, even among persons without diabetes or hypertension. Age, sex, race/ethnicity, and concomitant disease contribute to the variability of MA prevalence estimates. Copyright 2002 by the National Kidney Foundation, Inc.

Keppel KG, Pearcy JN, Wagener DK.
Trends in racial and ethnic-specific rates for the health status indicators: United States. 
Healthy People 2000 Stat Notes 2002 Jan;(23):1-16.

The Health Status Indicators (HSIs) were developed as part of the Healthy People 2000 process to facilitate the comparison of health status measures at national, State, and local levels. In this report national trends in racial and ethnic-specific rates for 17 HSIs are examined for the period from 1990-8. One of three overarching goals of Healthy People 2000 was to reduce health disparities. Examination of trends in the HSIs indicates that rates for most racial/ethnic groups improved. Rates for American Indian or Alaska Natives did not improve for six of the HSIs. An index of disparity, a summary measure of disparity among race/ethnic-specific rates, was used to measure changes in disparity between 1990 and 1998. The index of disparity decreased for 12 of the HSIs. Based on this index, racial/ethnic disparity in the percent of low birthweight infants declined by 19%, disparity in the percent of children under 18 years of age in poverty and in the syphilis case rate declined by 13%, and disparity in the stroke death rate declined by 11%. The index declined by less than 10% for eight other indicators. The index of disparity increased between 1990 and 1998 for the other five HSIs examined here. The index of disparity increased by more than 10% for work-related injury death rates, motor vehicle crash death rates, and suicide death rates. While rates for the HSIs have improved, not all groups have benefited equally and substantial differences among racial/ethnic groups persist.

Kogan MD, Alexander GR, Kotelchuck M, MacDorman MF, Buekens P, Papiernik E.
A comparison of risk factors for twin preterm birth in the United States between 1981-82 and 1996-97.
Maternal and Child Health Journal 2002 Mar;6(1):29-35. 

OBJECTIVE: This paper examines risk factors for twin preterm birth in 1981-82 and 1996-97 in the United States in order to see if they have changed over time. METHODS:  We studied all U.S. twin births for the years examined (n = 346,567). Since the gestational age distributions for twins differs from singletons, the risk of preterm birth was examined at <33, 33-34, and 35-36 weeks. Logistic regression was used to examine the contributions of sociodemographic and obstetric factors at each period. RESULTS:  While the <33 week twin preterm rate rose 7% from 1981-82 to 1996-97, the 33-34-week rate rose 31%, and the 35-36-week rate rose 51%. Women with less education, teenagers, unmarried women, primiparas, and blacks were more likely to deliver preterm across all three preterm birth levels. However, the effect of these low socioeconomic status markers diminished over the study period. Additionally, the odds of preterm birth among blacks increased with earlier gestational ages. Women who had intensive prenatal care utilization as compared with less than adequate utilization were more likely to deliver preterm (35-36 weeks) in 1996-97 (odds ratio (OR) = 2.05) compared with 1981-82 (OR = 1.44). Smaller increases were noted for <33 and 33-34 weeks. CONCLUSIONS: Obstetric factors appear to be playing a greater role in the rise of twin preterm births at 35-36 weeks gestation. Temporal sociodemographic changes do not explain the rise in the preterm rate. Changing clinical practices may be having unintended consequences on the public health goals of reducing preterm and low birthweight rates in the United States.

Kottiri BJ, Friedman SR, Neaigus A, Curtis R, Des Jarlais DC. Risk networks and racial/ethnic differences in the prevalence of HIV infection among injection drug users.
Journal of Acquired Immune Deficiency Syndromes 2002 May 1;30(1):95-104.  

Studies among injection drug users (IDUs) find a higher prevalence of HIV infection among black and Puerto Rican IDUs than among white IDUs. Risk behaviors seldom explain these differences. We examine how risk networks contribute to racial/ethnic variations in HIV prevalence. Six hundred sixty-two IDUs were recruited on the street in Bushwick (New York City), interviewed, and tested for HIV. Risk behaviors and networks were analyzed to explain racial/ethnic variations in HIV. Forty percent of IDUs were infected with HIV. HIV prevalence was greater for Puerto Ricans (45%) and blacks (44%) than for whites (32%). Egocentric sexual and drug risk networks were predominantly racially/ethnically homogeneous. After multivariate adjustments for risk behaviors and risk networks, black-white differences in HIV prevalence were no longer significant. Although differences between Puerto Ricans and whites persisted, post hoc analyses suggested that network partner characteristics might explain these differences. In Bushwick, racially/ethnically discordant risk partnerships involving black IDUs may function as potential bridges of transmission between groups.

Kozak LJ.
Hospital transfers to LTC facilities in the 1990s.
Long-Term Care Interface 2002 June 3(6): 34-38.

This article reviews data from the 1990-99 National Hospital Discharge Survey.  The survey shows that the number of transfers from hospitals to LTC institutions increased from 1.6 million in 1990 to 2.8 million in 1999.  The average length of a hospital stay for a transferred patient declined by a third, with almost half of patients who were transferred having hospitals stays of 5 days or fewer in 1999.  These trends suggest an increasing substitution of subacute care in LTC institutions for hospital care during the 1990s.  Continued monitoring of hospital transfer patterns may help to clarify effects of the ongoing changes in the organization and financing of LTC services.

Kozak LJ, Weeks JD.
U.S. trends in obstetric procedures, 1990-2000.
Birth 2002 Sep;29(3):157-61. 

BACKGROUND: During the 1980s the rate of obstetric procedures performed during delivery rose precipitously. This study follows the use of obstetric procedures through the 1990s to explore whether the patterns witnessed in the previous decade continued through the next. METHODS: Data on total obstetric procedures and eight specific procedures (cesarean section, medical and surgical induction of labor, other artificial rupture of membranes, episiotomy, repair of current obstetric laceration, vacuum extraction, forceps delivery) were obtained from the National Hospital Discharge Survey, a nationally representative survey of discharges from short-stay non-Federal hospitals. Approximately 32,000 records for women with deliveries were included in the survey each year. RESULTS:  The total rate of all obstetric procedures did not change significantly from 1990 through 2000. However, as during the 1980s, rates increased for induction of labor, vacuum extraction, and repair of current obstetric laceration. Rates decreased for forceps delivery and episiotomy, also continuing 1980s trends. After a long period of increase, the rate of cesarean section declined from 1988 to 1995 but increased again from 1995 to 2000. CONCLUSIONS: Unlike the 1980s, the overall rate of obstetric procedures did not increase from 1990 to 2000, but the mix of obstetric procedures performed continued to change during this period.

Looker AC, Dawson-Hughes B, Calvo MS, Gunter EW, Sahyoun NR.
Serum 25-hydroxyvitamin D status of adolescents and adults in two seasonal subpopulations from NHANES III. 
Bone 2002 May;30(5):771-7. 

Subclinical vitamin D deficiency may be common in certain subgroups in the United States, but to date vitamin D data from other groups in the population have not been available. We used serum 25-hydroxyvitamin D (25-OHD) data from 18,875 individuals examined in the Third National Health and Nutrition Examination Survey (NHANES III 1988-94) to assess the vitamin D status of selected groups of the noninstitutionalized U.S. adolescent and adult population. Serum 25-OHD levels were measured by a radioimmunoassay kit (DiaSorin, Inc., Stillwater, MN; normal range 22.5-94 nmol/L). Because physical exams are performed in mobile vans in NHANES, data could not be collected in northern latitudes during the winter; instead data were collected in northern latitudes during summer and in southern latitudes in winter. To address this season-latitude aspect of the NHANES design, we stratified the sample into two seasonal subpopulations (winter/lower latitude and summer/higher latitude) before examining vitamin D status. Less than 1% of the winter/lower latitude subpopulation had vitamin D deficiency (25-OHD <17.5 nmol/L). However, the prevalence of vitamin D insufficiency in this group ranged from 1%-5% with 25-OHD <25 nmol/L to 25%-57% with 25-OHD <62.5 nmol/L, even though the median latitude for this subsample (32 degrees N) was considerably lower than the latitude at which vitamin D is not synthesized during winter months (approximately 42 degrees N). With the exception of elderly women, prevalence rates of vitamin D insufficiency were lower in the summer/higher latitude subpopulation (<1%-3% with 25-OHD <25 nmol/L to 21%-49% with 25-OHD <62.5 nmol/L). Mean 25-OHD levels were highest in non-Hispanic whites, intermediate in Mexican Americans, and lowest in non-Hispanic blacks. Our findings suggest that vitamin D deficiency is unlikely in the two seasonal subpopulations of noninstitutionalized adolescents and adults that can be validly assessed in NHANES III. However, vitamin D insufficiency is more common in these two seasonal subpopulations. Of particular interest is that insufficiency occurred fairly frequently in younger individuals, especially in the winter/lower latitude subsample. Our findings support continued monitoring of this vitamin in the U.S. population.

Lovely RS, Falls LA, Al-Mondhiry HA, Chambers CE, Sexton GJ, Ni H, Farrell DH.
Association of gammaA/gamma' fibrinogen levels and coronary artery disease.
Thrombosis and Haemostasis  2002 Jul;88(1):26-31. 

GammaA/gamma' fibrinogen is a fibrinogen isoform that constitutes about 15% of total plasma fibrinogen. This isoform contains an additional binding site for zymogen factor XIII and for active thrombin, and forms fibrin clots that are resistant to fibrinolysis in vitro. Little is known about the variability of gammaA/gamma' fibrinogen levels in human populations, whereas total fibrinogen levels are known to increase with age and are higher in women than in men. In this report, evidence is presented that, in contrast to total fibrinogen levels, gammaA/gamma' fibrinogen levels showed no significant association with age or gender in a population of normal blood donors. A study of gammaA/gamma' fibrinogen levels in patients undergoing coronary angiography also showed that gammaA/gamma' fibrinogen levels were higher on average in coronary artery disease patients than in patients without coronary artery disease, and that this association was independent of total fibrinogen levels.

Lukacs SL, France EK, Baron AE, Crane LA. 
Effectiveness of an asthma management program for pediatric members of a large health maintenance organization. 
Archives of Pediatrics & Adolescent Medicine 2002 Sep;156(9):872-6 

OBJECTIVE:To assess the impact of an asthma management program on the dispensing of inhaled corticosteroids, hospitalizations, and emergency department (ED) visits on children, adolescents, and young adults. DESIGN: We used medical record and pharmacy data for the 18 months after initiation of a pilot asthma management program. Two intervention offices were matched with two control offices on pediatric volume, number of pediatricians or family practitioners, and specialist availability. SETTING: Primary care offices at Kaiser Permanente Colorado, in Denver and Boulder. PATIENTS: We identified 298 patients, 18 years or younger, who were listed in an asthma registry between February 1 and July 31, 1997, as having moderate or severe asthma. INTERVENTION: The Kaiser Permanente Colorado Asthma Care Management Program is an outpatient-based program that provides comprehensive evaluation, education, and follow-up to patients identified from an asthma registry or referred by providers. MAIN OUTCOME MEASURES: The proportion of patients who received more than one dispensing of inhaled corticosteroid during the observation period. Additional outcomes measured the proportion of patients with one or more hospitalizations or ED visits. RESULTS:   A significantly greater proportion of patients from the intervention group received more than one dispensing of inhaled corticosteroid compared with controls (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.72). We found no significant difference in the proportion of patients who were hospitalized (RR, 1.37; 95% CI, 0.48-3.71) or visited the ED (RR, 0.86; 95% CI, 0.49-1.40). CONCLUSIONS: The presence of an asthma management program may improve dispensing of inhaled corticosteroids to young patients with moderate or severe asthma, as recommended by national guidelines. This type of program may not have an effect on hospitalizations or ED visits.

MacDorman MF, Mathews TJ, Martin JA, Malloy MH. 
Trends and characteristics of induced labour in the United States, 1989-98.
Paediatric and Perinatal Epidemiology 2002 Jul;16(3):263-73.  

Induction of labour is one of the fastest growing medical procedures in the United States. In 1998, 19.2% of all U.S. births were a product of induced labour, more than twice the 9.0% in 1989. Induction of labour has been efficacious in the management of post-term pregnancy and in expediting delivery when the mother or infant is sufficiently ill to make continuation of the pregnancy hazardous. However, the recent rapid increase in induction, and particularly the doubling of the induction rate for preterm pregnancies (from 6.7% in 1989 to 13.4% in 1998), has generated concern among some clinicians. The present study uses vital statistics natality data to examine the epidemiology of induced labour in the United States. Multivariable analysis is used to examine the probability of having an induced delivery in relation to a wide variety of sociodemographic and medical characteristics, and also in relation to relative indications and contraindications for induced labour as outlined by the American College of Obstetricians and Gynecologists (ACOG). Induction rates were higher for women who were non-Hispanic white, college educated, born in the United States, primaparae and those with intensive prenatal care utilization. Induction rates were also higher for women with various medical conditions including hypertension, eclampsia, and renal disease. For non-Hispanic white women with singleton births, 59% of the increase in the preterm birth rate from 1989 to 1998 can be accounted for by the increase in preterm inductions. The adjusted odds ratio for neonatal mortality among preterm births with induced labour was 1.20 [95% confidence interval 1.11, 1.31]. The rapid increase in induction rates, particularly among preterm births, marks a shift in the obstetric management of pregnancy. More detailed studies are needed to examine physician decisionmaking protocols, particularly for preterm induction, and to assess the impact of these practice changes on patient outcomes.

MacDorman MF, Minino AM, Strobino DM, Guyer B.
Annual summary of vital statistics--2001.
Pediatrics 2002 Dec;110(6):1037-52. 

The number of births, the crude birth rate (14.5 in 2001), and the fertility rate (67.2 in 2001) all declined slightly (by 1% or less) from 2000 to 2001. Fertility rates were highest for Hispanic women (107.4), followed by Native American (70.7), Asian or Pacific Islander (69.4), black (69.3), and non-Hispanic white women (58.0). During the early to mid 1990s, fertility declined for non-Hispanic white, black, and American Indian women. Rates for these population groups have changed relatively little since 1995; however, fertility has increased for Asian or Pacific Islander and Hispanic women. The birth rate for teen mothers continued to fall, dropping 5% from 2000 to 2001 to 45.9 births per 1000 females aged 15 to 19 years, another record low. The teen birth rate has fallen 26% since 1991; declines were more rapid (35%) for younger teens aged 15 to 17 years than for older teens aged 18 to 19 years (20%). The proportion of all births to unmarried women remained about the same at one-third. Smoking during pregnancy continued to decline; smoking rates were highest among teen mothers. The use of timely prenatal care increased slightly to 83.4% in 2001. From 1990 to 2001, the use of timely prenatal care increased by 6% (to 88.5%) for non-Hispanic white women, by 23% (to 74.5%) for black women, and by 26% (to 75.7%) for Hispanic women. The number and rate of twin births continued to rise, but the triplet/+ birth rate declined for the second year in a row. For the first year in almost a decade, the preterm birth rate declined (to 11.6%); however, the low birthweight rate was unchanged at 7.6%. The total cesarean delivery rate jumped 7% from 2000 to 2001 to 24.4% of all births, the highest level reported since these data became available on birth certificates (1989). The primary cesarean rate rose 5%, whereas the rate of vaginal birth after a previous cesarean delivery tumbled 20%. In 2001, the provisional infant mortality rate was 6.9 per 1000 live births, the same as in 2000. Racial differences in infant mortality remain a major public health concern, with the rate for infants of black mothers 2.5 times those for infants of non-Hispanic white or Hispanic mothers. In 2000, 66% of all infant deaths occurred among the 7.6% of infants born low birth weight. Among all States, Maine and Massachusetts had the lowest infant mortality rates. The United States continues to rank poorly in international comparisons of infant mortality. The provisional death rate in 2001 was 8.7 deaths per 1000 population, the same as the 2000 final rate. In 2000, unintentional injuries and homicide remained the leading and second-leading causes of death for children 1 to 19 years of age, although the death rate for homicide decreased by 10% from 1999 to 2000. Among unintentional injuries to children, two-thirds were motor vehicle-related; among homicides, two-thirds were firearm-related.

Mannino DM,  Homa  DM, Akinbami LJ, Ford  ES, Redd  SC.  
Chronic obstructive pulmonary disease surveillance - United States, 1971-2000.  
Morbidity and Mortality Weekly Report Surveillance Summary 2002 Aug 2;51(6):1-16.

PROBLEM/CONDITION: Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema but has been defined recently as the physiologic finding of nonreversible pulmonary function impairment. This surveillance summary reports trends in different measures of COPD during 1971-2000. REPORTING PERIOD COVERED: This report presents national data regarding objectively determined COPD (1971-94); COPD-associated activity and functional limitations (1980-96); self-reported COPD prevalence, COPD physician office and hospital outpatient department visits, COPD hospitalizations, and COPD deaths (1980-2000); and COPD emergency department visits (1992-2000). DESCRIPTION OF SYSTEMS: CDC's National Center for Health Statistics (NCHS) conducts the National Health Interview Survey annually, which includes questions concerning COPD and activity limitations. NCHS collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient department data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. Data regarding pulmonary function were obtained from the National Health and Nutrition Examination Surveys (NHANES) I (1971-75) and III (1988-94), and data regarding functional limitation were obtained from NHANES III, Phase 2 (1991-94). RESULTS:   During 2000, an estimated 10 million U.S. adults reported physician-diagnosed COPD. However, data from NHANES III estimate that approximately 24 million U.S. adults have evidence of impaired lung function, indicating that COPD is underdiagnosed. During 2000, COPD was responsible for 8 million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths. During the period analyzed, the most substantial changes was the increase in the COPD death rate for women, from 20.1/100,000 in 1980 to 56.7/100,000 in 2000, compared with the more modest increase in the death rate for men, from 73.0/100,000 in 1980 to 82.6/100,000 in 2000. In 2000, for the first time, the number of women dying from COPD surpassed the number of men dying from COPD (59,936 versus 59,118). Another substantial change observed is that the proportion of the population aged 55 years and over with mild or moderate COPD, on the basis of pulmonary function testing, decreased from 1971-75 to 1988-94, possibly indicating that the upward trends in COPD hospitalizations and mortality might not continue. INTERPRETATION: COPD is a major cause of morbidity, mortality, and disability in the United States. Despite its ease of diagnosis, COPD remains an underdiagnosed disease, chiefly in its milder and more treatable form.

Mannino DM,  Homa  DM, Akinbami LJ, Ford  ES, Redd  SC.  Chronic obstructive pulmonary disease surveillance - United States, 1971--2000. 
Respiratory Care 2002 Oct;47(10):1184-99.

PROBLEM/CONDITION: Chronic obstructive pulmonary disease (COPD) includes chronic bronchitis and emphysema but has been defined recently as the physiologic finding of nonreversible pulmonary function impairment. This surveillance summary reports trends in different measures of COPD during 1971-2000. REPORTING PERIOD COVERED: This report presents national data regarding objectively determined COPD (1971-94); COPD-associated activity and functional limitations (1980-96); self-reported COPD prevalence, COPD physician office and hospital outpatient department visits, COPD hospitalizations, and COPD deaths (1980-2000); and COPD emergency department visits (1992-2000). DESCRIPTION OF SYSTEMS: The Centers for Disease Control's National Center for Health Statistics conducts the National Health Interview Survey annually, which includes questions concerning COPD and activity limitations. The National Center for Health Statistics collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient department data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. Data regarding pulmonary function were obtained from the National Health and Nutrition Examination Surveys (NHANES) I (1971-75) and III (1988-94), and data regarding functional limitation were obtained from NHANES III, Phase 2 (1991-94). RESULTS:   During 2000, an estimated 10 million U.S. adults reported physician-diagnosed COPD. However, data from NHANES III estimate that approximately 24 million United States adults have evidence of impaired lung function, indicating that COPD is underdiagnosed. During 2000, COPD was responsible for 8 million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths. During the period analyzed, the most substantial change was the increase in the COPD death rate for women, from 20.1/100,000 in 1980 to 56.7/100,000 in 2000, compared with the more modest increase in the death rate for men, from 73.0/100,000 in 1980 to 82.6/100,000 in 2000. In 2000, for the first time, the number of women dying from COPD surpassed the number of men dying from COPD (59,936 vs. 59,118). Another substantial change observed is that the proportion of the population aged 55 years and older with mild or moderate COPD, on the basis of pulmonary function testing, decreased from 1971-1975 to 1988-1994, possibly indicating that the upward trends in COPD hospitalizations and mortality might not continue. INTERPRETATION: COPD is a major cause of morbidity, mortality, and disability in the United States. Despite its ease of diagnosis, COPD remains an underdiagnosed disease, chiefly in its milder and more treatable form.

Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC.
Surveillance for asthma--United States, 1980-99.
Morbidity and Mortality Weekly Report Surveillance Summary 2002 Mar 29;51(1):1-13.

PROBLEM/CONDITION: Asthma, a chronic disease occurring among both children and adults, has been the focus of clinical and public health interventions during recent years. In addition, CDC has outlined a strategy to improve the timeliness and geographic specificity of asthma surveillance as part of a comprehensive public health approach to asthma surveillance. REPORTING PERIOD COVERED: This report presents national data regarding self-reported asthma prevalence, school and work days lost because of asthma, and asthma-associated activity limitations (1980-96); asthma-associated outpatient visits, asthma-associated hospitalizations, and asthma-associated deaths (1980-99); asthma-associated emergency department visits (1992-99); and self-reported asthma episodes or attacks (1997-99). DESCRIPTION OF SYSTEMS: CDC's National Center for Health Statistics (NCHS) conducts the National Health Interview Survey annually, which includes questions regarding asthma and asthma-related activity limitations. NCHS collects physician office-visit data in the National Ambulatory Medical Care Survey, emergency department and hospital outpatient data in the National Hospital Ambulatory Medical Care Survey, hospitalization data in the National Hospital Discharge Survey, and death data in the Mortality Component of the National Vital Statistics System. RESULTS:   During 1980-96, asthma prevalence increased. Annual rates of persons reporting asthma episodes or attacks, measured during 1997-99, were lower than the previously reported asthma prevalence rates, whereas the rates of lifetime asthma, also measured during 1997-99, were higher than the previously reported rates. Since 1980, the proportion of children and adults with asthma who report activity limitation has remained stable. Since 1995, the rate of outpatient visits and emergency department visits for asthma increased, whereas the rates of hospitalization and death decreased. Blacks continue to have higher rates of asthma emergency department visits, hospitalizations, and deaths than do whites. INTERPRETATION: Since the previous report in 1998 (CDC. Surveillance for Asthma--United States, 1960-1995. Morbidity and Mortality Weekly Report 1998;47[No. SS-1]:1-28), changes in asthma-associated morbidity and death have been limited. Asthma remains a critical clinical and public health problem. Although data in this report indicate certain early indications of success in current asthma intervention programs (e.g., limited decreases in asthma hospitalization and death rates), the continued presence of substantial racial disparities in these asthma endpoints highlights the need for continued surveillance and targeted interventions.

Martin JA, Hoyert DL.
The national fetal death file.
Seminars in Perinatology 2002 Feb;26(1):3-11. 

The most comprehensive source of U.S. data on fetal deaths of 20 gestational weeks or greater is available through the National Vital Statistics System (NVSS). The NVSS is a collaborative effort between the independent reporting areas (the individual States and the territories), and the Federal government or its agent, the Centers for Disease Control and Prevention's, National Center for Health Statistics (NCHS). The Federal government has no authority to register vital events. The registration of births, deaths, fetal deaths, marriages, and divorces is solely a state responsibility. However, NCHS is mandated by law to produce national data based on vital events. To promote the uniformity necessary to create a national file from this decentralized system, NCHS attempts to influence State systems via the development of certain standards, primarily, The Model State Vital Statistics Act and Regulations (The Model Law), and the Standard Certificates and Reports. The Model Law definitions for live birth, fetal death, and induced termination of pregnancy are based on international standards set by The World Health Organization. All States have definitions of fetal death consistent with the Model Law. The Model Law also recommends reporting requirements for fetal death, but State requirements vary. This variation results in differences in reporting of fetal deaths among areas. Other limitations to the national fetal death file include: the under-reporting of fetal deaths incidence, higher than acceptable levels of missing data for some items, and the accuracy of the data reported. Also of concern is the potential misclassification of fetal deaths and short-lived live births. These limitations are amenable to improvement. The upcoming revision of the U.S. Standard Report of Fetal Death addresses these issues and offers an opportunity to strengthen the quality of fetal death data. The development of worksheets, detailed specifications and instruction manuals, and a reformatted cause of death section should importantly enhance the quality of national fetal death file and ultimately reduce the incidence of these tragic events.

Mathews TJ, MacDorman MF, Menacker F.
Infant mortality statistics from the 1999 period linked birth/infant death data set.
National Vital Statistics Report 2002 Jan 30;50(4):1-28. 

OBJECTIVES: This report presents 1999 period infant mortality statistics from the linked birth/infant death data set (linked file) by a variety of maternal and infant characteristics. METHODS: Descriptive tabulations of data are presented. RESULTS:   In general, mortality rates were lowest for infants born to Chinese and Japanese mothers (2.9 and 3.4 per 1,000, respectively). Infants of Cuban, Central and South American, Mexican, and non-Hispanic white mothers had low rates, while rates were higher for infants of Puerto Rican and highest for non-Hispanic black mothers (13.9). Filipino mothers also had low rates. Rates were high for infants of Hawaiian and American Indian mothers. Infant mortality rates were higher for those infants whose mothers had no prenatal care, were teenagers, had 9-11 years of education, were unmarried, or smoked during pregnancy. Infant mortality was also higher for male infants, multiple births, and infants born preterm or at low birthweight. The three leading causes of infant death--Congenital malformations, low birthweight, and Sudden infant death syndrome (SIDS)--taken together accounted for 45% all infant deaths in the United States in 1999. Cause-specific mortality rates varied considerably by race and Hispanic origin. For infants of black mothers, the infant mortality rate for low birthweight was four times that for white mothers. For infants of American Indian mothers, the SIDS rate was 2.4 times that for non-Hispanic white mothers. SIDS rates for infants of Hispanic and Asian or Pacific Islander mothers, were 40-50% lower than those for non-Hispanic white mothers.

Mathews TJ, Menacker F, MacDorman MF.
Infant mortality statistics from the 2000 period linked birth/infant death data set.
National Vital Statistics Report 2002 Aug 28;50(12):1-28. 

OBJECTIVES: This report presents the 2000 period infant mortality statistics from the linked birth/infant death data set (linked file) by a variety of maternal and infant characteristics. METHODS: Descriptive tabulations of data are presented and interpreted. RESULTS:   Infant mortality rates ranged from 3.5 per 1,000 live births for Chinese mothers to 13.5 for black mothers. Among Hispanics, rates ranged from 4.5 for Cuban mothers to 8.2 for Puerto Rican mothers. Infant mortality rates were higher for those infants whose mothers had no prenatal care, were teenagers, had 9-11 years of education, were unmarried, or smoked during pregnancy. Infant mortality was also higher for male infants, multiple births, and infants born preterm or at low birthweight. The three leading causes of infant death--Congenital malformations, low birthweight, and Sudden infant death syndrome (SIDS)--taken together accounted for 45% of all infant deaths in the United States in 2000. Cause-specific mortality rates varied considerably by race and Hispanic origin. For infants of black mothers, the infant mortality rate for low birthweight was nearly four times that for white mothers. For infants of black and American Indian mothers, the SIDS rates were 2.4 and 2.3 times that for non-Hispanic white mothers.

McCaig LF, Besser RE, Hughes JM. 
Trends in antimicrobial prescribing rates for children and adolescents.
Journal of the American Medical Association 2002 Jun 19;287(23):3096-102. 

CONTEXT: Annual rates of antimicrobial prescribing for children by office-based physicians increased from 1980 through 1992. The development of antimicrobial resistance, which increased for many organisms during the 1990s, is associated with antimicrobial use. To combat development of antimicrobial resistance, professional and public health organizations undertook efforts to promote appropriate antimicrobial prescribing. OBJECTIVE: To assess changes in antimicrobial prescribing rates overall and for respiratory tract infections for children and adolescents younger than 15 years. DESIGN, SETTING, AND PARTICIPANTS: National Ambulatory Medical Care Survey data provided by 2,500 to 3,500 office-based physicians for 6,500 to 13,600 pediatric visits during 2-year periods from 1989-1990 through 1999-2000. MAIN OUTCOME MEASURES: Population- and visit-based antimicrobial prescribing rates overall and for respiratory tract infections (otitis media, pharyngitis, bronchitis, sinusitis, and upper respiratory tract infection) among children and adolescents younger than 15 years. RESULTS:   The average population-based annual rate of overall antimicrobial prescriptions per 1,000 children and adolescents younger than 15 years decreased from 838 (95% confidence interval [CI], 711-966) in 1989-1990 to 503 (95% CI, 419-588) in 1999-2000 (P for slope <.001). The visit-based rate decreased from 330 antimicrobial prescriptions per 1,000 office visits (95% CI, 305-355) to 234 (95% CI, 210-257; P for slope <.001). For the five respiratory tract infections, the population-based prescribing rate decreased from 674 (95% CI, 568-781) to 379 (95% CI, 311-447; P for slope <.001) and the visit-based prescribing rate decreased from 715 (95% CI, 682-748) to 613 (95% CI, 570-657; P for slope <.001). Both population- and visit-based prescribing rates decreased for pharyngitis and upper respiratory tract infection; however, for otitis media and bronchitis, declines were only observed in the population-based rate. Prescribing rates for sinusitis remained stable. CONCLUSION: The rate of antimicrobial prescribing overall and for respiratory tract infections by office-based physicians for children and adolescents younger than 15 years decreased significantly between 1989-1990 and 1999-2000.

McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M.
Serologic immunity to diphtheria and tetanus in the United States.
Annuals of Internal Medicine 2002 May 7;136(9):660-6. 

BACKGROUND: Serologic data on diseases that are preventable by vaccine are useful to evaluate the success of immunization programs and to identify susceptible subgroups. OBJECTIVE: To provide national estimates of immunity to diphtheria and tetanus by measurement of serum antibody levels. DESIGN: Examination of data from the Third National Health and Nutrition Examination Survey, a representative cross-sectional sample of the U.S. population. SETTING: 89 randomly selected locations throughout the United States. PARTICIPANTS: 18,045 persons 6 years of age or older who were examined from 1988 to 1994. MEASUREMENTS: Serum samples obtained at a single time point were tested for diphtheria and tetanus antitoxin. RESULTS:   Overall, 60.5% of Americans 6 years of age or older had fully protective levels of diphtheria antibody (> or =0.10 IU/mL) and 72.3% had protective levels of tetanus antibody (> 0.15 IU/mL). Ninety-one percent of Americans 6 to 11 years of age had protective levels of both diphtheria and tetanus antibody; this proportion decreased to approximately 30% among persons 70 years of age (29.5% for diphtheria and 31.0% for tetanus). Adult Mexican-Americans were slightly less likely to have protective levels of antibody to both toxins. Only 47% of persons 20 years of age or older had levels that were protective against both diseases, and only 63% of adults who were protected against tetanus were also protected against diphtheria. CONCLUSIONS: A substantial proportion of adults in the United States do not have antibody levels that are protective against diphtheria and tetanus. In addition, although the recommended vaccine is a combination of tetanus and diphtheria, only 63% of adults with protective antibody to tetanus also had protective antibody to diphtheria.

Nelson DE, Bland S, Powell-Griner E, Klein R, Wells HE, Hogelin G, Marks JS.
State trends in health risk factors and receipt of clinical preventive services among U.S. adults during the 1990s. 
Journal of the American Medical Association 2002 May 22-29;287(20):2659-67. 

CONTEXT: Monitoring trends is essential for evaluating past activities and guiding current preventive health program and policy efforts. Although tracking progress toward national health goals is helpful, use of national estimates is limited because most preventive health care activities, policies, and other efforts occur at the State or community level. There may be important State trends that are obscured by national data. OBJECTIVE: To estimate State-specific trends for five health risk factors and six clinical preventive services. DESIGN: Telephone surveys were conducted from 1991 through 2000 as part of the Behavioral Risk Factor Surveillance System. SETTING AND PARTICIPANTS: Randomly selected adults aged 18 years or older from 49 U.S. States. Annual State sample sizes ranged from 1,188 to 7,543. MAIN OUTCOME MEASURES: Statistically significant changes (P<.01) in State prevalences of cigarette smoking, binge alcohol use, physical inactivity, obesity, safety belt use, and mammography; screening for cervical cancer, colorectal cancer, and cholesterol levels; and receipt of influenza and pneumococcal disease vaccination. RESULTS:   There were statistically significant increases in safety belt use for 39 of 47 States and receipt of mammography in the past 2 years for women aged 40 years or older for 43 of 47 States. For persons aged 65 years or older, there were increases in receipt of influenza vaccination for 44 of 49 States and ever receiving pneumococcal vaccination for 48 of 49 States. State trends were mixed for binge alcohol use (increasing in 19 of 47 States and declining in 3), physical inactivity (increasing in 3 of 48 States and declining in 11), and cholesterol screening (increasing in 13 of 47 States and decreasing in 5). Obesity increased in all States and smoking increased in 14 of 47 States (declining only in Minnesota). Cervical cancer screening increased in 8 of 48 States and colorectal cancer screening increased in 13 of 49 States. New York experienced improvements for 8 of 11 measures, while 7 of 11 measures improved in Delaware, Kentucky, and Maryland; in contrast, Alaska experienced improvements for no measures and at least 4 of 11 measures worsened in Iowa, North Dakota, and South Dakota. CONCLUSIONS: Most States experienced increases in safety belt use, mammography, and adult vaccinations. Trends for smoking and binge alcohol use are disturbing, and obesity data support previous findings. Trend data are useful for targeting State preventive health efforts.

Nesby-O'Dell S, Scanlon KS, Cogswell ME, Gillespie C, Hollis BW, Looker AC, Allen C, Doughertly C, Gunter EW, Bowman BA.
Hypovitaminosis D prevalence and determinants among African American and white women of reproductive age: Third National Health and Nutrition Examination Survey, 1988-94.
American Journal of Clinical Nutrition 2002 Jul;76(1):187-92. 

BACKGROUND: Recent reports of rickets among African American children drew attention to the vitamin D status of these infants and their mothers. African American women are at higher risk of vitamin D deficiency than are white women, but few studies have examined determinants of hypovitaminosis D in this population. OBJECTIVE: We examined the prevalence and determinants of hypovitaminosis D among African American and white women of reproductive age. DESIGN: We examined 1,546 African American women and 1,426 white women aged 15-49 years who were not pregnant and who participated in the Third National Health and Nutrition Examination Survey (1988-94). Hypovitaminosis D was defined as a serum 25-hydroxyvitamin D concentration < or =37.5 nmol/L. Multiple logistic regression was used to examine the independent association of dietary, demographic, and behavioral determinants of hypovitaminosis D. RESULTS:   The prevalence of hypovitaminosis D was 42.4 +/- 3.1% ( +/- SE) among African Americans and 4.2 +/- 0.7% among whites. Among African Americans, hypovitaminosis D was independently associated with consumption of milk or breakfast cereal <3 times/wk, no use of vitamin D supplements, season, urban residence, low body mass index, and no use of oral contraceptives. Even among 243 African Americans who consumed the adequate intake of vitamin D from supplements (200 IU/d), 28.2 +/- 2.7% had hypovitaminosis D. CONCLUSIONS: The high prevalence of hypovitaminosis D among African American women warrants further examination of vitamin D recommendations for these women. The determinants of hypovitaminosis D among women should be considered when these women are advised on dietary intake and supplement use.

Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA.  Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. 
Injury Prevention 2002 Sep;8(3):185-91.

OBJECTIVE: To characterize national trends in nonfatal BB/pellet gun related injury rates for persons aged 19 years or younger in relation to trends in nonfatal and fatal firearm related injury rates and discuss these trends in light of injury prevention and violence prevention efforts. SETTING: The National Electronic Injury Surveillance System (NEISS) includes approximately 100 hospitals with at least six beds that provide emergency services. These hospitals comprise a stratified probability sample of all U.S. hospitals with emergency departments. The National Vital Statistics System (NVSS) is a complete census of all death certificates filed by States and is compiled annually. METHODS: National data on BB/pellet gun related injuries and injury rates were examined along with fatal and nonfatal firearm related injuries and injury rates. Nonfatal injury data for all BB/pellet gun related injury cases from 1985 through 1999, and firearm related injury cases from 1993 through 1999 were obtained from hospital emergency department records using the NEISS. Firearm related deaths from 1985 through 1999 were obtained from the NVSS. RESULTS:   BB/pellet gun related injury rates increased from age 3 years to a peak at age 13 years and declined thereafter. In contrast, firearm related injury and death rates increased gradually until age 13 and then increased sharply until age 18 years. For persons aged 19 years and younger, BB/pellet gun related injury rates increased from the late 1980s until the early 1990s and then declined until 1999; these injury rates per 100,000 population were 24.0 in 1988, 32.8 in 1992, and 18.3 in 1999. This trend was similar to those for fatal and nonfatal firearm related injury rates per 100,000, which were 4.5 in 1985, 7.8 in 1993, and 4.3 in 1999 (fatal) and 38.6 in 1993 and 16.3 in 1999 (nonfatal). In 1999, an estimated 14,313 (95% confidence interval (CI) 12 025 to 16,601) cases with nonfatal BB/pellet gun injuries and an estimated 12,748 (95% CI 7,881-17,615) cases with nonfatal firearm related injuries among persons aged 19 years and younger were treated in U.S. hospital emergency departments. CONCLUSIONS: BB/pellet gun related and firearm related injury rates show similar declines since the early 1990s. These declines coincide with a growing number of prevention efforts aimed at reducing injuries to children from unsupervised access to guns and from youth violence. Evaluations at the State and local level are needed to determine true associations.

Ni H, Barnes P, Hardy AM.
Recreational injury and its relation to socioeconomic status among school aged children in the United States.
Injury Prevention 2002 Mar;8(1):60-5. 

OBJECTIVES: This study described epidemiologic patterns of recreational injuries among school aged children in the United States and assessed the relation of these patterns to socioeconomic status. METHODS: Combined data from the 1997-98 National Health Interview Surveys for 38,458 children aged 6-17 years regarding nonfatal recreational injury episodes that received medical attention, reported by a household adult, were analyzed. Logistic regression analysis was used to assess the association between recreational injury and socioeconomic status while controlling for confounding factors. RESULTS:  The annualized rate of recreational injury was 91.2 episodes per 1,000 children, with an increased risk associated with a higher family income status or being non-Hispanic white. For children from not poor families, most injury episodes occurred in sport facilities, whereas for children from poor and near poor families, most occurred outside the home. CONCLUSION: Recreational injury is a significant health problem for school aged children in the United States. Non-Hispanic white children and children from affluent families are at increased risk of recreational injury.

Ni H, Simile C, Hardy AM.
Utilization of complementary and alternative medicine by United States adults: Results from the 1999 National Health Interview Survey.
Medical Care 2002 Apr;40(4):353-8. 

OBJECTIVE: To measure utilization of complementary and alternative medicine (CAM) by U.S. adults. METHODS: We analyzed data from the 1999 National Health Interview Survey (NHIS), which covers the noninstitutionalized civilian U.S. population. Information on 12 types of CAM use in the past 12 months was obtained from 30,801 respondents aged 18 years and older. Statistical analyses were performed using the SUDAAN software package to account for the complex sample design of the NHIS. RESULTS:   An estimated 28.9% of U.S. adults used at least one CAM therapy in the past year. The three most commonly used therapies were spiritual healing or prayer (13.7%), herbal medicine (9.6%), and chiropractic therapies (7.6%). The use of CAM was most prevalent among women, persons aged 35-54 years, and persons with an educational attainment of > or = 16 years. The overall CAM use was higher for white non-Hispanic persons (30.8%) than for Hispanic (19.9%) and black non-Hispanic persons (24.1%). Although the use was higher for persons who had health insurance than for those who did not, the difference was not statistically significant after adjusting for age, gender, and educational attainment. Compared with nonusers, CAM users were more likely to use conventional medical services. CONCLUSIONS: Estimates of CAM use in this nationally representative sample were considerably lower than have been reported in previous surveys. Most CAM therapies are used by U.S. adults in conjunction with conventional medical services.

Ogden CL, Flegal KM, Carroll MD, Johnson CL. 
Prevalence and trends in overweight among U.S. children and adolescents, 1999-2000.
Journal of the American Medical Association 2002 Oct 9;288(14):1728-32.

CONTEXT: The prevalence of overweight among children in the United States increased between 1976-1980 and 1988-1994, but estimates for the current decade are unknown. OBJECTIVE: To determine the prevalence of overweight in U.S. children using the most recent national data with measured weights and heights and to examine trends in overweight prevalence. DESIGN, SETTING, AND PARTICIPANTS: Survey of 4,722 children from birth through 19 years of age with weight and height measurements obtained in 1999-2000 as part of the National Health and Nutrition Examination Survey (NHANES), a cross-sectional, stratified, multistage probability sample of the U.S. population. MAIN OUTCOME MEASURE: Prevalence of overweight among U.S. children by sex, age group, and race/ethnicity. Overweight among those aged 2 through 19 years was defined as at or above the 95th percentile of the sex-specific body mass index (BMI) for age growth charts. RESULTS:  The prevalence of overweight was 15.5% among 12- 19-year-olds, 15.3% among 6-11-year-olds, and 10.4% among 2- 5-year-olds, compared with 10.5%, 11.3%, and 7.2%, respectively, in 1988-1994 (NHANES III). The prevalence of overweight among non-Hispanic black and Mexican-American adolescents increased more than 10 percentage points between 1988-1994 and 1999-2000. CONCLUSION: The prevalence of overweight among children in the United States is continuing to increase, especially among Mexican-American and non-Hispanic black adolescents.

Ogden CL, Kuczmarski RJ, Flegal KM, Mei Z, Guo S, Wei R, Grummer-Strawn LM, Curtin LR, Roche AF, Johnson CL. Centers for Disease Control and Prevention 2000 growth charts for the United States: Improvements to the 1977 National Center for Health Statistics version.
Pediatrics 2002 Jan;109(1):45-60. 

OBJECTIVE: To present a clinical version of the 2000 Centers for Disease Control and Prevention (CDC) growth charts and to compare them with the previous version, the 1977 National Center for Health Statistics (NCHS) growth charts. METHODS: The 2000 CDC percentile curves were developed in two stages. In the first stage, the empirical percentiles were smoothed by a variety of parametric and nonparametric procedures. To obtain corresponding percentiles and z scores, we approximated the smoothed percentiles using a modified LMS estimation procedure in the second stage. The charts include of a set of curves for infants, birth-6 months of age, and a set for children and adolescents, 2- 20 years of age. RESULTS:  The charts represent a cross-section of children who live in the United States; breast-fed infants are represented on the basis of their distribution in the U.S. population. The 2000 CDC growth charts more closely match the national distribution of birthweights than did the 1977 NCHS growth charts, and the disjunction between weight-for-length and weight-for-stature or length-for-age and stature-for-age found in the 1977 charts has been corrected. Moreover, the 2000 CDC growth charts can be used to obtain both percentiles and z scores. Finally, body mass index-for-age charts are available for children and adolescents 2-20 years of age. CONCLUSION: The 2000 CDC growth charts are recommended for use in the United States. Pediatric clinics should make the transition from the 1977 NCHS to the 2000 CDC charts for routine monitoring of growth in infants, children, and adolescents.

Overpeck MD, Brenner RA, Cosgrove C, Trumble AC, Kochanek K, MacDorman M.
National underascertainment of sudden unexpected infant deaths associated with deaths of unknown cause.
Pediatrics 2002 Feb;109(2):274-83. 

OBJECTIVE: To investigate underascertainment of unexpected infant deaths at the national level as a result of probable classification as attributable to unknown cause. METHODS: Using linked birth and death certificates for all U.S. birth cohorts from 1983-91 and 1995-96, we identified 53,470 sudden infant death syndrome (SIDS) fatalities, 9,071 unintentional injury deaths, 3,473 injury deaths classified with intentional or suspicious intent, and 8,097 deaths with unknown underlying cause. For these deaths, we compared relative risks (RRs) for maternal and infant variables available on birth certificates known to be predictive of SIDS, unintentional injury, and homicides. Variables available on death certificates were compared for unlinked and linked records. Factors related to State and national management of cases pending final cause determination are reviewed. RESULTS:  For deaths from unknown cause, rates were consistently high among the same risk groups that have been shown to be at increased risk for SIDS, unintentional injury, and homicides. For most risk factors, RRs for deaths attributable to unknown causes were somewhat lower than for RRs for intentional/suspicious injury deaths but higher than for SIDS or unintentional injury, indicating combined contributions from all causes. For example, age at death from unknown cause includes RRs that more strongly resemble patterns of intentional/suspicious injuries than SIDS or unintentional injury. Deaths from unknown cause were more likely to occur during the first week of life for unattended births occurring outside clinical settings or when birth certificates were not found, similar to intentional/suspicious injury deaths. CONCLUSIONS: Risk profiles indicate that deaths of unknown cause are likely to represent a mixture of unexpected deaths. The process for determination of cause of unexpected death affects national underascertainment of SIDS and injury deaths. Better coordination among child fatality review teams and local, State, and national officials should reduce underascertainment and improve documentation of circumstances surrounding deaths for prevention efforts.

Parker JD, Schoendorf KC. 
Implications of cleaning gestational age data. 
Paediatric and Perinatal Epidemiology 2002 Apr;16(2):181-7.

Gestational age is an important birth characteristic examined in epidemiological studies. Though there are well-documented problems with the reporting of gestational age on birth certificates, schemes for addressing this issue have not been systematically evaluated. With singleton births from the 1995-97 U.S. linked birth/infant death files, we compared a handful of perinatal outcome estimates derived from the resulting analytical files using two published methods often used to manage inconsistent gestational age data. The first method (Alexander et al., 1996), provides cut-points for implausible birthweight-gestational age combinations and excludes infants with birthweights outside a plausible range. The second (Zhang and Bowes, 1995), provides different cut-points for implausible birthweight-gestational age combinations and then substitutes the clinical gestational age estimate for the original value, if available, reducing the number of births at the affected gestational age, but excluding fewer births from the resulting analytical files. The Alexander method excluded 0.4 of our study population and the Zhang method reassigned and excluded 1.0 and 0.2, respectively; however, over 20 of birth records with gestational age 28-30 weeks were modified by either method. Using either method, more high-risk than low-risk and more black than white births were excluded. These differential exclusions affected corresponding perinatal outcome estimates and relative risks between maternal risk groups for preterm delivery, gestation-specific infant mortality and birthweight; overall infant mortality rates were not affected. Systematic comparisons between results of different studies will need to consider the data modifications used, the populations affected, and the outcomes assessed when drawing conclusions.

Parker JD, Makuc DM.
Methodologic implications of allocating multiple-race data to single-race categories.
Health Services Research, 2002 Feb;37(1):173-86.  

OBJECTIVE: To illustrate methods for comparing race data collected under the 1977 Federal Office of Management and Budget (OMB) directive, known as OMB-15, with race data collected under the revised 1997 OMB standard. DATA SOURCES/STUDY SETTING: Secondary data from the 1993-95 National Health Interview Surveys. Multiple-race responses, available on in-house files, were analyzed. STUDY DESIGN: Race-specific estimates of employer-sponsored health insurance were calculated using proposed allocation methods from the OMB. Estimates were calculated overall and for three population subgroups: children, those in households below poverty, and Hispanics. PRINCIPAL FINDINGS: Although race distributions varied between the different methods, estimates of employer-sponsored health insurance were similar. Health insurance estimates for the American Indian/Alaska Native group varied the most. CONCLUSIONS: Employer-sponsored health insurance estimates for American Indian/Alaska Natives from data collected under the 1977 OMB directive will not be comparable with estimates from data collected under the 1997 standard. The selection of a method to distribute to the race categories used prior to the 1997 revision will likely have little impact on estimates of employer-sponsored health insurance for other groups. Additional research is needed to determine the effects of these methods for other health service measures.

Parker JD, Madans JH.
The correspondence between interracials births and multiple race reporting. 
American Journal of Public Health 2002 Dec;92(12):1976-81.

OBJECTIVES: Race-specific health statistics are routinely reported in scientific publications; most describe health disparities across groups. Census 2000 showed that 2.4% of the U.S. population identifies with more than one race group. We examined the hypothesis that multiple-race reporting is associated with interracial births by comparing parental race reported on birth certificates with reported race in a national health survey. METHODS: U.S. natality data from 1968 through 1998 and National Health Interview Survey data from 1990 through 1998 were compared, by year of birth. RESULTS:  Overall multiple-race survey responses correspond to expectations from interracial births. However, there are discrepancies for specific multiple-race combinations. CONCLUSIONS: Projected estimates of the multiple-race population can be only partially informed by vital records.

Pearcy JN, Keppel KG.
A summary measure of health disparity.
Public Health Reports 2002 May-Jun;117(3):273-80. 

OBJECTIVES: Eliminating health disparities is a goal of Healthy People 2010. In order to track progress toward this goal, we need improved methods for measuring disparity. The authors present the Index of Disparity (ID) as a summary measure of disparity. METHODS: The ID, a modified coefficient of variation, was used to measure disparity across populations defined on the basis of race/ethnicity, income, education, and gender. Disparity was also assessed for a diverse range of health indicators and over time to monitor trends. RESULTS:   Disparity in cardiovascular disease deaths decreased based on gender from 1989 to 1998 but was largely unchanged based on race/ethnicity. The magnitude of disparities in cervical cancer and cholesterol screening, smoking, exercise, and health insurance ranged from 1.9% to 78.6%. The largest disparities for health indicators were not associated with any particular population classification, whether defined on the basis of race/ethnicity, education, or income. CONCLUSIONS: To eliminate disparities, we need a means to assess disparities across many types of health indicators. Furthermore, for a given health indicator, disparities may differ for populations defined on the basis of race/ethnicity, education, income, and so on. The ID is a simple method for summarizing disparities across groups within a population that can be applied across health indicators regardless of magnitude, over time to monitor trends, and across different populations.

Pleis JR, Gentleman JF.
Using the National Health Interview Survey: Time trends in influenza vaccinations among targeted adults.
Effective Clinical Practice 2002 May-Jun;5(3 Suppl):E3. 

Context: Influenza and its complications result in significant morbidity and mortality each year. Certain groups are at increased risk for influenza and influenza-related complications. They, and others who are in close contact with them, are target groups to receive a yearly influenza immunization according to recommendations from the Advisory Committee on Immunization Practices (ACIP). OBJECTIVE: To estimate the proportions of adults in selected target groups who received influenza vaccination in 1995 and 1998 and to identify characteristics associated with vaccination receipt. Data Source: The National Health Interview Survey (NHIS), a nationally representative survey of civilian noninstitutionalized persons conducted annually by the Centers for Disease Control's National Center for Health Statistics. We used data for adults (under 18 years of age) from the 1995 and 1998 NHIS. Outcome Measure: Proportions of persons in target groups self-reporting influenza vaccination in the 12 months before the NHIS interview. RESULTS:   Between 1995 and 1998, influenza vaccination increased for persons aged 65 and older (58.2% to 63.3%; P<0.05) and for adults under 65 belonging to selected ACIP target groups (27.5% to 30.1%; P<0.05). Examination of 1998 data shows that regardless of age, the likelihood of influenza vaccination is strongly influenced by having health coverage or a regular source of care. For example, 66% of the elderly with private fee- for-service health care coverage were vaccinated, compared with 23% of the elderly with no insurance (adjusted odds ratio [OR], 3.9; 95% CI, 1.6 to 9.3). For persons aged 18 to 64 years belonging to an ACIP target group, the corresponding figures are 32% vs. 16% (adjusted OR, 1.8; CI, 1.4 to 2.3). The likelihood of vaccination also varied by race and ethnicity: For age 65 and older, 66% of non-Hispanic whites were vaccinated compared with 46% of non-Hispanic blacks (adjusted OR, 2; CI, 1.6 to 2.4). CONCLUSIONS: The use of influenza vaccination among adults at high risk for influenza and influenza-related complications increased between 1995 and 1998. Younger individuals at high risk, people without insurance or a regular source of care, and nonwhites still have low vaccination rates.

Rhodes JC, Barfield WD, Kohn MA, Hedberg K, Schoendorf KC.
Releasing pre-adoption birth records:  A survey of Oregonian adoptees. 
Public Health Reports 2002; 117:463-471. 

OBJECTIVE: In June 2000, Oregon implemented a citizen-initiated ballot measure that grants adult adoptees access to their birth records, which contain their birth parents' identifying information. Because other States are considering similar policy changes, the authors explored whether Oregon's new law is meeting the information needs of adoptees. METHODS: Birth records were abstracted for a 9% (221/2,529) random sample of adoptees who obtained their records from June 20, 2000, to July 20, 2000, to describe the population and the information they obtained. Telephone interviews documented their motivations, expectations, and whether they considered the birth record useful. RESULTS:   The mean age of the adoptees was 41 years, 64% were female, and 97% were white. Virtually all received information about their birth mother; however, only one-third received information about their birth father. Of the 221 sampled, 123 (59%) participated in the telephone survey, 12 were ineligible, 84 could not be reached, and 2 refused. The most common motivations for requesting records were to find birth parents (29%) and to obtain medical information (29%). Twenty-nine percent received less information than they expected, with many expecting, but not receiving, birth father information. Thirty-three (47%) of the 70 adoptees who tried to find their birth mother were successful. The records were considered "very" useful by 52% of respondents, "somewhat" or "a little" useful by 42%, and "not at all" useful by 6%. CONCLUSIONS: The results indicate that many adoptees received less information than they expected, and many did not meet their goals of finding birth parents or obtaining medical information. Nonetheless, the majority considered their birth records useful and important.

Saaddine JB, Fagot-Campagna A, Rolka D, Narayan KM, Geiss L, Eberhardt M, Flegal KM.
Distribution of HbA(1c) levels for children and young adults in the U.S.: Third National Health and Nutrition Examination Survey.
Diabetes Care 2002 Aug;25(8):1326-30.

OBJECTIVE: To describe the distribution of HbA(1c) levels among children and young adults in the United States and to evaluate the effects of age, sex, race/ethnicity, socioeconomic status, parental history of diabetes, overweight, and serum glucose on HbA(1c) levels. RESEARCH DESIGN AND METHODS: We analyzed HbA(1c) data from the Third National Health and Nutrition Examination Survey, 1988-94, for 7,968 participants aged 5-24 years who had not been treated for diabetes. After adjusting for the complex sample design, we compared the distributions of HbA(1c) in subgroups and developed multiple linear regression models to examine factors associated with HbA(1c). RESULTS:   Mean HbA(1c) level was 4.99% (SD 0.50%) and varied from 4.93% (95% CI +/-0.04) in non-Hispanic whites to 5.05% (+/-0.02) in Mexican Americans to 5.17% (+/-0.02) in non-Hispanic blacks. There were very small differences among subgroups. Within each age-group, among men and women, among overweight and nonoverweight subjects, and at any level of education, mean HbA(1c) levels were higher in non-Hispanic blacks than in non-Hispanic whites. After adjusting for confounders, HbA(1c) levels for non-Hispanic blacks (5.15%, 95% CI +/-0.04) and Mexican Americans (5.01%, +/-0.04) were higher than those for non-Hispanic whites (4.93%, +/-0.04). CONCLUSIONS: These data provide national reference levels for HbA(1c) distributions among Americans aged 5-24 years and show statistically significant racial/ethnic differences in HbA(1c) levels that are not completely explained by demographic and health-related variables.

Saydah SH, Eberhardt MS, Loria CM, Brancati FL.
Age and the burden of death attributable to diabetes in the United States.
American Journal of Epidemiology 2002 Oct 15;156(8):714-9. 

Diabetes is a well-established cause of cardiovascular disease (CVD) and all-cause mortality. The burden of death attributable to diabetes in the United States is not well quantified, particularly with regard to age. The authors analyzed data from the Second National Health and Nutrition Examination Survey (NHANES II) (1976-80) and the NHANES II Mortality Study, in which a nationally representative cohort of 9,250 adults aged 30-75 years was followed for 12-16 years, to determine all-cause and cause-specific mortality. Overall, between 1976 and 1980, the prevalence of diagnosed diabetes was 4.3%. By 1992, the relative hazard of all-cause mortality was 1.9 (95% confidence interval: 1.5, 2.3), and the population attributable risk (PAR) was 3.6%. The relative hazard of CVD mortality was 2.3 (95% confidence interval: 1.8, 2.8), and the PAR was 5.2%. Including participants with undiagnosed diabetes in the estimates increased the PAR for all-cause mortality to 5.1% and that for CVD mortality to 6.8%. Women had a higher prevalence of diagnosed diabetes than men and a greater relative hazard of death than nondiabetic women, leading to a higher PAR for women (3.8% for all causes and 7.3% for CVD) versus men (3.3% for all causes and 3.8% for CVD). These data suggest that diabetes accounts for at least 3.6% of all deaths and 5.2% of CVD deaths in U.S. adults. Improvements in diabetes prevention and treatment should produce noticeable effects on U.S. life expectancy.

Schenker N, Gentleman JF, Rose D, Hing E, Shimizu IM. Combining estimates from complementary surveys: A case study using prevalence estimates from national health surveys of households and nursing homes. 
Public Health Reports 2002 Jul-Aug;117(4):393-407. 

OBJECTIVES: When a single survey does not cover a domain of interest, estimates from two or more complementary surveys can be combined to extend coverage. The purposes of this article are to discuss and demonstrate the benefits of combining estimates from complementary surveys and to provide a catalog of the analytic issues involved. METHODS: The authors present a case study in which data from the National Health Interview Survey and the National Nursing Home Survey were combined to obtain prevalence estimates for several chronic health conditions for the years 1985, 1995, and 1997. The combined prevalences were estimated by ratio estimation, and the associated variances were estimated by Taylor linearization. The survey weights, stratification, and clustering were reflected in the estimation procedures. RESULTS:   In the case study, for the age group of 65 and older, the combined prevalence estimates for households and nursing homes are close to those for households alone. For the age group of 85 and older, however, the combined estimates are sometimes substantially different from the household estimates. Such differences are seen both for estimates within a single year and for estimates of trends across years. CONCLUSIONS: Several general issues regarding comparability arise when there is a goal of combining complementary survey data. As illustrated by this case study, combining estimates can be very useful for improving coverage and avoiding misleading conclusions.

Shepard CW, Soriano-Gabarro M, Zell ER, Hayslett J, Lukacs S, Goldstein S, Factor S, Jones J, Ridzon R, Williams I, Rosenstein N; CDC Adverse Events Working Group. Antimicrobial postexposure prophylaxis for anthrax: Adverse events and adherence.
Emerging Infectious Diseases 2002 Oct;8(10):1124-32.

We collected data during postexposure antimicrobial prophylaxis campaigns and from a prophylaxis program evaluation 60 days after start of antimicrobial prophylaxis involving persons from six U.S. sites where Bacillus anthracis exposures occurred. Adverse events associated with antimicrobial prophylaxis to prevent anthrax were commonly reported, but hospitalizations and serious adverse events as defined by Food and Drug Administration criteria were rare. Overall adherence during 60 days of antimicrobial prophylaxis was poor (44%), ranging from 21% of persons exposed in the Morgan postal facility in New York City to 64% of persons exposed at the Brentwood postal facility in Washington, D.C.  Adherence was highest among participants in an investigational new drug protocol to receive additional antibiotics with or without anthrax vaccine--a likely surrogate for anthrax risk perception. Adherence of less than 60 days was not consistently associated with adverse events.

Shimizu I, Lan F.
Approximation of variable costs for the National Health Interview Survey.
2001 Proceedings of the American Statistical Association, Survey Methods Research Section [CD-ROM], Alexandria, VA: American Statistical Association 2002.  

The National Center for Health Statistics is currently conducting sample redesign research for the National Health Interview Survey (NHIS), which is to be implemented in 2005.  A primary focus of the redesign research is on improving the reliability of population subdomain estimates.  Efficient sample designs require information on variable survey costs, which increase whenever the sample size increases.  This paper discusses the processes and data used to produce estimates of the annual variable costs for the NHIS, which can be used subsequently to evaluate alternative design options for the 2005-2014 NHIS.  Preliminary findings are discussed.

Spillman BC, Lubitz J. 
New estimates of lifetime nursing home use: Have patterns of use changed?
Medical Care 2002 Oct;40(10):965-75. 

OBJECTIVES: The elderly population at risk for costly nursing home care is increasing. It is important to understand patterns of lifetime nursing home use and their implications for public and private payers. We provide new lifetime nursing home use estimates, project future use, and discuss cost implications. METHODS: Data are next-of-kin reports of nursing home use for representative samples of decedents from the 1986 and 1993 National Mortality Followback Surveys. Future use is based on projected mortality from the Social Security Administration. RESULTS:   The proportion of elderly decedents who ever used a nursing home rose modestly between 1986 and 1993, with increased use before the last year of life. Rising longevity after age 65 and older the next 20 years will increase the risk for a 65 year old ever entering a nursing home to 46%. With increased survival to age 65, the number of 65-year-olds ultimately using nursing homes will double by 2020. CONCLUSIONS: Disability declines and changes in Medicare policy between 1986 and 1993 had little impact on overall patterns of nursing home use. Barring dramatic changes in health status or other factors, population aging will make nursing home costs a growing share of national health spending. More needs to be known about relationships between nursing home use and alternative care settings and the cost and quality implications of shifts from one setting to the other. A key issue is how constraints on Medicare SNF and home health benefits will affect use and the distribution of costs.

Stewart P, Rice C, Beatty P, Wilson B, Stewart W, Blair A.
A qualitative evaluation of questions and responses from five occupational questionnaires developed to assess exposures.
Applied Occupational and Environmental Hygiene 2002 Jun;17(6):444-53. 

Questionnaires are increasingly being used in the workplace to assess exposures to chemicals and other agents. Although the literature contains much information on questionnaire design in general, little information is available on the challenges related to questionnaires applied to the occupational setting. Questionnaires on dry cleaning workers, nurses, farmers, car mechanics, and truck drivers were administered to a total of 25 people currently performing one of these jobs. After asking each question, the interviewer probed to identify the difficulties the respondents had in answering the questions. Overall, the respondents were able to answer the questions. Problems were found, however, with particular questions that reduced the effectiveness of the questionnaire. These included the use of unclear terms, questions open to multiple interpretations, difficult computational requirements (e.g., asking for averages for highly variable tasks), ineffective transitions between topics, and overlapping response categories. This type of testing is a crucial part of questionnaire development and can be used to effectively identify potential problems with questions and, therefore, improve them to enhance collection of higher-quality data for assessments of occupational exposures.

Tarver-Carr ME, Powe NR, Eberhardt MS, LaVeist TA, Kington RS, Coresh J, Brancati FL. 
Excess risk of chronic kidney disease among African-American versus white subjects in the United States: A population-based study of potential explanatory factors.
Journal of the American Society of Nephrology 2002 Sep;13(9):2363-70. 

African Americans experience higher rates of chronic kidney disease (CKD) than do whites. It was hypothesized that racial differences in modifiable factors would account for much of the excess risk of CKD. A cohort study of 9,082 African-American and white adults 30 to 74 years of age, who participated in the Second National Health and Nutrition Examination Survey in 1976 to 1980 and were monitored for vital status through 1992 in the Second National Health and Nutrition Examination Survey Mortality Study, was conducted. Incident CKD was defined as treated CKD cases (ascertained by linkage to the Medicare Registry) and deaths related to kidney disease. The incidence of all-cause CKD was 2.7 times higher among African Americans, compared with whites. Adjustment for sociodemographic factors decreased the relative risk (RR) to 2.49, explaining 12% of the excess risk of CKD among African Americans. Further adjustment for lifestyle factors explained 24% of the excess risk, whereas adjustment for clinical factors alone explained 32%. Simultaneous adjustment for sociodemographic, lifestyle, and clinical factors attenuated the RR to 1.95 (95% confidence interval, 1.05 to 3.63), explaining 44% of the excess risk. Although the excess risk of CKD among African Americans was much greater among middle-age adults (30 to 59 years of age; RR = 4.23, statistically significant) than among older adults (60 to 74 years of age; RR = 1.27), indicating an interaction between race and age, the same patterns of explanatory factors were observed for the two age groups. Nearly one-half of the excess risk of CKD among African-American adults can be explained on the basis of potentially modifiable risk factors; however, much of the excess risk remains unexplained.

Van Dyck PC, McPherson M, Strickland BB, Nesseler K, Blumberg SJ, Cynamon ML, Newacheck PW. 
The national survey of children with special health care needs.
Ambulatory Pediatrics 2002 Jan-Feb;2(1):29-37.

CONTEXT: The Federal and State-level Children with Special Health Care Needs (CSHCN) programs are vested with the responsibility for planning and developing systems of care for children with special health care needs. To support achievement of this goal, the Federal Maternal and Child Health Bureau (MCHB), in partnership with the National Center for Health Statistics (NCHS), has developed a new survey that will provide uniform national and state data on the prevalence and impact of special health care needs among children. PURPOSE: The National Survey of CSHCN is designed to produce reliable state- and national-level estimates of the prevalence of special health care needs using MCHB's definition of CSHCN. It will also provide baseline estimates for Federal and State Title V Maternal and Child Health performance measures, for Healthy People 2010 national prevention objectives, and for each State's Title V needs assessment. In addition, it will provide a resource for researchers, advocacy groups, and other interested parties. It is anticipated that this survey will be repeated periodically, thereby making trend analysis possible. METHODS: This survey is being conducted using the State and Local Area Integrated Telephone Survey mechanism, which shares the random-digit-dial sampling frame of the National Immunization Survey (sponsored by the National Immunization Program and NCHS). Using the CSHCN Screener, developed under the auspices of the Foundation for Accountability, 750 children with special health care needs will be identified and selected from each State and from the District of Columbia. Parents or guardians of these children then complete a comprehensive battery of questions on demographics, health and functional status, health insurance coverage, adequacy of health insurance coverage, public program participation, access to care, utilization of health care services, care coordination, satisfaction with care, and the impact of the special need on the family. Data collection began in October 2000 and will continue through March 2002. Summary reports and electronic data files will be available to the public within 6 to 12 months following completion of data collection. CONCLUSIONS: The National Survey of CSHCN will offer a unique data source for individuals and organizations interested in understanding and improving service delivery for CSHCN. It is an accomplishment that reflects the contributions of State and Federal Title V programs, family organizations, provider organizations, health services researchers, and the broader maternal and child health community.

Vargas CM, Dye BA, Hayes KL. 
Oral health status of rural adults in the United States. 
Journal of the American Dental Association 2002 Dec;133(12):1672-81. 

BACKGROUND: Many sociodemographic indicators of oral health disparity in the United States have been documented. Rural residence, however, has not been researched thoroughly, though it has been considered to be a potential indicator of disparity. The authors conducted this study to present information on the effects of rural residence on oral health in the United States. METHODS: The authors conducted their analyses using data from adults aged 18 to 64 years from the 1995, 1997 and 1998 National Health Interview Surveys and the Third National Health and Nutritional Examination Survey, 1988-94. The authors present national estimates for various oral health status indicators including dental insurance coverage, unmet care needs, frequency of dental visits, caries experience and prevalence of edentulism by rural/urban residence. RESULTS:   The authors found that adults living in rural areas were more likely to report having unmet dental care needs and were less likely to have had a dental visit in the past year compared with adults living in urban areas. The prevalence of edentulism among rural adults was 16.3%-almost twice that of urban adults. Caries experience also was more likely to be greater among adults residing in rural areas. CONCLUSIONS: Oral health disparities exist among U.S. adults living in rural and urban areas. Compared with urban residents, rural residents were less likely to report a dental visit in the past year and were more likely to be edentulous. PRACTICE IMPLICATIONS: By understanding the rural/urban differences in adult oral health status, practitioners, policy-makers and rural health advocates will have better information to use to promote activities that better meet the needs of rural adults in the United States.