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OBJECTIVES: We examined characteristics and birth outcomes of Asian/Pacific Islander (API) mothers to determine whether differences in outcomes existed between mothers of single race/ethnicity and multiple race/ethnicity. METHODS: We used data from California and Hawaii birth certificates from 2003 through 2005 to describe variation in birth outcomes for API subgroups by self-reported maternal race/ethnicity (single versus multiple race or API subgroup), and we also compared these outcomes to those of non-Hispanic White women. RESULTS: Low birthweight (LBW) and preterm birth (PTB) varied more among API subgroups than between mothers of single versus multiple race/ethnicity. After adjustment for sociodemographic and behavioral risk factors, API mothers of multiple race/ethnicity had outcomes similar to mothers of single race/ethnicity, with exceptions for multiple-race/ethnicity Chinese (higher PTB), Filipino (lower LBW and PTB), and Thai (higher LBW) subgroups. Compared with single-race non-Hispanic Whites, adverse outcomes were elevated for most API subgroups: only single-race/ethnicity Korean mothers had lower rates of both LBW (3.4%) and PTB (5.6%); single-race/ethnicity Cambodian, Laotian, and Marshallese mothers had the highest rates of both LBW (8.8%, 9.2%, and 8.4%, respectively) and PTB (14.0%, 13.7%, and 18.8%, respectively). CONCLUSIONS: Strategies to improve birth outcomes for API mothers should consider variations in risk by API subgroup and multiple race/ethnicity. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study examined parental employment and health insurance coverage among children with and without special health care needs. Special needs were defined as conditions likely to require a high amount of parental care, potentially affecting parental employment. METHODS: Data from the 1994 National Health Interview Survey were analyzed for 21,415 children aged 5 to 17 years, including 1604 children with special needs. Logistic regression was used to estimate the effect of special needs on the odds of full-time parental employment and on the odds of a child's being uninsured, having Medicaid, or having employer-sponsored insurance. RESULTS: Parents of children with special needs had less full-time employment. Their children had lower odds of having employer-sponsored insurance (adjusted odds ratio [OR] = 0.7) than other children. Children with special needs had greater odds of Medicaid coverage (adjusted OR = 2.3-5.1, depending on family income). Children with and without special needs were equally likely to be uninsured. CONCLUSIONS: Lower full-time employment among parents of children with special needs contributes to the children's being less likely to have employer-sponsored health insurance. Medicaid covers many children with special needs, but many others remain uninsured. [ABSTRACT FROM AUTHOR]

This study investigates national changes between 1973-74 and 1985 in women's use of three preventive health services based on data from the National Health Interview Survey. Smoothed proportions of women with recent preventive care were estimated using weighted least squares for subgroups categorized by age (20-39, 40-59, 60-79), race (White, Black), income (poor, nonpoor), and year of interview. Older women and Black women experienced the largest increases in recent use of clinical breast examinations and Pap tests. Between 1973 and 1985 changes in recent breast examination ranged from zero for White women ages 20-39 years to a 23 percentage point increase (95% CI = 17,30) for Black women ages 60-79 years. A similar pattern was found for Pap testing. Changes between 1974 and 1985 in recent blood pressure testing ranged from zero for women ages 20-39 years to an 8 percentage point increase (95% CI = 6,10) for women ages 60-79 years. Despite the increases among older women, in 1985 recent use of breast exams and Pap tests remained lower among older women. Further, the poor remained less likely than the nonpoor to have recent preventive care (except blood pressure testing among older women). Most women without recent cancer screening tests had a recent physician contact, highlighting the need for greater emphasis on cancer prevention by health care providers. [ABSTRACT FROM AUTHOR]

Many reports present analyses of trends over time based on multiple years of data from National Center for Health Statistics (NCHS) surveys and the National Vital Statistics System (NVSS). Trend analyses of NCHS data involve analytic choices that can lead to different conclusions about the trends. This report discusses issues that should be considered when conducting a time trend analysis using NCHS data and presents guidelines for making trend analysis choices. Trend analysis issues discussed include: choosing the observed time points to include in the analysis, considerations for survey data and vital records data (record level and aggregated), a general approach for conducting trend analyses, assorted other analytic issues, and joinpoint regression. This report provides 12 guidelines for trend analyses, examples of analyses using NCHS survey and vital records data, statistical details for some analysis issues, and SAS and SUDAAN code for specification of joinpoint regression models. Several an lytic choices must be made during the course of a trend analysis, and the choices made can affect the results. This report highlights the strengths and limitations of different choices and presents guidelines for making some of these choices. While this report focuses on time trend analyses, the issues discussed and guidelines presented are applicable to trend analyses involving other ordinal and interval variables., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Background: National Health and Nutrition Examination Survey (NHANES) records have been linked to health care use and expenditure information from Medicare records. Claims data are generally available only for traditional fee-for-service (FFS) enrollees and not for Medicare Advantage enrollees. Differences in health characteristics between Medicare Advantage and traditional FFS enrollees could affect conclusions from analyses of the linked files that are restricted to traditional FFS enrollees., Methods: Data from the 1999-2004 NHANES linked to the 2007 Medicare enrollment data were analyzed. Using examination and interview data collected in NHANES, we compared health characteristics of Medicare beneficiaries aged 65 and over at the NHANES interview by their type of Medicare enrollment in 2007., Results: We found that the overall percentage of Medicare beneficiaries who had hypertension at the time of the NHANES medical examination was lower for Medicare Advantage enrollees compared with traditional FFS enrollees; this was found for the non-Hispanic white population but not for other race and ethnicity groups. We found no statistically significant differences between Medicare Advantage and traditional FFS enrollees overall or within race and ethnicity groups for other health characteristics that were measured or reported at the time of the NHANES interview or medical examination in 1999-2004., Conclusions: Despite finding no large differences in health characteristics by Medicare enrollment in this analysis, users of the National Center for Health Statistics Medicare linked files should consider potential differences in health characteristics between Medicare Advantage and traditional FFS enrollees that could influence results limited to traditional FFS beneficiaries only.

In 2008, the number of poisoning deaths exceeded the number of motor vehicle traffic deaths and was the leading cause of injury death for the fi rst time since at least 1980. During the past three decades, the poisoning death rate nearly tripled, while the motor vehicle traffic death rate decreased by one-half. During this period, the percentage of poisoning deaths that were caused by drugs increased from about 60% to about 90%. The population groups with the highest drug poisoning death rates in 2008 were males, people aged 45–54 years, and non-Hispanic white and American Indian or Alaska Native persons. The vast majority of drug poisoning deaths are unintentional (see Appendix table). Opioid analgesics were involved in more drug poisoning deaths than other specified drugs, including heroin and cocaine. Opioid analgesics were involved in nearly 15,000 deaths in 2008, while cocaine was involved in about 5,100 deaths and heroin was involved in about 3,000 deaths (data not shown). Deaths involving opioid analgesics may involve other drugs as well, including benzodiazepines (2). In addition to an increase in the number of deaths caused by drug poisoning, increases in drug use, abuse, misuse, and nonfatal health outcomes have been observed. In the past two decades, there has been an increase in the distribution and medical use of prescription drugs, including opioid analgesics (3). From 1999 to 2008, the use of prescription medications increased (4). In 2007–2008, 48% of Americans used at least one prescription drug in the past month and 11% of Americans used five or more prescriptions in the past month. Analgesics for pain relief were among the common drugs taken by adults aged 20–59 years (4). In 2009–2010, over 5 million Americans reported using prescription pain relievers nonmedically in the past month (that is, without a doctor’s prescription or only for the experience or feeling they caused), and the majority of people using prescription pain relievers nonmedically reported getting the drugs from friends or family (5,6). From 2004 to 2008, the estimated rate of emergency department visits involving nonmedical use of opioid analgesics doubled from 49 per 100,000 to 101 per 100,000 (7). Government agencies and other organizations joined together to achieve great reductions in the number of deaths from motor vehicle crashes in the past three decades (8,9). A comprehensive approach, including improvements in the safety of vehicles; improvements in roadways; increased use of restraint systems, such as seat belts and child safety seats; reductions in speed; and also efforts to reduce driving under the influence of alcohol and drugs, contributed to the decline in motor vehicle related deaths (8,9). Using a comprehensive, multifaceted approach, it may be possible to reverse the trend in drug poisoning mortality., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Lack of health insurance presents a barrier to obtaining routine preventive care and early diagnosis and management of chronic conditions. In 2005-2008, approximately 23% of adults aged 20-64 had no health insurance. Hypercholesterolemia (high total cholesterol or taking medication to lower cholesterol) and hypertension (high blood pressure or taking medication to lower blood pressure) are major risk factors for cardiovascular disease, particularly when untreated and uncontrolled and are common among nonelderly adults. In 2005-2008, 23% of adults aged 20-64 had hypercholesterolemia and 23% had hypertension. The objective of this report is to quantify the association between health insurance coverage and the diagnosis and control of hypercholesterolemia and hypertension among persons with those conditions. The criteria used to define these conditions are provided in the "Definitions" section of the report., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Key Findings: Data from the National Vital Statistics System Mortality File. From 1999 through 2006, the number of fatal poisonings involving opioid analgesics more than tripled from 4,000 to 13,800 deaths. Opioid analgesics were involved in almost 40% of all poisoning deaths in 2006. In 2006, the rate of poisoning deaths involving opioid analgesics was higher for males, persons aged 35-54 years, and non-Hispanic white persons than for females and those in other age and racial/ethnic groups. In about one-half of the deaths involving opioid analgesics, more than one type of drug was specified as contributing to the death, with benzodiazepines specified with opioid analgesics most frequently. The age-adjusted death rate for poisoning involving opioid analgesics varied more than eightfold among the states in 2006., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Objectives: This report presents long-term trends in the number and percentage of persons under age 65 years with different types of health insurance coverage and with no coverage. It documents changes in how the National Health Interview Survey (NHIS) has collected information about coverage over almost 50 years. It also compares recent trends in coverage estimates based on the NHIS and the U.S. Census Bureau's Current Population Survey (CPS)., Methods: Estimates were derived from 32 years of the NHIS, from 1959 to 2007. The types of estimates available differ over these years, reflecting changes in the availability of different types of coverage and changes in the NHIS questions. Joinpoint regression was used to estimate average annual percent change over time and to identify statistically significant changes in trends., Results: The percentage of persons under age 65 years with private coverage rose between 1959 and 1968, to 79%, remained stable until 1980, and then declined to 67% by 2007. During the 1980s, the percentage of persons with no coverage increased, while the percentage with private coverage declined and the percentage with Medicaid remained stable. Since 1990, the percentage of nonelderly persons without coverage has remained stable, but the number has increased by more than 6 million persons, to 43.3 million in 2007. During this period, the percentage with private coverage has continued to decline, while the percentage with Medicaid has increased. Recent trends in coverage based on the NHIS and CPS are similar.

Objectives: This report presents state, regional, and national estimates of the percentages of persons under 65 years of age who were uninsured, who had private health insurance coverage, and who had Medicaid or State Children's Health Insurance Program (SCHIP) coverage., Methods: The estimates were derived from the Family Core component of the 2004-2006 National Health Interview Survey (NHIS). Three years of data were combined to increase the reliability of estimates. Regional and national estimates are based on data from all 50 states and the District of Columbia. State estimates are shown for the 41 states with at least 1000 NHIS respondents during 2004-2006. Differences between national and subnational estimates were tested for statistical significance to identify those regions and states that differ significantly from the U.S. overall., Results: The results show that the percentage of persons under age 65 who lacked any insurance coverage at a point in time varied by 20 percentage points among the states. Almost all states that were significantly higher than the U.S. rate on the percentage uninsured were significantly lower than the U.S. rate on the percentage with private coverage and vice versa.

Objectives: We sought to establish national data on the prevalence of visual impairment, blindness, and selected eye conditions (cataract, diabetic retinopathy, glaucoma, and macular degeneration) and to characterize these conditions within sociodemographic subgroups., Methods: Information on self-reported visual impairment and diagnosed eye diseases was collected from 31,044 adults. We calculated weighted prevalence estimates and odds ratios with logistic regression using SUDAAN., Results: Among noninstitutionalized US adults 18 years and older, the estimated prevalence for visual impairment was 9.3% (19.1 million Americans), including 0.3% (0.7 million) with blindness. Lifetime prevalence of diagnosed diseases was as follows: cataract, 8.6% (17 million); glaucoma, 2.0% (4 million); macular degeneration, 1.1% (2 million); and diabetic retinopathy, 0.7% (1.3 million). The prevalence of diabetic retinopathy among persons with diagnosed diabetes was 9.9%., Conclusions: We present the most recently available national data on self-reported visual impairment and selected eye diseases in the United States. The results of this study provide a baseline for future public health initiatives relating to visual impairment.

Objective: This study investigates how out-of-pocket payments for mammograms vary according to the characteristics of women and the states where they reside., Methods: We conducted a cross-sectional analysis for women >or=40 years using data from the 2000 National Health Interview Survey (NHIS) Cancer Control Module linked with state characteristics. Descriptive tabulations and logistic regressions were used to examine characteristics associated with out-of-pocket payment for a woman's most recent mammogram for the subset of approximately 7000 women reporting a mammogram within the past 2 years., Results: In 2000, the majority of women who received a mammogram within the past 2 years paid no out-of-pocket costs: 68% among those aged 40-64 and 85% among those aged >or=66. Among women aged 40-64 with a recent mammogram, characteristics associated with paying out-of-pocket for the last mammogram were white, non-Hispanic race/ethnicity, being uninsured, having non-HMO private coverage, place of residence outside the Northeast, in a non-metropolitan county, and in a state with low HMO penetration., Conclusions: Public insurance and HMO coverage have been especially effective in eliminating financial barriers to mammography, but women 40-64 years with public coverage still lag behind their privately insured counterparts in using mammography. Out-of-pocket costs remain a barrier to use for uninsured women. Older women, although less likely than younger women to pay out-of-pocket for mammograms, remain less likely to use mammography than younger women.

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.

Objective: To examine the impact of family structure on the relationship between parental employment characteristics and employer-sponsored health insurance coverage among children with employed parents in the United States., Methods: National Health Interview Survey data for 1993-1995 was used to estimate proportions of children without employer-sponsored health insurance, by family structure, separately according to maternal and paternal employment characteristics. In addition, relative odds of being without employer-sponsored insurance were estimated, controlling for family structure and child's age, race, and poverty status., Results: Children with 2 employed parents were more likely to have employer-sponsored health insurance coverage than children with 1 employed parent, even among children in 2-parent families. However, among children with employed parents, the percentage with employer-sponsored health insurance coverage varied widely, depending on the hours worked, employment sector, occupation, industry, and firm size., Conclusions: Employer-sponsored health insurance coverage for children is extremely variable, depending on employment characteristics and marital status of the parents.

We estimate that 17% of Medicaid-eligible children in the United States are uninsured, with 27% covered by private insurance. Uninsured children have become a target for state outreach and enrollment efforts. However, the effort may not be a worthwhile use of resources if these children have sufficient access to primary care and are able to enroll in Medicaid should serious health problems arise. This analysis of health status, access to care, and use of preventive and other services suggests otherwise. Although the uninsured Medicaid-eligible children are slightly healthier than their enrolled counterparts, they face reduced access to care and lower rates of service use. After controlling for health status and other characteristics, we find that being uninsured increases the likelihood of being without a usual source of care by eight percentage points, and increases reporting of unmet needs by seven percentage points. Being uninsured also decreases by nine percentage points the proportion of children with any health provider visits, and increases by 12 percentage points the proportion with family out-of-pocket expenses exceeding $500. These findings lend support to the hypothesis that the enrollment process is onerous for some families. Targeted efforts to enroll uninsured Medicaid-eligible children could help in reducing the effect of barriers and reducing differences in access to care.

Objective: To describe national trends in mammography use by race and income and to test whether higher use of mammography among low-income African American women than low-income white women can be explained by health insurance coverage, usual place of health care, or place of residence., Data Sources/study Setting: Data from five years of the National Health Interview Survey spanning the period 1987-1994., Study Design: Trends in the percentage of women 50-64 years of age with a mammogram within the past two years were analyzed by race and income. Data for 1993-1994 were pooled, and with logistic regression analysis, variation in use of recent mammography for low-income women was investigated. Independent variables are age, race, family income, education, health insurance coverage, place of usual source of health care, metropolitan residence, and geographic region., Data Collection/extraction Methods: The National Health Interview Survey is a cross-sectional national survey conducted by the National Center for Health Statistics. Data are collected through household interviews. [Editor's note: in keeping with HSR policy, the term black is used to conform to its use in the surveys studied. In other references to race, the term African American is used.], Principal Findings: Among women 50-64 years of age use of recent mammograms increased rapidly between 1987 and 1991 for all groups of women, and between 1991 and 1994 the increases slowed. However, increases between 1991 and 1994 have been more rapid among low-income black women than among low-income white women. In 1993-1994, low-income black women were about one-third more likely than low-income white women to report mammography within the past two years. This difference could not be explained by health insurance coverage, usual source of health care, metropolitan status, or region of residence., Conclusions: These results, which provide some evidence of success for screening programs targeted to the poor, raise the question of why low-income black women appear to be to more likely than low-income white women to have benefited from recent efforts to promote mammography. Continued evaluation of mammography programs focused on women who are underserved as well as the monitoring of trends and variations in service use by race and income are needed.

Objectives: This report presents national estimates of ambulatory health care use by children under 15 years of age according to principal diagnosis, place of visit (physician office, hospital outpatient department, and hospital emergency department), and patient characteristics (age, sex, and race)., Methods: Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Data were from 1993-95., Results: In 1993-95 children under 15 years of age made 165.3 million visits per year (289 visits per 100 children). Visit rates were highest among infants and varied inversely with age. Visit rates were 43 percent higher among white children than black children. Three-quarters of ambulatory visits occurred in physician offices, 8 percent in hospital outpatient departments, and 14 percent in hospital emergency departments. Visits by white children were more likely to occur in physician offices than visits by black children (81 percent and 54 percent). Conversely, visits by black children were more likely to occur in hospital outpatient departments (19 percent and 7 percent) and hospital emergency departments (28 percent and 12 percent) than visits by white children. The following principal diagnoses accounted for almost 40 percent of visits: well-child visit, 15 percent; middle ear infection, 12 percent; and injury, 10 percent. Rates for well-child visits were almost 80 percent higher among white infants than black infants. Continued monitoring of these differences in use of ambulatory care among children are needed, particularly in view of the possible impact of changes in the health care system on these differences.

Several studies have examined relatively large body iron stores and the risk of coronary heart disease with conflicting results. No reports of studies that associated body iron stores with stroke were found. To test the hypothesis that relatively high transferrin saturation is associated with increased stroke incidence and mortality in women and men, data from a follow-up study of a national cohort were examined. A total of 5,033 women and men aged 45-74 years from the First National Health and Nutrition Examination Survey Epidemiologic Followup Study who were free of stroke at baseline were followed an average of 12 years. Transferrin saturation (serum iron concentration divided by total iron binding capacity) was used as a measure of the amount of circulating iron available to tissues. In white women aged 45-74, after adjusting for age or for age and other risk variables, the authors observed a significant U-shaped association of transferrin saturation with risk of incident stroke (> 44% vs. 30-36%, relative risk = 1.96, 95% confidence interval 1.15-3.36; < 20% vs. 30-36%, relative risk = 1.80, 95% confidence interval 1.20-2.71). However, no significant associations were found in white men aged 45-74 after adjusting for other risk variables. Similar findings were observed for stroke mortality in whites, but no significant associations were seen in blacks. The significantly increased risk of stroke that was seen at both high and low levels of transferrin saturation in white women should be confirmed in other cohorts of women and men.

Erythrocyte sedimentation rate (ESR) is a simple and relatively inexpensive laboratory test. Data were examined to determine whether elevated ESR was a predictor of CHD incidence and death in a large U.S. national sample of persons aged 45-74 at baseline. In the NHANES I Epidemiologic Follow-up Study cohort, white men aged 45-64 years with ESR in the upper quintile at baseline had increased incidence of CHD (RR = 1.73, 95% CL 1.12, 2.68) over a 15 year follow-up after controlling multiple risk factors compared to white men with ESR in the lowest quintile. Furthermore, men aged 45-64 with ESR in the upper quintile had more than twice the risk of CHD death (RR = 2.73, 95% CL 1.21, 6.15) of men with ESR in the lowest quintile after adjusting other risk factors. No significant associations were seen in white women. The mechanism of this association is unclear. Further studies are needed to replicate this finding and elucidate the mechanism for this association in longitudinal studies in which plasma fibrinogen, HDL cholesterol, as well as ESR are measured.

Relatively high serum albumin levels have been associated with reduced cardiovascular mortality and coronary heart disease incidence. No prospective studies have examined serum albumin and stroke mortality and incidence. Therefore, data from the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study were examined to assess serum albumin level as a risk factor for stroke. White men aged 65-74 years with serum albumin concentrations of > 4.4 g/dl had a risk of stroke incidence over a follow-up period of 9-16 years of only about two-thirds that of men with serum albumin concentrations of < 4.2 g/dl. This effect persisted after controlling for multiple stroke risk variables (relative risk = 0.61, 95% confidence interval 0.41-0.89). A similar association with stroke death was found in white men aged 65-74 years. Serum albumin was not associated with stroke risk in white women aged 65-74 years. In blacks aged 45-74 years, serum albumin concentrations of > 4.4 g/dl were associated with a risk of stroke incidence only one-half and a risk of stroke death only one-fourth that seen at levels < 4.2 g/dl after controlling other risk variables. Further studies are needed to confirm these findings and to elucidate mechanisms for the effect of serum albumin on stroke incidence and death.

A 1982 report (J Chronic Dis 1982;35:703-14) that a relatively high white blood cell (WBC) count predicted increased incidence of cerebral thrombosis could not establish whether this association was independent of smoking. Therefore, the authors examined data from the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, conducted in 1971-1987, to assess WBC count as a risk factor for stroke in a sample of the US population. White men with a WBC count of > 8,100 cells/mm3 had a 39% increase in age-adjusted stroke incidence compared with those with a WBC count of < 6,600 cells/mm3. However, controlling for cigarette smoking reduced the association and rendered it statistically nonsignificant (relative risk = 1.26, 95% confidence interval 0.93-1.70). No significant associations of WBC count with stroke incidence were seen in white women or in blacks. In white men, elevated WBC count may be a mediator of cardiovascular effects of smoking, an indicator of smoking exposure, or both. Further studies are needed to confirm these findings and to elucidate mechanisms for the effect of smoking and WBC count on stroke incidence and death.

This report presents alternative strategies for analysis of data from the NHANES I Epidemiologic Followup Study (NHEFS) using Cox proportional hazards and person-time logistic regression models. Analytic issues related to the complex survey design of the NHANES I and the variable length of followup of NHEFS participants are discussed.

Background: Recent studies have suggested an association between higher body iron stores and the risk of coronary heart disease. To assess these findings, we examined the association between transferrin saturation and the risk of coronary heart disease, myocardial infarction, overall mortality, and mortality from cardiovascular causes in a large population., Methods: We studied a total of 4518 men and women from the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, using a multivariate Cox proportional-hazards model. Base-line data were collected from 1971 to 1974, with follow-up through 1987. Transferrin saturation (serum iron concentration divided by total iron-binding capacity) was used as a measure of the amount of circulating iron available to tissues., Results: The risk of coronary heart disease was not related to transferrin-saturation levels in white men or women. Estimates of the relative risk of coronary heart disease for the fifth quintile of transferrin saturation as compared with the first quintile were 0.72 (95 percent confidence interval, 0.51 to 1.00) for men and 0.85 (95 percent confidence interval, 0.60 to 1.21) for women. The results were similar for myocardial infarction. A significant inverse association with transferrin saturation was found for overall mortality and for mortality from cardiovascular causes in white men and women. Transferrin saturation was not associated with any of the clinical outcomes in blacks, possibly owing to the small sample., Conclusions: Higher transferrin-saturation levels were not associated with an increased risk of coronary heart disease or myocardial infarction. On the contrary, the results indicate that there may be an inverse association of iron stores with overall mortality and with mortality from cardiovascular causes.

Little is known about the relation of overweight to risk of coronary heart disease in older women. In this paper, the authors used measured weight for 1,259 white women aged 65-74 years from the Epidemiologic Follow-up Study of the First National Health and Nutrition Examination Survey to examine the effect of overweight on coronary heart disease incidence (mean length of follow-up, 14 years). They also used reported lifetime maximum weight to examine the effect of weight loss on this association. Women with a Quetelet index (weight (kg)/height (m)2) of 29 or more showed an increased risk of coronary heart disease (relative risk (RR) = 1.5, 95% confidence interval (CI) 1.1-2.1) after adjustment for age and smoking in comparison with those with a Quetelet index of less than 21, while women with a Quetelet index of 23-24 had a lower risk of coronary heart disease (RR = 0.6, 95% CI 0.4-0.9). However, the pattern of risk associated with measured weight was modified by weight loss. Among heavier women whose weight was relatively stable, those with a Quetelet index of 29 or more had an increased risk of heart disease (RR = 2.7, 95% CI 1.7-4.4). Among those with greater weight loss, the relation between Quetelet index and risk of coronary heart disease was J-shaped. Overweight is an independent risk factor for coronary heart disease in older women, a finding strengthened after previous weight loss is accounted for. Reasons for the unexpected increase in risk of coronary heart disease in thinner women who lost weight are unclear, and further investigation is warranted.

To confirm the reported association of elevated WBC count with increased risk of CHD incidence and death in white men and to determine whether such associations exist for CHD incidence and death in women and blacks, data were examined from the NHANES I Epidemiologic Follow-up Study. Over a follow-up period of 7 to 16 years, WBC counts > 8100 cells/mm3 compared with WBC counts < 6600 cells/mm3 were associated with increased risk of CHD incidence in white men (RR = 1.31; 95% CL 1.07, 1.61) and in white women (RR = 1.31; 1.05, 1.63) aged 45 to 74 after adjustment for baseline risk factors. The association was found in white female but not in white male subjects who had never smoked. Increases in risk of death from all causes, cardiovascular diseases, and noncardiovascular diseases were also seen in all white men in the sample. RRs for death for all causes at ages 45 to 74, which compared the upper and lower strata of WBC counts, were 1.43 (95% CL 1.22, 1.68) in all white men and 1.33 (95% CL 1.00, 1.78) in subjects who had never smoked after adjustment for baseline risk factors. Similar increases in risk of death from all causes were seen in blacks aged 45 to 64 despite small sample size. Thus this analysis failed to clearly establish an increased risk of CHD incidence in white men with relatively elevated WBC counts who never smoked cigarettes, although such an association was evident in white women. The increased risk of death from all causes in men appeared to be only partially due to effects of smoking.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of low serum cholesterol and mortality was examined in data from the NHANES I Epidemiologic Followup Study (NHEFS) for 10,295 persons aged 35-74, 5833 women with 1281 deaths and 4462 men with 1748 deaths (mean (followup = 14.1 years). Serum cholesterol below 4.1 mmol/l was associated with increased risk of death in comparison with serum cholesterol of 4.1-5.1 mmol/l (relative risk (RR) for women = 1.7, 95% confidence interval (CI) = (1.2, 2.3); for men RR = 1.4, CI = (1.1, 1.7)). However, the low serum cholesterol-mortality relationship was modified by time, age, and among older persons, activity level. The low serum cholesterol-mortality association was strongest in the first 10 years of followup. Moreover, this relationship occurred primarily among older persons (RR for low serum cholesterol for women 35-59 = 1.0 (0.6, 1.8), for women 70-74, RR = 2.1 (1.2, 3.7); RR for low serum cholesterol for men 35-59 = 1.2 (0.8, 2.0), for men 70-74, RR = 1.9 (1.3, 2.7)). Among older persons, however, the low serum cholesterol-mortality association was confined only to those with low activity at baseline. Factors related to underlying health status, rather than a mortality-enhancing effect of low cholesterol, likely accounts for the excess risk of death among persons with low cholesterol. The observed low cholesterol-mortality association therefore should not discourage public health programs directed at lowering serum cholesterol.

To confirm a reported association between elevated serum albumin concentrations and reduced risk of death in middle-aged white men and to determine whether such associations exist for CHD incidence in white men and CHD and death in white women and black men and women, data were examined from the NHANES I Epidemiologic Follow-up Study. Over a follow-up period of 9 to 16 years, serum albumin concentrations of 4.5 gm/dl or more were associated with reduced risk of CHD incidence in white men aged 45 to 64 years (RR = 0.51; 95% CL = 0.36, 0.73) and in white women aged 45 to 74 years (RR = 0.70; 95% CL = 0.55, 0.88), independent of baseline risk factors. Independent reductions in risk of death from all causes, cardiovascular diseases, and noncardiovascular diseases were also seen in white men and women. Relative risk of death from all causes at ages 45 to 74 years in the white population was 0.73 (95% CL = 0.62, 0.85) for men and 0.71 (95% CL = 0.59, 0.85) for women. Similar reductions in risk of death from all causes and cardiovascular diseases were seen in black men and women, despite the small numbers. Further studies are needed to confirm these findings for women and black persons and to elucidate mechanisms for the effect of serum albumin.

The relationship between cholesterol and 14-year incidence of coronary heart disease was compared for men and women of two age groups, 25 to 64 years and 65 to 74 years. While cholesterol levels of 6.2 mmol/L or higher were associated with a risk of coronary heart disease in the younger group, this was not true for either men or women aged 65 to 74. Further analyses for older persons showed that weight loss modified the cholesterol-heart disease relationship. Those with stable weight showed a positive relationship between cholesterol and coronary heart disease, similar to the younger age group (relative risk [RR] = 1.8 [95% confidence interval: 1.1, 2.9] for men; RR = 1.6 [.7, 3.4] for women). Among those with a weight loss of 10% or more, the relationship of cholesterol to heart disease was inverse (RR = .8 [.5, 1.2] for men; RR = .6 [.3, 1.0] for women). These data suggest that the relationship of cholesterol to coronary disease in healthier older persons may be similar to that in younger persons, and that health status should be considered in analyses of cholesterol risk in old age.

The objectives of this report are to document methods used to identify health service areas for the United States and to describe and evaluate these areas. A health service area is defined as one or more counties that are relatively self-contained with respect to the provision of routine hospital care. Service areas that include more than one county are characterized by travel between the counties for routine hospital care.

Although coronary heart disease remains a leading cause of death and disability in old age, the relationship of serum cholesterol level to risk of coronary heart disease in old age is controversial. Data for 2,388 white persons aged 65-74 who participated in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (NHEFS) were examined to determine the relationship of serum cholesterol level to coronary heart disease incidence and whether activity level would modify this relationship. While there was no overall relationship between serum cholesterol level and coronary heart disease risk in either men or women, the relationship between serum cholesterol level and coronary heart disease differed within activity groups. For persons who were more active, serum cholesterol level was associated with a graded increase in risk of coronary heart disease, from 1.3 (95% CI 0.7, 2.3) in those with serum cholesterol level of 4.7-5.1 to 1.7 in those with serum cholesterol level of 6.2 mmol/L or more (95% CI 1.0, 2.7), when compared with those with serum cholesterol level below 4.7. For the least active persons, all levels of cholesterol were associated with a significant inverse relative risk, including cholesterol of 6.2 mmol/L or more (Relative risk = 0.4 (95% CI 0.2, 0.7]. These data suggest that factors such as activity level may modify the serum cholesterol-coronary heart disease association in old age. The serum cholesterol-coronary heart disease association in more active older persons resembles that seen in younger populations, whereas the association in less active persons is that of serum cholesterol level and risk of cancer or death. The modification of the serum cholesterol-coronary heart disease association by activity level may have implications for appropriate clinical management as well as appropriate design of research studies of this association.

To determine whether associations of elevated resting pulse rate with CHD incidence or death in white men are independent of other risk factors and whether such associations exist for women and blacks, data were examined from the NHANES I Epidemiologic Follow-up Study. Over a follow-up period of 6 to 13 years, elevated RR for CHD incidence were found for older white men with baseline pulse greater than 84 beats/min compared with less than 74 beats/min after controlling multiple risk factors (RR = 1.37, 95% CL 1.02, 1.84). Risks of death from all causes, cardiovascular diseases, and noncardiovascular diseases were also elevated for white men with elevated pulse rate independent of other risk factors. CHD incidence was increased in white women with elevated pulse rate. Risks of death from all causes, cardiovascular diseases, and noncardiovascular diseases, were also elevated for white men with elevated pulse rate independent of other risk factors. CHD incidence was increased in white women with elevated pulse rate. Risk of death from all causes and cardiovascular diseases was elevated in black men and women with elevated pulse rate. Risk of death from noncardiovascular disease was elevated in black men with elevated pulse rate. The association with cardiovascular death was particularly striking in black women, even after adjusting for baseline risk factors (RR 3.03, 95% CL 1.46, 6.28). Further studies are needed to assess associations of pulse rate with CHD in blacks and to elucidate mechanisms in all groups.

Measurement of the availability of health care providers in a geographic area is a useful component in assessing access to health care. One of the problems associated with the county provider-to-population ratio as a measure of availability is that patients frequently travel outside their counties of residence for health care, especially those residing in nonmetropolitan counties. Thus, in measuring the number of providers per capita, it is important that the geographic unit of analysis be a health service area. We have defined health care service areas for the coterminous United States, based on 1988 Medicare data on travel patterns between counties for routine hospital care. We used hierarchical cluster analysis to group counties into 802 service areas. More than one half of the service areas include only nonmetropolitan counties. The service areas vary substantially in the availability of health care resources as measured by physicians and hospital beds per 100,000 population. For almost all of the service areas, the majority of hospital stays by area residents occur within the service area. In contrast, for 39 percent of counties, the majority of hospital stays by county residents occur outside the county. Thus, the service areas are a more appropriate geographic unit than the county for measuring the availability of health care.

The authors examined national changes in socioeconomic differentials in mortality for middle-aged and older white men and women in the United States with the use of 1960 data from the Matched Records Study and 1971-1984 data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (NHEFS). In 1960, there was little difference in mortality by educational level among middle-aged and older men. Since 1960, death rates among men declined more rapidly for the more educated than the less educated, which resulted in substantial educational differentials in mortality in 1971-1984. In contrast, among women, death rates declined at about the same rate regardless of educational attainment, so that a strong inverse relation between education and mortality in 1960 remained about the same magnitude during 1971-1984. Trends in educational differentials for heart disease mortality are responsible for much of the change for all causes of death. Relative risk estimates based on the NHEFS indicate that after taking into account selected baseline risk factors the least educated are still at substantially elevated risk of death from heart disease, ranging from a relative risk of 1.38 for men aged 65-74 years at baseline to 2.27 for men aged 45-64 years. Reasons for the observed educational differentials and their changes over time are not easily explained and are likely to be multifactorial.