0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Contribution |

State Trends in Health Risk Factors and Receipt of Clinical Preventive Services Among US Adults During the 1990s FREE

David E. Nelson, MD, MPH; Shayne Bland, MS; Eve Powell-Griner, PhD; Richard Klein, MPH; Henry E. Wells, MS; Gary Hogelin, MPH, MPA; James S. Marks, MD, MPH
[+] Author Affiliations

Author Affiliations: National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Ga (Drs Nelson, Powell-Griner, and Marks and Messrs Bland and Hogelin); National Center for Health Statistics, Hyattsville, Md (Mr Klein); and Research Triangle Institute, Research Triangle Park, NC (Mr Wells). Dr Nelson is now with the Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Md.
Mr Bland died March 20, 2002.


JAMA. 2002;287(20):2659-2667. doi:10.1001/jama.287.20.2659.
Text Size: A A A
Published online

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 5 health risk factors and 6 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 US states. Annual state sample sizes ranged from 1188 to 7543.

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.

It is well established that premature mortality can be reduced through changes in health risk factors and timely receipt of clinical preventive services. For instance, there is a strong scientific consensus that tobacco use, excessive alcohol use, physical inactivity, obesity, and failure to use safety belts increase mortality risk16 and that timely receipt of adult immunizations, screening for breast and cervical cancer, and screening for high blood cholesterol levels can reduce the risk of premature death.711

Population-based monitoring of progress toward health goals is a critical part of the assessment function of public health and a key role for health agencies.12 At the national level, monitoring of health trends is well established through the Healthy People initiative that began in 1980.1315 Such information is essential for guiding current and future efforts to improve health. State improvements in preventive health depend on many factors, including socioeconomic status and other variables (eg, employment status, income level, and insurance status), state and local programs and policies, clinical standards of care, and the presence of consumers who are informed about prevention and health care services.

Although tracking progress toward national health goals is helpful, the use of national estimates is limited because most preventive health care activities, policies, and other efforts occur at the state or community level. Important state trends may exist that are obscured by national data.16,17 State mortality rates vary widely,18 as do the prevalence of health risk factors and receipt of clinical preventive services19; state mortality rates are known to correlate strongly with state risk factor estimates for certain measures, such as coronary heart disease20 and lung cancer (Suzanne Proctor, MSPH, written communication, National Center for Health Statistics, June 25, 2001).

A few studies have examined state-specific trends for health risk factors and receipt of clinical preventive services during part of the 1990s,17,2126 but they focused on trends for specific measures (eg, obesity and mammography screening) rather than on a more comprehensive examination of multiple measures. These studies used different methods and years and did not account for the role of changes in demographics, thus limiting their usefulness. The purpose of this study was to provide a comprehensive overview of state trends during the 1990s, using a standard statistical approach, for 5 adult health risk factors and 6 clinical preventive services that are known to have a substantial impact on preventable morbidity and mortality in the United States. The trends we examined include cigarette smoking, binge alcohol use, physical inactivity, obesity, and safety belt use, as well as receipt of mammography, cervical cancer screening, colorectal cancer screening, cholesterol screening, and vaccination for influenza and for pneumococcal disease.

Source of Data

Data used in this study came from the Behavioral Risk Factor Surveillance System (BRFSS) from 1991 through 2000. Details of the BRFSS have been published elsewhere.2729 The BRFSS is a state-based system of health surveys coordinated by the Centers for Disease Control and Prevention. Begun in 15 states in 1984, by 1994 all states were participating in the BRFSS. Data are obtained monthly by state health departments through telephone surveys of randomly selected persons aged 18 years or older.

The system obtains self-reported information primarily on health risk factors related to chronic disease and injury, including health risk behaviors, receipt of clinical preventive services, and health care access. In most states, the BRFSS is the sole source for these data. Results from 30 methodological studies suggest that most measures included in the BRFSS are both reliable and valid.30

For the study period from 1991 through 2000, the total sample size increased from 87 846 to 182 444 and the median state sample size increased from 1790 to 3338. Annual state sample sizes ranged from 1188 to 7543. Median annual response rates, based on persons actually reached by telephone, ranged from 84.1% in 1991 to 59.6% in 2000.

A change in the survey design in 1993 resulted in data collection at different intervals for certain topics. In all years, questions were asked on cigarette smoking, obesity, mammography, and cervical cancer screening (Papanicolaou test); in odd-numbered years for alcohol use, safety belt use, colorectal cancer screening, cholesterol screening, pneumococcal vaccination, and influenza vaccination; and in even-numbered years for physical inactivity (Table 1). Because of variation in the year in which states began to participate in the BRFSS and because of missing data for certain years, trend data are only available for selected measures for Arizona, Arkansas, Kansas, and Nevada and are not available for the District of Columbia and Wyoming.

Table Graphic Jump LocationTable 1. Characteristics of Measures of Health Risk Factors and Clinical Preventive Services

To provide stable estimates of state trends, analyses were restricted to topics that were included on the survey by 1993 and for which data were collected for 4 or more years. Data on safety belt use were collected only through 1997. The questions used to define receipt of a Papanicolaou test changed in 1992; thus, analyses for these questions were restricted to 1992 through 2000.

Definitions

Definitions for the 5 health risk factors and the 6 clinical preventive services are listed in Table 1. We used definitions that are consistent with those used to measure national Healthy People 2000 objectives14,15,31,32 or that are commonly used within the respective subject areas.

Except for cigarette smoking, mammography, and colorectal cancer screening, the wording of survey questions was highly consistent across all years for all measures. In 1996, a question that was used to define current cigarette smoking was changed to make BRFSS questions comparable with other major national surveys (Table 1). Based on data from the National Health Interview Survey, this change increased the estimate of smoking prevalence by about 1 percentage point.33 Because of this question's change, we adjusted model-based prevalence estimates downward by 1 percentage point for the year 2000.

The introductory sentence to the mammography screening question was altered slightly in 1992 to describe a mammogram as a radiograph that involves pressing the breast between 2 plastic plates. This change resulted in a slight decrease in the prevalence of mammography use,34 but we did not adjust our data because the wording change occurred only in 1 year and the overall effects were minor. Because of changes in screening recommendations, the colorectal cancer screening question referred to proctoscopy in 1993 and 1995, proctoscopy or sigmoidoscopy in 1997, and sigmoidoscopy or colonoscopy in 1999. We were unable to examine trends for fecal occult blood testing, another method used for colorectal cancer screening, because these questions were not included until 1997.

To estimate alcohol use, we examined state trends in binge drinking, which was defined as consumption of 5 or more alcoholic beverages on 1 or more occasions in the past 30 days. Binge drinking is strongly associated with many health risk behaviors and adverse outcomes, including alcohol-impaired driving, unprotected sexual activity, and acute alcohol poisoning.2,35

There is no consensus on the most appropriate survey questions for assessing moderate or vigorous physical activity.36 Because of this lack of consensus, we chose to examine trends in physical inactivity, which we defined as participating in no leisure-time physical activity in the past 30 days. Using guidelines from the World Health Organization,37 we defined obesity as having a body mass index of at least 30 kg/m2. Safety belt use was defined as always using a safety belt because this definition produces estimates similar to those obtained from observational surveys.38,39

Recommendations differ on the optimal age for beginning routine breast cancer screening.40 In this study, we examined trends in receipt of mammography in the past 2 years for women aged 40 years or older. For receipt of cervical cancer screening within the past 3 years, analyses were restricted to women aged 18 years or older with an intact uterus. Cholesterol screening was defined as receipt of a blood cholesterol test within the past 5 years among persons aged 18 years or older.32 For receipt of influenza vaccination in the past year and ever receiving a pneumococcal vaccination, analyses were restricted to persons aged 65 years or older.31,32

Statistical Analyses

Because all 11 of the outcomes we modeled were prevalences, we used logit models to evaluate state trends. Using logit models allowed us to evaluate trends while controlling for the effects age, sex, race/ethnicity, and education level have on the various outcomes. Thus, the unit of analysis in all models was the individual survey respondent. Respondents' answers were used to define dichotomous outcome variables. The independent variables in the models were year, age, sex, race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, or other), and education level (less than high school graduate, high school graduate, and some college/college graduate). SUDAAN was used to take into account the complex survey design in the modeling.41

To determine the appropriateness of a linear trend, we added year2 (a quadratic term) to the models and examined its P value, setting the significance level at P<.01 because of the large sample sizes and the number of states. If the P value for the quadratic term was not less than .01, we assumed the trend was linear. Of the 525 total state trends examined, a total of 458 (87%) met our assumption of linearity. For these models, we removed the quadratic term, refit the models, and used the estimated β coefficients for year to calculate odds ratios (ORs). These ORs reflect the average annual change per year (or per 2 years) in overall state odds estimates for each outcome, controlling for the effects of demographic changes on each outcome. Odds ratios with 99% confidence intervals (CIs) that excluded the null value of 1 were considered statistically significant. β Coefficients with P<.01 were considered statistically significant.

For the 67 trends (13%) that violated the linearity assumption, we treated year as a categorical variable and used the contrast between the estimate available from the last year of the decade with the estimate from the first year of the decade. The β value for the contrast was used to calculate an OR that compared the overall odds estimate from the last year with the overall odds estimate from the first year of the decade. These ORs represent the average change across the entire decade using the first and last data points available, controlling for the effects of demographic changes on each outcome. β Coefficients with P<.01 were considered statistically significant.

Finally, we used our models to determine the predicted prevalence at the start and end of the decade for each measure in each state. Estimates were indirectly standardized to the age, sex, race/ethnicity, and education level of a typical person based on the pooled annual BRFSS sample population from all states.41,42 Although these model-based values are not the actual prevalence estimates, they allow for appropriate comparisons across states over time and are similar to published state estimates.30

State trends during the 1990s for the 5 health risk factor measures are summarized in Table 2. Median state estimates showed a substantial increase in both obesity and safety belt use and a slight increase in binge alcohol use, and were essentially unchanged for physical inactivity and cigarette smoking.

Table Graphic Jump LocationTable 2. Model-Based State Estimates of and Trends in Health Risk Factors During the 1990s*

Smoking prevalence decreased significantly only in Minnesota; in contrast, it was unchanged in 32 states and increased in 14 states primarily located in the Midwest (7 states) and South (4 states). Binge alcohol use declined in Arizona, Minnesota, and Pennsylvania, remained unchanged in 25 states, and increased in 19 states. Increases were concentrated primarily in the South (8 states) and Midwest (6 states), although baseline prevalence estimates were generally low in southern states. The prevalence of physical inactivity decreased in 11 states, increased in 3 states (Arizona, Minnesota, and Montana), and was unchanged in 34 states; about half the states registering declines were in the South. The prevalence of obesity increased in all states, and safety belt use increased in 39 of 47 states.

The pattern for receipt of clinical preventive services was different from that for health risk factors (Table 3). Median state estimates increased substantially for mammography, influenza immunization, and pneumococcal immunization, as most states experienced increases for these measures. In contrast, median estimates increased only slightly for colorectal cancer, cervical cancer, and cholesterol screening. Receipt of mammography for women aged 40 years or older in the prior 2 years increased significantly in 43 of 47 states (all except Alaska, Colorado, Minnesota, and Washington). Receipt of cervical cancer screening increased in 8 of 48 states, all of which were in the Northeast or South (Connecticut, Delaware, Kentucky, Maryland, Massachusetts, New York, Pennsylvania, and Rhode Island).

Table Graphic Jump LocationTable 3. Model-Based State Estimates of and Trends in Receipt of Clinical Preventive Services During the 1990s*

The use of colorectal cancer screening increased in 13 of 49 states, with 11 of these states in the Northeast or South. Trends in the receipt of cholesterol screening demonstrated a mixed picture, as increases occurred in 13 of 47 states (11 of which were in the South), but declines in screening occurred in Iowa, Minnesota, North Dakota, South Dakota, and Washington state. The trend in the increased use of vaccinations among persons aged 65 years or older was almost nationwide. Increases in the receipt of influenza vaccination in the past year occurred in 44 of 49 states, and the percentage of the older population who had ever received pneumococcal vaccination increased in 48 of 49 states.

Health Risk Factors

With the exception of Minnesota, state trends in cigarette smoking during the 1990s were discouraging. After adjusting for changes in demographics, nearly 30% of states experienced an increase in smoking during this period, with half of these states located in the Midwest. Only Utah achieved the Healthy People 2000 goal for adult smoking prevalence of 15%,14 but this state had already attained this goal before the start of the decade. Reasons for the decline in smoking in Minnesota are unclear from these data, and there were few state or local tobacco control policies implemented in this state during the 1990s.43,44 The lack of a reduction in smoking in nearly all states indicates the continued need for major tobacco prevention and control efforts, such as increasing excise taxes and smoking cessation activities,45 because cigarette smoking remains the leading cause of preventable death in the United States.6

State trends in binge alcohol use during the 1990s were disturbing. Although per capita consumption of alcohol-containing beverages decreased from 1991 through 1998 in most states,46 national alcohol survey data suggest that binge alcohol use leveled off between 1990 and 1995 after decreasing in earlier years.47 Reasons for the increase in binge drinking in 19 states, and for the decline of such drinking in Arizona and Pennsylvania,48 are unknown. Minnesota's decrease in binge drinking during the 1990s may have resulted from that state's extensive educational and policy efforts directed toward reducing drinking and driving, fetal alcohol exposure, and adolescent drinking.4951

Physical inactivity decreased in 11 states. The reasons for this improvement are unclear but may have resulted from state and local health promotion programs designed to improve cardiovascular health. In contrast, physical inactivity prevalence increased or was unchanged in 37 states. For obesity, all states experienced a significant increase from 1991 through 2000, confirming findings from previous studies on the growing nationwide epidemic of obesity.24,5255 Multiple approaches for increasing physical activity and reducing obesity are needed, including educational programs, policies, and environmental interventions to increase physical activity and improve dietary patterns.3,24

Although data were available only through 1997, adult safety belt use increased in most states. Even among some states that showed no improvement (ie, Hawaii, Maryland, New Jersey, and Virginia), safety belt use was already high in 1991 and remained so during the study period. By the end of 1997, California, Hawaii, North Carolina, New Mexico, and Oregon had achieved the Healthy People 2000 goal of 85% for safety belt use.14 The extensive enactment of safety belt laws during the 1980s and 1990s and changing societal norms about safety belt use have probably been the major contributors to the increase in safety belt use.56 Despite the increases, enhanced efforts to improve safety belt use are still warranted in most states.

Receipt of Clinical Preventive Services

State trends of increasing mammography screening among women aged 40 years or older are very encouraging and confirm findings from earlier studies.22,5759 Educational campaigns directed toward health care practitioners and the general public, state mandates for insurance coverage of mammograms, and programs for providing mammography services to low-income women have all played a role in increasing breast cancer screening in nearly all states.22 Efforts to increase mammography are needed in Alaska, Colorado, Minnesota, and Washington.

State trends in cervical cancer screening are difficult to interpret. Median estimates were high in 1991 and increased only slightly by 2000; however, most states reached the Healthy People 2000 goal of 85% for receipt of a Papanicolaou test in the prior 3 years.14 The situation is further complicated because during the 1990s, various organizations issued differing recommendations on frequency and age groups for cervical cancer screening.22,60,61 More research is needed to delineate state-specific trends among subpopulations of women to ascertain whether changes in screening are occurring among women who are at different risks for developing cervical cancer.

Colorectal cancer screening, defined as receipt of proctoscopy, sigmoidoscopy, or colonoscopy among persons aged 50 years or older, increased in 13 states during the 1990s. Despite these improvements, fewer than half of persons in this age group in all states received this type of screening in 1999. Unfortunately, trend data on receipt of fecal occult blood testing, another means of screening for colorectal cancer, are not available, as these questions were not included on the BRFSS until 1997. Data from 1997 and 1999 indicate that about 20% of adults aged 50 years or older reported undergoing fecal occult blood testing in the past year.26,62 Because colorectal cancer is the second leading cause of cancer-related deaths in the United States,63 increased efforts directed toward the public and health care practitioners are needed to increase the use of colorectal cancer screening.

Cholesterol screening trends among states were variable. Although receipt of screening increased in 13 states, the nationwide median for all states increased only modestly. Decreases in the receipt of screening in Iowa, Minnesota, North Dakota, South Dakota, and Washington are of special concern. Because heart disease is the leading cause of death in the United States and because high blood cholesterol levels increase the risk for this disease, major efforts are needed to improve cholesterol screening and lower cholesterol levels.23

State trends in adult vaccination were highly encouraging. Forty-eight of 49 states met the Healthy People 2000 goal of 60% for influenza vaccination, although only 8 of 49 states reached the goal of 60% for pneumococcal vaccination.14 (Data are not available from the BRFSS to ascertain influenza or pneumococcal disease vaccination among persons with selected chronic conditions that warrant receipt of these vaccines.) Reasons for these increases probably include a greater acceptance of using preventive medical services by practitioners and consumers, increased delivery and administration of vaccines from multiple sources, and Medicare reimbursement for vaccination.25

Summary of State Progress in Preventive Health

While examining state trends for specific health risk factors and clinical preventive service measures is important, it is also useful to consider state trends across the entire spectrum of measures. New York showed the greatest positive change during the 1990s, with improvements in 8 measures. Delaware, Kentucky, and Maryland improved in 7 measures, but these increases were tempered somewhat by increases in binge alcohol use in Delaware and Maryland and in smoking in Kentucky. In contrast, Alaska had statistically significant improvements for no measures, North and South Dakota had 4 measures that improved and 4 that worsened, and Iowa had 5 measures that improved and 4 that worsened.

Reasons for the state-to-state differences in trends across all 11 measures cannot be ascertained from these data. Contributing factors may include changes and differences in states' economies, health or other policies, migration patterns, socioeconomic status, educational or mass media efforts, social norms, and health-related activities by voluntary, professional, and private organizations.

Study Limitations

This study has several limitations. First, we relied on self-reports. Depending on the measure, self-reports can result in overestimates or underestimates compared with other data sources, such as health care records, physiological measures, or biochemical verification. Social desirability64 can lead to reporting of behavior in a more favorable light, probably resulting in underestimates of obesity, binge drinking, and smoking. Social desirability,64 unfamiliarity with medical terms, and telescoping65 (recalling that events occurred more recently than they actually occurred) can affect the validity of self-reported data on clinical preventive services and probably result in overestimates.66,67 For example, self-reports overestimate prevalence of receipt of mammography67 and underestimate prevalence of obesity.68 The effects of social desirability, unfamiliarity with medical terms, and telescoping on state trends during the 1990s is unknown.

As mentioned previously, there were wording changes to questions on smoking, mammography, and colorectal cancer screening; adjustments were made only for smoking. The impact of these wording changes on trends is unclear, although any effect would be consistent across states. The effect of the 1992 wording change for mammography occurred only for 1 year and probably had little effect.

The most substantial changes in question wording occurred for colorectal cancer screening, and this question applied to different examinations across the study period. How well the average adult can distinguish between terms used to describe different medical instruments for examining the colon is unknown. Thus, trends in receipt of colorectal cancer screening should be interpreted cautiously, although as with other measures, the effects of wording changes on trends should be consistent across states.

Households without telephones were excluded, which probably resulted in slight underestimates of risk factors and overestimates of receipt of clinical preventive services for most measures.69 Typical of other telephone surveys conducted during the 1990s,70 response rates declined for nearly all states. Weighting procedures used in the BRFSS partially adjust for nonresponse; however, the effect of declines in response rates on trends is not known.

Because of different baseline values, states with high estimates early in the decade were unlikely to experience increases to the same extent as states with lower estimates (similarly, states with low estimates were unlikely to experience declines to the same extent as those with higher initial estimates). This finding was evident in states with high initial values for safety belt use and receipt of cervical cancer screening. States had different sample sizes, and some measures were applicable only to subpopulations with smaller numbers of respondents (eg, vaccination among persons aged ≥65 years and mammography among women aged ≥40 years). States with consistently larger sample sizes in general were probably more likely to have statistically significant differences compared with states with smaller sample sizes. This may, for example, partially explain the lack of significant changes found for most measures in Alaska, which was a state with smaller sample sizes in many years.

The numbers of years with data and, consequently, the number of data points per measure differed (eg, 10 data points for mammography and 4 for colorectal cancer screening). The effect of differing numbers of data points on our results is not clear; however, for some measures, the assumption of linearity was based on a limited number of data points. Finally, because of the lack of linearity of data for 67 models, we used a different approach for our regression analyses that relied only on data from the first and last years. Thus, in these analyses, we were only able to compare estimates from the beginning and end of the decade but could not examine trends over the entire decade.

State monitoring of preventive health measures is an invaluable role for public health,12 especially given the heterogeneity of state trends. One of the most important purposes of the Healthy People 2000 and 2010 initiatives was to create health goals to be used throughout the nation14,15 and not merely as part of an exercise in federal data collection and reporting. The BRFSS is, in turn, an invaluable data source for monitoring states' progress towards reaching national objectives related to health risk factors and the receipt of clinical preventive services.

This study demonstrates a mixed picture of state progress in adult preventive health during the 1990s. With the exception of safety belt use, there was limited progress in improving health risk factors. The trends in smoking, obesity, and binge alcohol use are especially worrisome and will require strong efforts to reduce the extent of these problems. Progress in increasing the use of clinical preventive services has been substantial, especially for the receipt of mammography and for influenza and pneumococcal vaccination. Our findings suggest that increased efforts are especially needed to increase the use of colorectal cancer and cholesterol screening.

US Department of Health and Human Services.  Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville, Md: Centers for Disease Control; 1989. DHHS publication (CDC) 89-8411.
National Institute on Alcohol Abuse and Alcoholism.  Ninth Special Report to Congress on Alcohol and Health. Bethesda, Md: National Institutes of Health; 1997. NIH publication 97-4017.
US Department of Health and Human Services.  Physical Activity and Health: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention; 1996.
National Institutes of Health Consensus Development Panel on Health Implications of Obesity.  Health implications of obesity.  Ann Intern Med.1985;103:1073-1077.
Evans L. The effectiveness of safety belts in preventing fatalities.  Accid Anal Prev.1986;18:229-241.
McGinnis JM, Foege WH. Actual causes of death in the United States.  JAMA.1993;270:2207-2212.
Kerlikowske K, Grady D, Rubim SM, Sandrock C, Ernster VL. Efficacy of screening mammography: a meta-analysis.  JAMA.1995;273:149-154.
Cramer DW. The role of cervical cytology in the declining morbidity and mortality of cervical cancer.  Cancer.1974;34:2018-2027.
Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM. Screening sigmoidoscopy and colorectal cancer mortality.  J Natl Cancer Inst.1992;84:1572-1575.
Atkinson W, Humiston SG, Pollard B. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atlanta, Ga: Centers for Disease Control and Prevention; 1997.
National Cholesterol Education Program.  Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Bethesda, Md: National Institutes of Health; 1993. Publication 93-3095.
Institute of Medicine.  The Future of Public HealthWashington, DC: Institute of Medicine; 1988.
US Public Health Service.  Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: US Dept of Health and Human Services; 1980.
US Department of Health and Human Services.  Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of Health and Human Services; 1990.
US Department of Health and Human Services.  Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.
Holtzman D, Powell-Griner E, Bolen JC, Rhodes L. State- and sex-specific prevalence of selected characteristics--Behavioral Risk Factor Surveillance System, 1996 and 1997.  Mor Mortal Wkly Rep CDC Surveill Summ.2000;49:1-39.
Siegel M, Mowery PD, Pechacek TP.  et al.  Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994.  Am J Public Health.2000;90:372-379.
National Center for Health Statistics.  Health, United States, 2000, With Adolescent Chartbook. Hyattsville, Md: National Center for Health Statistics; 2000.
Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986.  JAMA.1990;264:2654-2659.
Byers T, Anda R, McQueen D.  et al.  The correspondence between coronary heart disease mortality and risk factor prevalence among states in the United States, 1991-1992.  Prev Med.1998;27:311-316.
Nelson DE, Tomar SL, Mowery P, Siegel PZ. Trends in smokeless tobacco use among men in four states, 1988-1993.  Am J Public Health.1996;86:1300-1303.
Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolaou tests (1991-1997)--Behavioral Risk Factor Surveillance System.  Mor Mortal Wkly Rep CDC Surveill Summ.1999;48:1-22.
 State-specific cholesterol screening trends—United States, 1991-1999.  MMWR Morb Mortal Wkly Rep.2000;49:750-755.
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998.  JAMA.1999;282:1519-1522.
Singleton JA, Greby SM, Wooten KG, Walker FJ, Strikas R. Influenza, pneumococcal, and tetanus toxoid vaccination of adults—United States, 1993-1997.  Mor Mortal Wkly Rep CDC Surveill Summ.2000;49(SS-09):39-62.
 Trends in screening for colorectal cancer—United States, 1997 and 1999.  MMWR Morb Mortal Wkly Rep.2001;50:162-166.
Marks J, Hogelin G, Gentry E.  et al.  The Behavioral Risk Factor Surveys, I: state-specific prevalence estimates of behavioral risk factors.  Am J Prev Med.1985;1:1-8.
Powell-Griner E, Anderson JE, Murphy W. State- and sex-specific prevalence of selected characteristics—Behavioral Risk Factor Surveillance System, 1994 and 1995.  Mor Mortal Wkly Rep CDC Surveill Summ.1997;46:1-31.
Nelson DE, Holtzman D, Waller M, Leutzinger C, Condon K. Objectives and design of the Behavioral Risk Factor Surveillance System. In: Proceedings of the 1998 American Statistical Association Section on Survey Research Methods; August 9-13, 1998; Dallas, Tex.
 State estimates and methodology used in the Behavioral Risk Factor Surveillance System. Available at: http://www.cdc.gov/nccdphp/brfss. Accessed June 25, 2001.
Ryan C, Schober S, Turczyn K. Operational Definitions for Year 2000 Objectives: Priority Area 20, Immunization and Infectious DiseasesHyattsville, Md: National Center for Health Statistics; February 1997. Healthy People 2000 statistical note 11.
Ryan C, Klein RJ, Wagener D. Operational Definitions for Year 2000 Objectives: Priority Area 21, Clinical Preventive ServicesHyattsville, Md: National Center for Health Statistics; December 1998. Healthy People 2000 statistical note 17.
 Cigarette smoking among adults—United States, 1992, and changes in the definition of current cigarette smoking.  MMWR Morb Mortal Wkly Rep.1994;43:342-346.
Siegel PZ, Qualters JR, Mowery PD, Campostrini S, Leutzinger C, McQueen DV. Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence.  Am J Public Health.2001;91:817-820.
Liu S, Siegel PZ, Brewer RD, Mokdad AH, Sleet DA, Serdula M. Prevalence of alcohol-impaired driving: results from a national self-reported survey of health behaviors.  JAMA.1997;277:122-125.
Jacobs DR, Ainsworth BE, Hartman TJ, Leon AS. A simultaneous evaluation of 10 commonly used physical activity questionnaires.  Med Sci Sports Exerc.1993;25:81-91.
WHO Expert Committee on Physical Status.  The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. World Health Organization technical report series 854.
Streff FM, Wagenaar AC. Are there really shortcuts? estimating seat belt use with self-report measures.  Accid Anal Prev.1989;21:509-516.
Nelson DE. The validity of self-reported data on injury prevention behavior: lessons from observational and self-reported surveys of safety belt use in the United States.  Inj Prev.1996;2:67-69.
NIH Consensus Statement.  Breast cancer screening for women ages 40-49.  NIH Consens Statement.1997;15:1-35.
 SUDAAN User's Manual, Release 8.0, Vol. I.  Research Triangle Park, NC: Research Triangle Institute; 2000:233-247.
Korn EL, Graubard BI. Analysis of Health Surveys. New York, NY: John Wiley & Sons Inc; 1999:128-29.
Blaine TM, Forster JL, Hennrikus D, O'Neil S, Wolfson M, Pham H. Creating tobacco control policy at the local level: implementation of a direct action organizing approach.  Health Educ Behav.1997;24:640-651.
National Cancer Institute.  State and Local Legislative Action to Reduce Tobacco Use. Bethesda, Md: National Institutes of Health; 2000. NIH publication 00-4804.
US Department of Health and Human Services.  Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services; 2000.
Nephew TM, Williams GD, Stinson FS, Nguyen K, Dufour MC. Apparent Per Capita Alcohol Consumption: National, State, and Regional Trends, 1977-98. Bethesda, Md: National Institute on Alcohol Abuse and Alcoholism; 2000. Surveillance report 55.
Greenfield TK, Midanik LT, Rogers JD. A 10-year national trend study of alcohol consumption, 1984-1995: is the period of declining drinking over?  Am J Public Health.2000;90:47-52.
 Alcohol Policies in the United States: Highlights from the 50 States.  Minneapolis: University of Minnesota Alcohol Epidemiology Program; 2000.
Perry CL, Williams CL, Komro KA.  et al.  Project Northland High School interventions: community action to reduce adolescent alcohol use.  Health Educ Behav.2000;27:29-49.
Lussky R. Minnesota responds to fetal alcohol syndrome.  Minn Med.1998;81:35-38.
Ross HL, Simon S, Cleary J. License plate confiscation for persistent alcohol impaired drivers.  Accid Anal Prev.1996;28:53-61.
Galuska DA, Serdula M, Pamuk E, Siegel P, Byers T. Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey.  Am J Public Health.1996;86:1729-1735.
Flegal KM, Carrol MD, Kuczmarski RJ, Johnson CL. Overweight and obesity trends in the United States: prevalence and trends, 1969-1994.  Int J Obes Relat Metab Disord.1998;22:39-47.
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The continuing epidemic of obesity in the United States.  JAMA.2000;284:1650-1651.
Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States.  JAMA.2001;286:1195-1200.
Nelson DE, Bolen J, Krasny M. Trends in safety belt use by demographics and by type of state safety belt law, 1987-1993.  Am J Public Health.1998;88:245-249.
Anderson LM, May DS. Has the use of cervical, breast, and colorectal cancer screening increased in the United States?  Am J Public Health.1995;85:840-842.
National Center for Health Statistics.  Healthy People 2000 Review, 1993. Hyattsville, Md: National Center for Health Statistics; 1994.
Horton JA, Cruess DF, Romans MC. Compliance with mammography screening guidelines: 1995 mammography attitudes and usage study report.  Womens Health Issues.1996;6:239-245.
US Preventive Services Task Force.  Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
American Cancer Society.  Guidelines for the Cancer-Related Checkup: An Update. Atlanta, Ga: American Cancer Society; 1993.
 Screening for colorectal cancer—United States, 1997.  MMWR Morb Mortal Wkly Rep.1999;48:116-121.
American Cancer Society.  Cancer Facts and Figures, 1999Atlanta, Ga: American Cancer Society; 1999. Publication 5008.99.
Hingson R, Strunin L. Validity, reliability, and generalizability in studies of AIDS knowledge, attitudes, and behavioral risks based on subject self-report.  Am J Prev Med.1993;9:62-64.
Sudman SN, Bradburn NM. Effects of time and memory factors on response in surveys.  J Am Stat Assoc.1973;68:805-815.
Newell SA, Girgis A, Sanson-Fisher RW, Savolainen NJ. The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review.  Am J Prev Med.1999;17:211-229.
King ES, Rimer BK, Trock B, Balshen A, Engstrom P. How valid are mammography self-reports?  Am J Public Health.1990;80:1386-1388.
Najar MF, Rowland M. Anthropometric reference data and prevalence of overweight, United States, 1976-80.  Vital Health Stat 11.1987;(238):1-73.
Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nichols WL, eds. Telephone Survey Methodology. New York, NY: John Wiley & Sons; 1988:25-49.
Massey JT, O'Connor D, Krotki K. Response rates in random digit dialing (RDD) telephone surveys. In: Proceedings of the 1997 American Statistical Association Section on Survey Research Methods; August 10-14, 1997; Anaheim, Calif.

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of Measures of Health Risk Factors and Clinical Preventive Services
Table Graphic Jump LocationTable 2. Model-Based State Estimates of and Trends in Health Risk Factors During the 1990s*
Table Graphic Jump LocationTable 3. Model-Based State Estimates of and Trends in Receipt of Clinical Preventive Services During the 1990s*

References

US Department of Health and Human Services.  Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville, Md: Centers for Disease Control; 1989. DHHS publication (CDC) 89-8411.
National Institute on Alcohol Abuse and Alcoholism.  Ninth Special Report to Congress on Alcohol and Health. Bethesda, Md: National Institutes of Health; 1997. NIH publication 97-4017.
US Department of Health and Human Services.  Physical Activity and Health: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention; 1996.
National Institutes of Health Consensus Development Panel on Health Implications of Obesity.  Health implications of obesity.  Ann Intern Med.1985;103:1073-1077.
Evans L. The effectiveness of safety belts in preventing fatalities.  Accid Anal Prev.1986;18:229-241.
McGinnis JM, Foege WH. Actual causes of death in the United States.  JAMA.1993;270:2207-2212.
Kerlikowske K, Grady D, Rubim SM, Sandrock C, Ernster VL. Efficacy of screening mammography: a meta-analysis.  JAMA.1995;273:149-154.
Cramer DW. The role of cervical cytology in the declining morbidity and mortality of cervical cancer.  Cancer.1974;34:2018-2027.
Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM. Screening sigmoidoscopy and colorectal cancer mortality.  J Natl Cancer Inst.1992;84:1572-1575.
Atkinson W, Humiston SG, Pollard B. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atlanta, Ga: Centers for Disease Control and Prevention; 1997.
National Cholesterol Education Program.  Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Bethesda, Md: National Institutes of Health; 1993. Publication 93-3095.
Institute of Medicine.  The Future of Public HealthWashington, DC: Institute of Medicine; 1988.
US Public Health Service.  Promoting Health/Preventing Disease: Objectives for the Nation. Washington, DC: US Dept of Health and Human Services; 1980.
US Department of Health and Human Services.  Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of Health and Human Services; 1990.
US Department of Health and Human Services.  Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.
Holtzman D, Powell-Griner E, Bolen JC, Rhodes L. State- and sex-specific prevalence of selected characteristics--Behavioral Risk Factor Surveillance System, 1996 and 1997.  Mor Mortal Wkly Rep CDC Surveill Summ.2000;49:1-39.
Siegel M, Mowery PD, Pechacek TP.  et al.  Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994.  Am J Public Health.2000;90:372-379.
National Center for Health Statistics.  Health, United States, 2000, With Adolescent Chartbook. Hyattsville, Md: National Center for Health Statistics; 2000.
Hahn RA, Teutsch SM, Rothenberg RB, Marks JS. Excess deaths from nine chronic diseases in the United States, 1986.  JAMA.1990;264:2654-2659.
Byers T, Anda R, McQueen D.  et al.  The correspondence between coronary heart disease mortality and risk factor prevalence among states in the United States, 1991-1992.  Prev Med.1998;27:311-316.
Nelson DE, Tomar SL, Mowery P, Siegel PZ. Trends in smokeless tobacco use among men in four states, 1988-1993.  Am J Public Health.1996;86:1300-1303.
Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolaou tests (1991-1997)--Behavioral Risk Factor Surveillance System.  Mor Mortal Wkly Rep CDC Surveill Summ.1999;48:1-22.
 State-specific cholesterol screening trends—United States, 1991-1999.  MMWR Morb Mortal Wkly Rep.2000;49:750-755.
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998.  JAMA.1999;282:1519-1522.
Singleton JA, Greby SM, Wooten KG, Walker FJ, Strikas R. Influenza, pneumococcal, and tetanus toxoid vaccination of adults—United States, 1993-1997.  Mor Mortal Wkly Rep CDC Surveill Summ.2000;49(SS-09):39-62.
 Trends in screening for colorectal cancer—United States, 1997 and 1999.  MMWR Morb Mortal Wkly Rep.2001;50:162-166.
Marks J, Hogelin G, Gentry E.  et al.  The Behavioral Risk Factor Surveys, I: state-specific prevalence estimates of behavioral risk factors.  Am J Prev Med.1985;1:1-8.
Powell-Griner E, Anderson JE, Murphy W. State- and sex-specific prevalence of selected characteristics—Behavioral Risk Factor Surveillance System, 1994 and 1995.  Mor Mortal Wkly Rep CDC Surveill Summ.1997;46:1-31.
Nelson DE, Holtzman D, Waller M, Leutzinger C, Condon K. Objectives and design of the Behavioral Risk Factor Surveillance System. In: Proceedings of the 1998 American Statistical Association Section on Survey Research Methods; August 9-13, 1998; Dallas, Tex.
 State estimates and methodology used in the Behavioral Risk Factor Surveillance System. Available at: http://www.cdc.gov/nccdphp/brfss. Accessed June 25, 2001.
Ryan C, Schober S, Turczyn K. Operational Definitions for Year 2000 Objectives: Priority Area 20, Immunization and Infectious DiseasesHyattsville, Md: National Center for Health Statistics; February 1997. Healthy People 2000 statistical note 11.
Ryan C, Klein RJ, Wagener D. Operational Definitions for Year 2000 Objectives: Priority Area 21, Clinical Preventive ServicesHyattsville, Md: National Center for Health Statistics; December 1998. Healthy People 2000 statistical note 17.
 Cigarette smoking among adults—United States, 1992, and changes in the definition of current cigarette smoking.  MMWR Morb Mortal Wkly Rep.1994;43:342-346.
Siegel PZ, Qualters JR, Mowery PD, Campostrini S, Leutzinger C, McQueen DV. Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence.  Am J Public Health.2001;91:817-820.
Liu S, Siegel PZ, Brewer RD, Mokdad AH, Sleet DA, Serdula M. Prevalence of alcohol-impaired driving: results from a national self-reported survey of health behaviors.  JAMA.1997;277:122-125.
Jacobs DR, Ainsworth BE, Hartman TJ, Leon AS. A simultaneous evaluation of 10 commonly used physical activity questionnaires.  Med Sci Sports Exerc.1993;25:81-91.
WHO Expert Committee on Physical Status.  The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995. World Health Organization technical report series 854.
Streff FM, Wagenaar AC. Are there really shortcuts? estimating seat belt use with self-report measures.  Accid Anal Prev.1989;21:509-516.
Nelson DE. The validity of self-reported data on injury prevention behavior: lessons from observational and self-reported surveys of safety belt use in the United States.  Inj Prev.1996;2:67-69.
NIH Consensus Statement.  Breast cancer screening for women ages 40-49.  NIH Consens Statement.1997;15:1-35.
 SUDAAN User's Manual, Release 8.0, Vol. I.  Research Triangle Park, NC: Research Triangle Institute; 2000:233-247.
Korn EL, Graubard BI. Analysis of Health Surveys. New York, NY: John Wiley & Sons Inc; 1999:128-29.
Blaine TM, Forster JL, Hennrikus D, O'Neil S, Wolfson M, Pham H. Creating tobacco control policy at the local level: implementation of a direct action organizing approach.  Health Educ Behav.1997;24:640-651.
National Cancer Institute.  State and Local Legislative Action to Reduce Tobacco Use. Bethesda, Md: National Institutes of Health; 2000. NIH publication 00-4804.
US Department of Health and Human Services.  Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services; 2000.
Nephew TM, Williams GD, Stinson FS, Nguyen K, Dufour MC. Apparent Per Capita Alcohol Consumption: National, State, and Regional Trends, 1977-98. Bethesda, Md: National Institute on Alcohol Abuse and Alcoholism; 2000. Surveillance report 55.
Greenfield TK, Midanik LT, Rogers JD. A 10-year national trend study of alcohol consumption, 1984-1995: is the period of declining drinking over?  Am J Public Health.2000;90:47-52.
 Alcohol Policies in the United States: Highlights from the 50 States.  Minneapolis: University of Minnesota Alcohol Epidemiology Program; 2000.
Perry CL, Williams CL, Komro KA.  et al.  Project Northland High School interventions: community action to reduce adolescent alcohol use.  Health Educ Behav.2000;27:29-49.
Lussky R. Minnesota responds to fetal alcohol syndrome.  Minn Med.1998;81:35-38.
Ross HL, Simon S, Cleary J. License plate confiscation for persistent alcohol impaired drivers.  Accid Anal Prev.1996;28:53-61.
Galuska DA, Serdula M, Pamuk E, Siegel P, Byers T. Trends in overweight among US adults from 1987 to 1993: a multistate telephone survey.  Am J Public Health.1996;86:1729-1735.
Flegal KM, Carrol MD, Kuczmarski RJ, Johnson CL. Overweight and obesity trends in the United States: prevalence and trends, 1969-1994.  Int J Obes Relat Metab Disord.1998;22:39-47.
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The continuing epidemic of obesity in the United States.  JAMA.2000;284:1650-1651.
Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States.  JAMA.2001;286:1195-1200.
Nelson DE, Bolen J, Krasny M. Trends in safety belt use by demographics and by type of state safety belt law, 1987-1993.  Am J Public Health.1998;88:245-249.
Anderson LM, May DS. Has the use of cervical, breast, and colorectal cancer screening increased in the United States?  Am J Public Health.1995;85:840-842.
National Center for Health Statistics.  Healthy People 2000 Review, 1993. Hyattsville, Md: National Center for Health Statistics; 1994.
Horton JA, Cruess DF, Romans MC. Compliance with mammography screening guidelines: 1995 mammography attitudes and usage study report.  Womens Health Issues.1996;6:239-245.
US Preventive Services Task Force.  Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
American Cancer Society.  Guidelines for the Cancer-Related Checkup: An Update. Atlanta, Ga: American Cancer Society; 1993.
 Screening for colorectal cancer—United States, 1997.  MMWR Morb Mortal Wkly Rep.1999;48:116-121.
American Cancer Society.  Cancer Facts and Figures, 1999Atlanta, Ga: American Cancer Society; 1999. Publication 5008.99.
Hingson R, Strunin L. Validity, reliability, and generalizability in studies of AIDS knowledge, attitudes, and behavioral risks based on subject self-report.  Am J Prev Med.1993;9:62-64.
Sudman SN, Bradburn NM. Effects of time and memory factors on response in surveys.  J Am Stat Assoc.1973;68:805-815.
Newell SA, Girgis A, Sanson-Fisher RW, Savolainen NJ. The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review.  Am J Prev Med.1999;17:211-229.
King ES, Rimer BK, Trock B, Balshen A, Engstrom P. How valid are mammography self-reports?  Am J Public Health.1990;80:1386-1388.
Najar MF, Rowland M. Anthropometric reference data and prevalence of overweight, United States, 1976-80.  Vital Health Stat 11.1987;(238):1-73.
Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nichols WL, eds. Telephone Survey Methodology. New York, NY: John Wiley & Sons; 1988:25-49.
Massey JT, O'Connor D, Krotki K. Response rates in random digit dialing (RDD) telephone surveys. In: Proceedings of the 1997 American Statistical Association Section on Survey Research Methods; August 10-14, 1997; Anaheim, Calif.
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 92

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
JAMAevidence.com

The Rational Clinical Examination EDUCATION GUIDES
Abdominal Aortic Aneurysm