Disparities in health care utilization by smoking status--NHANES 1999-2004.

The objective of this study was to assess disparities in health care utilization, by smoking status, among adults in the United States. We used 1999-2004 National Health and Nutrition Examination Survey (NHANES) data from 15,332 adults. Multivariate logistic regressions were used to examine the relationship between smoking status (current, former, and never smoker), with health care utilization. After controlling for demographic characteristics, current smokers and former smokers who quit either <2 years or > or =10 years prior to the survey were more likely to have had inpatient admission in the past year than never smokers. Current smokers did not differ from never smokers on whether they had an outpatient visit in the past year. They were, however, more likely than never smokers to have > or =4 outpatient visits. Smokers who quit either <2 years ago or > or =10 years ago were more likely to have had an outpatient visit than never smokers. Former smokers were more likely than never smokers to have > or =4 outpatient visits regardless of when they quit. Our results show that cigarette smoking is associated with higher health care utilization for current and former smokers than for never smokers. Frequent hospitalization and outpatient visits translate into higher medical costs. Therefore, more efforts are needed to promote interventions that discourage smoking initiation and encourage cessation.

State-level prevalence of cigarette smoking and treatment advice, by disability status, United States, 2004.

INTRODUCTION: To our knowledge, no study has determined whether smoking prevalence is higher among people with disabilities than among people without disabilities across all U.S. states. Neither do we know whether people with disabilities and people without disabilities receive the same quality of advice about tobacco-cessation treatment from medical providers. METHODS: We analyzed data from the 2004 Behavioral Risk Factor Surveillance System to estimate differences between people with and people without disabilities in smoking prevalence and the receipt of tobacco-cessation treatment advice from medical providers. RESULTS: We found that smoking prevalence for people with disabilities was approximately 50% higher than for people without disabilities. Smokers with disabilities were more likely than smokers without disabilities to have visited a medical provider at least once in the previous 12 months and to have received medical advice to quit. More than 40% of smokers with disabilities who were advised to quit, however, reported not being told about the types of tobacco-cessation treatment available. CONCLUSION: Ensuring that people with disabilities are included in state-based smoking cessation programs gives states an opportunity to eliminate health disparities and to improve the health and wellness of this group. Ways to reduce unmet preventive health care needs of people with disabilities include provider adoption of the Public Health Service's clinical practice guideline for treating tobacco use and dependence and the provision of smoking cessation services that include counseling and effective pharmaceutical treatment.

Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National Immunization Survey.

OBJECTIVE: In the third quarter of 2001, the National Immunization Survey (NIS) began collecting data on the initiation and duration of breastfeeding and whether it was the exclusive method of infant feeding. Using the data from the 2002 NIS, this study estimates breastfeeding rates in the United States by characteristics of the child, mother, or family. METHODS: The NIS uses random-digit dialing to survey households nationwide with children 19 to 35 months old about vaccinations and then validates the information through a mail survey of the health care providers who gave the vaccinations. In 2002, approximately 3500 households from the NIS were randomized to 1 of the 3 rotating topical modules that covered breastfeeding. RESULTS: More than two thirds (71.4%) of the children had ever been breastfed. At 3 months, 42.5% of infants were exclusively breastfed, and 51.5% were breastfed to some extent. At 6 months, these rates dropped to 13.3% and 35.1%, respectively. At 1 year, 16.1% of infants were receiving some breast milk. Non-Hispanic black children had the lowest breastfeeding rates. Breastfeeding rates also varied by participation in day care or the Women, Infants, and Children program, socioeconomic status, and geographic area of residence. CONCLUSIONS: Although the rate of breastfeeding initiation in the United States is near the national goal of 75%, at 6 and 12 months postpartum the rates of breastfeeding duration are still considerably below the national goals of 50% and 25%, respectively. In addition, rates of exclusive breastfeeding are low. Strenuous public health efforts are needed to improve breastfeeding behaviors, particularly among non-Hispanic black women and socioeconomically disadvantaged groups.

Underimmunization among children: effects of vaccine safety concerns on immunization status.

OBJECTIVE: To examine the attitudes, beliefs, and behaviors of parents whose children were underimmunized with respect to > or =2 vaccines that have recently received negative attention, compared with parents whose children were fully immunized with respect to the recommended vaccines. DESIGN: Case-control study. SETTING: A sample of households that participated in the National Immunization Survey were recontacted in 2001. MAIN OUTCOME MEASURE: Vaccination status was assessed. Case subjects were underimmunized with respect to > or =2 of 3 vaccines (diphtheria-tetanus-pertussis or diphtheria-tetanus-acellular pertussis, hepatitis B, or measles-containing vaccines), and control subjects were fully immunized. RESULTS: The response rate was 52.1% (2315 of 4440 subjects). Compared with control households, case households were more likely to make 0 dollar to 30,000 dollars (adjusted odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.5-4.6) than at least 75,000 dollars, to have > or =2 providers (OR: 2.0; 95% CI: 1.3-3.1) than 1, and to have > or =4 children (OR: 3.1; 95% CI: 1.5-6.3) than 1 child. With control for demographic and medical care factors, case subjects were more likely than control subjects to not want a new infant to receive all shots (OR: 3.8; 95% CI: 1.5-9.8), to score vaccines as unsafe or somewhat safe (OR: 2.0; 95% CI: 1.2-3.4), and to ask the doctor or nurse not to give the child a vaccine for reasons other than illness (OR: 2.7; 95% CI: 1.2-6.1). Among case subjects, 14.8% of underimmunization was attributable to parental attitudes, beliefs, and behaviors. CONCLUSIONS: Attitudes, beliefs, and behaviors indicative of vaccine safety concerns contribute substantially to underimmunization in the United States. Although concerns were significantly more common among parents of underimmunized children, many parents of fully immunized children demonstrated similar attitudes, beliefs, and behaviors, suggesting a risk to the currently high vaccination levels. Efforts to maintain and improve immunization coverage need to target those with attitudes/beliefs/behaviors indicative of vaccine safety concerns, as well as those with socioeconomic and health care access problems.

Evaluation of invalid vaccine doses.

BACKGROUND: The 2002 Recommended Childhood Immunization Schedule clarified the definition of an invalid dose of vaccine as any dose administered >/=5 days before the minimum age or interval had elapsed. Any invalid dose of vaccine should be repeated. OBJECTIVE: Determine the proportion of U.S. children who received an invalid dose of vaccine, evaluate the impact on vaccination coverage levels if invalid doses were not counted, and determine the vaccine purchase cost if at least one invalid dose is repeated. METHODS: Provider-reported vaccination histories of children aged 19 to 35 months sampled by the 2000 National Immunization Survey were evaluated. Analyses were performed in 2002 after the 2002 Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule was released. Any vaccine dose administered >/=5 days before the recommended minimum age or interval was classified as invalid. Change in vaccination coverage was determined by subtracting estimated valid-dose coverage (based on number of valid doses received) from the estimated up-to-date coverage (based on number of doses received regardless of age or spacing). RESULTS: Overall, 10.5% (+/-0.6%) of children had received at least one invalid dose of vaccine. Of the invalid doses, 51% were hepatitis B, 100% of which were the third dose; 19% were diphtheria-tetanus-pertussis (DTP/DTaP), 92% of which were the fourth dose; 12% were measles-containing vaccine (MCV); 15% were varicella vaccine; and 4% were polio vaccine, 96% of which were the first dose. Excluding invalid doses resulted in a small change in vaccination coverage: 2.2% for DTP/DTaP, 0.7% for polio, 6.5% for hepatitis B, 1.4% for MCV, and 1.7% for varicella. The vaccine purchase cost to repeat at least one invalid dose ranged from approximately $10 million (public-purchased) to approximately $18 million (private-purchased). CONCLUSIONS: Nationally about 595,000 of children aged 19 to 35 months, born between February 1997 and May 1999, received at least one invalid dose of vaccine. The cost of revaccinating these children is substantial and may have a negative impact on parents, physicians, and vaccine purchasers. Educating immunization providers regarding proper immunization timing should be conducted to reduce the administration of invalid doses of vaccines.