State-level Trends Research Articles

Trends and Factors Associated with Breastfeeding and Infant Sleep Practices in Georgia.

Breastfeeding benefits both infant and mother, including reducing the risk of Sudden Infant Death Syndrome (SIDS). To further reduce risk of SIDS, the American Academy of Pediatrics recommends infants sleep on their backs on a separate sleep surface. Our objective was to describe trends and factors associated with breastfeeding and infant sleep practices in Georgia. Pregnancy Risk Assessment Monitoring System 2004-2013 data were obtained from the Georgia Department of Public Health. Chi square tests for trends were utilized to determine whether there were significant linear trends in breastfeeding and infant sleep overtime and by survey phase. After exclusions, 4643 cases remained for analysis. From 2004 to 2013, there was a slight (insignificant) decrease in breastfeeding initiation, with the highest proportion in 2010 (79.9%) and the lowest in 2013 (66.9%). Rates of exclusive breastfeeding increased significantly from 2004 (31.3%) to 2013 (81.7%). During that time, the proportion of infants being placed back to sleep slightly decreased (though not significantly), from 59.7 to 48.9%. The proportion of mothers who reported never bed-sharing increased significantly from 26.7 to 45.1% over this period. The decreasing breastfeeding initiation rates in Georgia diverge from national upward trends, however, exclusive breastfeeding rates by survey phase were slightly higher than national trends. Our results suggest the need for targeted education and support for breastfeeding and safe sleep practices. State-level trends data on breastfeeding and infant sleep practices provide valuable information for state-level public health professionals and policy makers, health care providers, and breastfeeding and safe sleep advocates.

Trends in Sales of Flavored and Menthol Tobacco Products in the United States During 2011-2015.

Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels. Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change. Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland). Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption. Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

Tracking state trends in environmental public opinion

Trends in state-level public opinion on the environment within the U.S. are examined, using data from the General Social Survey (GSS) from 1976 to 2008. Multilevel Regression and Post-Stratification (MRP) approach estimates public support for environmental spending at the U.S. state-level over three decades. This allows for an analysis of inter-state homogeneity of environmental public opinion, over the latter half of the twenty century. The findings indicate state-level trends mirror those at the national-level, but state-level public opinion is becoming more analogous over time.

Estimated Budget Impact of Adopting the Affordable Care Act's Required Smoking Cessation Coverage on United States Healthcare Payers.

IntroductionDespite abundant information on the negative impacts of smoking, more than 40 million adult Americans continue to smoke. The Affordable Care Act (ACA) requires tobacco cessation as a preventive service with no patient cost share for all FDA-approved cessation medications. Health plans have a vital role in supporting smoking cessation by managing medication access, but uncertainty remains on the gaps between smoking cessation requirements and what is actually occurring in practice. This study presents current cessation patterns, real-world drug costs and plan benefit design data, and estimates the 1- to 5-year pharmacy budget impact of providing ACA-required coverage for smoking cessation products to understand the fiscal impact to a US healthcare plan.MethodsA closed cohort budget impact model was developed in Microsoft Excel® to estimate current and projected costs for US payers (commercial, Medicare, Medicaid) covering smoking cessation medicines, with assumptions for coverage and smoking cessation product utilization based on current, real-world national and state-level trends for hypothetical commercial, Medicare, and Medicaid plans with 1 million covered lives. A Markov methodology with five health states captures quit attempt and relapse patterns. Results include the number of smokers attempting to quit, number of successful quitters, annual costs, and cost per-member per-month (PMPM).ResultsThe projected PMPM cost of providing coverage for smoking cessation medications is $0.10 for commercial, $0.06 for Medicare, and $0.07 for Medicaid plans, reflecting a low incremental PMPM impact of covering two attempts ranging from $0.01 for Medicaid to $0.02 for commercial and Medicare payers.ConclusionThe projected PMPM impact of covering two quit attempts with access to all seven cessation medications at no patient cost share remains low. Results of this study reinforce that the impact of adopting the ACA requirements for smoking cessation coverage will have a limited near-term impact on health plan’s budgets.FundingPfizer Inc.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-016-0446-y) contains supplementary material, which is available to authorized users.

Single-parent households and mortality among children and youth

Although many studies have examined associations between family structure and child outcomes, few have considered how the increase in single-parent households since the 1960s may have affected child mortality rates. We examined state-level changes in the percentage of children living with single parents between 1968 and 2010 and state-level trends in mortality among children and youth (age 19 or younger) in the United States. Regression models with state and year fixed effects revealed that increases in single parenthood were associated with small increments in accidental deaths and homicides.

Changes in Public Prenatal Care Coverage Options for Noncitizens Since Welfare Reform

Before 1996, most lawfully present noncitizens were eligible for the same prenatal Medicaid benefits as U.S. citizens. However, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)-welfare reform-restricted benefits for certain lawful noncitizens for the first time. Welfare reform also gave states unprecedented authority to determine Medicaid eligibility. More recent federal policy changes have allowed states to cover some noncitizen pregnant women initially excluded under welfare reform. However, there are few comprehensive studies examining state implementation of these policy options. This study documents state-level trends in prenatal Medicaid and state-funded coverage options for low-income noncitizens just prior to and since welfare reform. While some states have substantially expanded prenatal coverage since PRWORA, wide variation remains. These findings have important implications for understanding the potential effects of the Affordable Care Act and Medicaid expansion on health care utilization and birth outcomes among pregnant noncitizens.

State-Level Trends and Correlates for Cross-Sector Collaboration on School Nutrition and Physical Education Activities, 2000-2012.

IntroductionCross-sector collaboration on child obesity prevention is common, yet little research has examined the context of collaboration at the state level. This study describes secular trends in collaboration between state agency staff responsible for school nutrition and physical education activities and other organizations from 2000 to 2012.MethodsData from the School Health Policies and Practices Study were used to describe collaboration between state agency staff and 13 types of public, private, and nonprofit organizations. Breadth of collaboration in 2012 was examined across political, social, and economic conditions.ResultsCollaboration between state agency staff and other organization types increased from 2000 to 2006 and decreased or stabilized from 2006 to 2012. Breadth of collaboration was greater in states with a physical education coordinator, higher levels of poverty, higher prevalence of childhood obesity, and more public health funding. Breadth was similar across states by census region, political party of governor, majority party in state legislature, percentage non-Hispanic white population, high school graduation rate, and unemployment rate.ConclusionCross-sector collaboration on school nutrition and physical education was widespread and did not vary substantially across most political, social, and economic measures. Expanded monitoring and surveillance of state-level collaboration would assist efforts to understand how state agencies work across sectors and whether this collaboration affects the support they provide to schools.

You Can't Take it with You: Appliance Choices and the Energy Efficiency Gap

The benefits of an investment in an energy efficient durable good depend on the life of the investment. If the expected length of ownership is mis-estimated, this will bias calculations of the benefits of energy efficiency, including estimates of the energy efficiency gap. This paper estimates how expected ownership length affects household appliance choices. I leverage the fact that some types of appliances are expected to convey (be included) with the sale of a house, while other appliances may or may not convey depending on local customs that vary at the state level. An appliance that conveys will be left behind when a homeowner moves, while an appliance that does not convey may be kept until the end of its useful life. I estimate the effect of an appliance conveying using a difference-in-differences across states and appliance types, allowing me to control for state-level trends using fixed effects. I find that consumers purchase less expensive refrigerators and clothes washers when those appliances convey. I show that accounting for whether an appliance conveys can substantially reduce or eliminate apparent undervaluation of energy efficiency benefits.

Nationwide shift from microscopic to endoscopic transsphenoidal pituitary surgery.

Transsphenoidal pituitary surgery can be carried out with either an operating microscope or with an endoscope, but the relative frequency of both techniques is unknown. All microscopic and endoscopic transsphenoidal pituitary surgeries were extracted from the Centers for Medicare and Medicaid Services Part B data files between the years 2003 and 2013. National and state-level trends were compared over time. Endoscopic surgery significantly increased and microscopic surgery significantly decreased over the years 2003-2013. Thirty-eight of 48 states increased their use of endoscopic surgery, while 38 of 48 states decreased their use of microscopic surgery. Nationwide data show a clear trend for an increasing use of endoscopic transsphenoidal surgery at the expense of microscopic surgery. The underlying causes of these trends are unknown, but clearly deserve further investigation.

State Variation in Medical Imaging: Despite Great Variation, the Medicare Spending Decline Continues.

The purpose of this study was to assess state-level trends in per beneficiary Medicare spending on medical imaging. Medicare part B 5% research identifiable files from 2004 through 2012 were used to compute national and state-by-state annual average per beneficiary spending on imaging. State-to-state geographic variation and temporal trends were analyzed. National average per beneficiary Medicare part B spending on imaging increased 7.8% annually between 2004 ($350.54) and its peak in 2006 ($405.41) then decreased 4.4% annually between 2006 and 2012 ($298.63). In 2012, annual per beneficiary spending was highest in Florida ($367.25) and New York ($355.67) and lowest in Ohio ($67.08) and Vermont ($72.78). Maximum state-to-state geographic variation increased over time, with the ratio of highest-spending state to lowest-spending state increasing from 4.0 in 2004 to 5.5 in 2012. Spending in nearly all states decreased since peaks in 2005 (six states) or 2006 (43 states). The average annual decrease among states was 5.1% ± 1.8% (range, 1.2-12.2%) The largest decrease was in Ohio. In only two states did per beneficiary spending increase (Maryland, 12.5% average annual increase since 2005; Oregon, 4.8% average annual increase since 2008). Medicare part B average per beneficiary spending on medical imaging declined in nearly every state since 2005 and 2006 peaks, abruptly reversing previously reported trends. Spending continued to increase, however, in Maryland and Oregon. Identification of state-level variation may facilitate future investigation of the potential effect of specific and regional changes in spending on patient access and outcomes.

Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013.

BackgroundNigeria has made notable gains in improving childhood survival but the country still accounts for a large portion of the world’s overall disease burden, particularly among women and children. To date, no systematic analyses have comprehensively assessed trends for health outcomes and interventions across states in Nigeria.MethodsWe extracted data from 19 surveys to generate estimates for 20 key maternal and child health (MCH) interventions and outcomes for 36 states and the Federal Capital Territory from 2000 to 2013. Source-specific estimates were generated for each indicator, after which a two-step statistical model was applied using a mixed-effects model followed by Gaussian process regression to produce state-level trends. National estimates were calculated by population-weighting state values.ResultsUnder-5 mortality decreased in all states from 2000 to 2013, but a large gap remained across them. Malaria intervention coverage stayed low despite increases between 2009 and 2013, largely driven by rising rates of insecticide-treated net ownership. Overall, vaccination coverage improved, with notable increases in the coverage of three-dose oral polio vaccine. Nevertheless, immunization coverage remained low for most vaccines, including measles. Coverage of other MCH interventions, such as antenatal care and skilled birth attendance, generally stagnated and even declined in many states, and the range between the lowest- and highest-performing states remained wide in 2013. Countrywide, a measure of overall intervention coverage increased from 33% in 2000 to 47% in 2013 with considerable variation across states, ranging from 21% in Sokoto to 66% in Ekiti.ConclusionsWe found that Nigeria made notable gains for a subset of MCH indicators between 2000 and 2013, but also experienced stalled progress and even declines for others. Despite progress for a subset of indicators, Nigeria’s absolute levels of intervention coverage remained quite low. As Nigeria rolls out its National Health Bill and seeks to strengthen its delivery of health services, continued monitoring of local health trends will help policymakers track successes and promptly address challenges as they arise. Subnational benchmarking ought to occur regularly in Nigeria and throughout sub-Saharan Africa to inform local decision-making and bolster health system performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0438-9) contains supplementary material, which is available to authorized users.

State-level differences in fatal law enforcement officer collisions

Purpose– The purpose of this paper is to investigate variability in law enforcement officer (LEO) traffic fatality rates among states in order to identify policy-relevant areas of opportunity to reduce deaths.Design/methodology/approach– Differences in state highway spending, regulatory policy, law enforcement training, LEO and general public traffic fatalities, and other state-level variables are explored through cross-sectional regression analysis and qualitative content analysis. Data were used from the Federal Bureau of Investigation Crime in the USA and LEOs Killed and Assaulted reports, and the National Highway Transportation Safety Administration Fatality Analysis Reporting System, among other sources.Findings– There are a number of significant state-level variables and trends that contribute to differences in LEO traffic fatality rates. Maximum highway speed limits and general population traffic fatalities are found to be statistically significant predictors. Thematic factors relating to LEO exceptionalism, agency sovereignty, training, and external control loci, emerged through qualitative analysis.Research limitations/implications– Limitations included differences in definition, consistency, and reporting among data sources. Qualitative analysis of some variables were limited and future research should pursue more robust and repeated/longitudinal measures.Practical implications– Policymakers have an opportunity to review significant factors contributing to higher/lower collision involvement rates and make changes to police practices to reduce collision involvement and improve safety for LEOs.Originality/value– No prior study has offered a national, cross-case analysis of LEO traffic fatalities by state. This paper offers law enforcement policymakers empirical examples of successful LEO traffic safety policies.

The Early Impact of the Affordable Care Act State-by-State

In this paper I examine the effects that state policy decisions have had on the early impact of the Affordable Care Act (ACA) using data through the first half of 2014. I focus on the individual health insurance market, which includes plans purchased through exchanges as well as plans purchased directly from insurers. In this market, at least 13.2 million people were covered in the second quarter of 2014, representing an increase of at least 4.2 million beyond pre-ACA state-level trends. I use data on coverage, premiums, and costs and a model developed by Martin Hackmann, Jonathan Kolstad, and myself (forthcoming) to calculate changes in selection and markups, which allow me to estimate the welfare impact of the ACA on participants in the individual health insurance market in each state. I then focus on comparisons across groups of states. The estimates from my model imply that market participants in the five “direct enforcement” states—those that ceded all enforcement of the ACA to the federal government—are experiencing welfare losses of approximately $245 per participant on an annualized basis, relative to participants in all other states. The estimates also imply that the impact of setting up a state exchange depends meaningfully on how well the exchange functions. Market participants in the six states that had severe exchange glitches are experiencing welfare losses of approximately $750 per participant on an annu-alized basis, relative to participants in other states with their own exchanges. Although the national impact of the ACA is likely to change over the course of 2014 as coverage, costs, and premiums evolve, I expect that the differential impacts that are observed across states will persist through the rest of 2014.

The Early Impact of the Affordable Care Act, State by State

In this paper I examine the effects that state policy decisions have had on the early impact of the Affordable Care Act (ACA) using data through the first half of 2014. I focus on the individual health insurance market, which includes plans purchased through exchanges as well as plans purchased directly from insurers. In this market, at least 13.2 million people were covered in the second quarter of 2014, representing an increase of at least 4.2 million beyond pre-ACA state-level trends. I use data on coverage, premiums, and costs and a model developed by Martin Hackmann, Jonathan Kolstad, and myself (forthcoming) to calculate changes in selection and markups, which allow me to estimate the welfare impact of the ACA on participants in the individual health insurance market in each state. I then focus on comparisons across groups of states. The estimates from my model imply that market participants in the five “direct enforcement” states—those that ceded all enforcement of the ACA to the federal government—are experiencing welfare losses of approximately $245 per participant on an annualized basis, relative to participants in all other states. The estimates also imply that the impact of setting up a state exchange depends meaningfully on how well the exchange functions. Market participants in the six states that had severe exchange glitches are experiencing welfare losses of approximately $750 per participant on an annu-alized basis, relative to participants in other states with their own exchanges. Although the national impact of the ACA is likely to change over the course of 2014 as coverage, costs, and premiums evolve, I expect that the differential impacts that are observed across states will persist through the rest of 2014.

Changing hepatocellular carcinoma incidence and liver cancer mortality rates in the United States.

The objectives were to describe Surveillance, Epidemiology and End Results (SEER) hepatocellular carcinoma (HCC) incidence trends and the US liver cancer mortality trends by geography, age, race/ethnicity, and gender. HCC incidence data from SEER 18 registries and liver cancer mortality data from the National Center for Health Statistics were analyzed. Rates and joinpoint trends were calculated by demographic subgroup. State-level liver cancer mortality rates and trends were mapped. HCC incidence rates in SEER registries did not significantly increase during 2007-2010; however, the US liver cancer mortality rates did increase. HCC incidence and liver cancer mortality rates increased among black, Hispanic, and white men aged 50+ years and decreased among 35-49-year-old men in all racial/ethnic groups including Asians/Pacific Islanders. Significantly increasing incidence and mortality rates among women were restricted to blacks, Hispanics, and whites aged 50+ years. Asian/Pacific Islander liver cancer mortality rates decreased during 2000-2010 with decreasing rates among women aged 50-64 years and men aged 35-49 years and stable rates in other groups. During 2006-2010, among individuals 50-64 years of age, blacks and Hispanics had higher incidence and mortality rates than Asians/Pacific Islanders. Liver cancer mortality rates were highest in Louisiana, Mississippi, Texas, and Washington, DC. Decreasing HCC incidence and liver cancer mortality rates among Asians/Pacific Islanders, men aged 35-49 years, and the nonsignificant increase in overall HCC incidence rates suggest that the peak of the epidemic may be near or have passed. Findings of geographic variation in mortality rates can inform control efforts.

Has the Rate of Reduction in Infant Mortality Increased in India Since the Launch of National Rural Health Mission? Analysis of Time Trends 2000-2009 with Projection to 2015.

National Rural Health Mission (NRHM) - India was launched in 2005 to tackle urban-rural health inequalities, especially in maternal and child health. We examined national and state level trends in Infant Mortality Rates (IMR) from 2000 through 2009 to: 1) assess whether the NRHM had increased the average annual reduction rate (AARR) of IMR 2) evaluate state-wise progress towards Millennium Development Goals (MDG4) and estimate required AARRs for 'off track' states. Log-linear regression models were applied to national and state IMR data collated from the Sample Registration System (SRS)-India to estimate average annual reduction rates and compare AAARs before and after introduction of NRHM. The log-linear trend of infant mortality rates was also projected forward to 2015. The infant mortality rate in rural India declined from 74 to 55/1000 live births between 2000 and 2009, with AARR of 3.0% (95% CI=2.6%-3.4%) and the urban-rural gap in infant mortality narrowed (p =0.036). However there was no evidence (p=0.49) that AARR in rural India increased post NRHM (3.4%, 95% CI 2.0-4.7%) compared to pre NRHM (2.8%, 95% CI 2.1%-3.5%). States varied widely in rates of infant mortality reduction. Projections of infant mortality rates suggested that only eight states might be on track to help India achieve MDG4 by 2015. Despite a narrowing urban-rural gap and high AARRs in some states, there was no evidence that the rate of reduction in infant mortality has increased in rural India post NRHM introduction. India appears unlikely to achieve child survival-related NRHM and millennium development goals. Government should revisit the child survival related NRHM strategies and ensure equitable access to health services. More robust monitoring and evaluation mechanisms must be inbuilt for following years.

The Emerging Education Reversal in the United States: National and State-Level Trends

For over two hundred years, educational attainment in the United States has climbed, with the largest gains occurring recently from 1940 through 1980. Today the adult population is at or near its highest level ever with 88 to 89 percent high school graduates and close to 30 percent college graduates. But there are signs of change. Shortly after 2000, attainment amongst adults has flattened. A closer look at this educational ‘ceiling’ reveals that the educational gains of the population have not only stopped but are beginning to decline: Census and ACS data show that a reversal is underway. This reversal emerged for the newest members of the adult population around 2000. In addition, college completion rates, although not yet reversed, are slowing dramatically. Looking at the problem spatially, no state had an educational reversal in 1990, but, by 2000, in nearly every western state the percentage of high school graduates was lower among young adults (age 25 to 34) than among prime age adults (age 45 to 64). By 2007, the reversal was deepening in several western states, had spread east through Texas and the Great Lakes region, and also appeared along the south Atlantic seaboard and the East Coast.

Reasons for and Challenges of Recent Increases in Teen Birth Rates: A Study of Family Planning Service Policies and Demographic Changes at the State Level

After declining for over a decade, the birth rate in the United States for adolescents aged 15-19 years increased by 3% in 2006 and 1% again in 2007. We examined demographic and policy reasons for this trend at state level. With data merged from multiple sources, descriptive analysis was used to detect state-level trends in birth rate and policy changes from 2000 to 2006, and variations in the distribution of teen birth rates, sex education, and family planning service policies, and demographic features across each state in 2006. Regression analysis was then conducted to estimate the effect of several reproductive health policies and demographic features on teen birth rates at the state level. Instrument variable was used to correct possible bias in the regression analysis. Medicaid family planning waivers were found to reduce teen birth rates across all ages and races. Abstinence-only education programs were found to cause an increase in teen birth rates among white and black teens. The increasing Hispanic population is another driving force for high teen birth rates. Both demographic factors and policy changes contributed to the increase in teen birth rates between 2000 and 2006. Future policy and behavioral interventions should focus on promoting and increasing access to contraceptive use. Family planning policies should be crafted to address the special needs of teens from different cultural backgrounds, especially Hispanics.

Voting with their feet: Relative economic conditions and state migration patterns

Over the past decade, state and local policymakers and business leaders across the U.S. have expressed concern regarding the ability to attract and retain skilled workers, given the economic climate of their states compared with other parts of the nation. Examining the factors underlying state-level migration trends is important to determine what role, if any, public policy might play in addressing their potential impact on local labor supply. Using data from the Internal Revenue Service for each of the 48 states in the continental United States from 1977 through 2006, this paper examines the role of three economic factors—namely labor market conditions, per capita incomes, and housing affordability—in determining domestic state-to-state migration flows. Estimates from a logistic model of out-migration show that while all three measures of relative economic conditions are significant determinants of migration, the magnitude of their impact varies and has changed considerably over time. For example, the importance of per capita income as a determining factor has fallen considerably since the late 1970s, while that of housing affordability has risen. Interestingly, the role of labor market conditions—while significant throughout the entire 30-year period—was most prominent in the late 1980s and early 1990s. Estimates from the model are used to forecast migration for 2009 for selected states. The results from this exercise are surprisingly accurate when compared to actual state migration patterns for that year.

Mammography Use from 2000 to 2006: State-Level Trends with Corresponding Breast Cancer Incidence Rates

Although breast cancer incidence and mortality rates have declined, a significant number of women are affected by this disease each year. Mammography is currently the most effective way to detect breast cancer at an early stage when it is most treatable, but there have been reports of decreasing or stagnant mammography use in the United States. For this study, we investigated the trend in mammography use for each state in comparison with the corresponding breast cancer incidence trend. We used data from the Behavioral Risk Factor Surveillance System for 2000, 2002, 2004, and 2006 to assess the percentage of women >or= 40 years old who reported undergoing mammography within the past 2 years and data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program to assess breast cancer incidence rates from 2000 through 2004, the latest year for which data were available at the time of the study. The majority of states had a decreasing tendency in mammography use from 2000 to 2006. Only one state had a statistically significant increase in reported mammography use, whereas two states had significant decreases. There was a correlation between breast cancer incidence rates and mammography use by states (r = 0.6), but no correlation between the time trends in breast cancer incidence rates and mammography use was observed. There was little statistically significant change in self-reported mammography use from 2000 to 2006. Continued monitoring of breast cancer screening practices and breast cancer incidence trends is important for targeting at-risk populations with effective interventions to improve breast cancer prevention and early detection.