Re-Validation of the COmprehensive Score for Financial Toxicity (COST): Assessing the Scale's Utility in Chronic Disease Populations.

OBJECTIVE: To report the psychometric properties of the COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure (PROM), an 11-item scale previously validated among patients diagnosed with cancer and receiving chemotherapy. METHODS: Data come from a cross-sectional survey (n = 2755 response rate of 87%) of participants in a remote digital health coaching intervention collected between January 2017 and February 2019. RESULTS: COST demonstrated very good internal consistency (Cronbach's alpha = .89) and good convergent validity. Lower financial toxicity was associated with improved physical and mental well-being HRQOL measures after controlling for covariates (b = 0.13, P < .0001; b = 0.28, P < .0001, respectively). Supplemental analyses indicated that the COST instrument loaded on 2 factors. CONCLUSIONS: The COST measure of financial toxicity has good internal consistency and predictive validity in a sample of patients with chronic conditions. However, contrary to previous research examining the psychometric properties of COST in a sample of individuals with cancer, which found COST to be unidimensional, our analyses indicated that the COST measure of financial toxicity is multidimensional in a sample of individuals with chronic conditions. In particular, the items that asked about "general financial wellbeing" loaded on the second factor while "illness-related financial wellbeing" loaded on the first.

An image-guided precision proton radiation platform for preclinical in vivo research.

There are many unknowns in the radiobiology of proton beams and other particle beams. We describe the development and testing of an image-guided low-energy proton system optimized for radiobiological research applications. A 50 MeV proton beam from an existing cyclotron was modified to produce collimated beams (as small as 2 mm in diameter). Ionization chamber and radiochromic film measurements were performed and benchmarked with Monte Carlo simulations (TOPAS). The proton beam was aligned with a commercially-available CT image-guided x-ray irradiator device (SARRP, Xstrahl Inc.). To examine the alternative possibility of adapting a clinical proton therapy system, we performed Monte Carlo simulations of a range-shifted 100 MeV clinical beam. The proton beam exhibits a pristine Bragg Peak at a depth of 21 mm in water with a dose rate of 8.4 Gy min-1 (3 mm depth). The energy of the incident beam can be modulated to lower energies while preserving the Bragg peak. The LET was: 2.0 keV µm-1 (water surface), 16 keV µm-1 (Bragg peak), 27 keV µm-1 (10% peak dose). Alignment of the proton beam with the SARRP system isocenter was measured at 0.24 mm agreement. The width of the beam changes very little with depth. Monte Carlo-based calculations of dose using the CT image data set as input demonstrate in vivo use. Monte Carlo simulations of the modulated 100 MeV clinical proton beam show a significantly reduced Bragg peak. We demonstrate the feasibility of a proton beam integrated with a commercial x-ray image-guidance system for preclinical in vivo studies. To our knowledge this is the first description of an experimental image-guided proton beam for preclinical radiobiology research. It will enable in vivo investigations of radiobiological effects in proton beams.

Consensus recommendations for incident learning database structures in radiation oncology.

PURPOSE: Incident learning plays a key role in improving quality and safety in a wide range of industries and medical disciplines. However, implementing an effective incident learning system is complex, especially in radiation oncology. One current barrier is the lack of technical standards to guide users or developers. This report, the product of an initiative by the Work Group on Prevention of Errors in Radiation Oncology of the American Association of Physicists in Medicine, provides technical recommendations for the content and structure of incident learning databases in radiation oncology. METHODS: A panel of experts was assembled and tasked with developing consensus recommendations in five key areas: definitions, process maps, severity scales, causality taxonomy, and data elements. Experts included representatives from all major North American radiation oncology organizations as well as users and developers of public and in-house reporting systems with over two decades of collective experience. Recommendations were developed that take into account existing incident learning systems as well as the requirements of outside agencies. RESULTS: Consensus recommendations are provided for the five major topic areas. In the process mapping task, 91 common steps were identified for external beam radiation therapy and 88 in brachytherapy. A novel feature of the process maps is the identification of "safety barriers," also known as critical control points, which are any process steps whose primary function is to prevent errors or mistakes from occurring or propagating through the radiotherapy workflow. Other recommendations include a ten-level medical severity scale designed to reflect the observed or estimated harm to a patient, a radiation oncology-specific root causes table to facilitate and regularize root-cause analyses, and recommendations for data elements and structures to aid in development of electronic databases. Also presented is a list of key functional requirements of any reporting system. CONCLUSIONS: Incident learning is recognized as an invaluable tool for improving the quality and safety of treatments. The consensus recommendations in this report are intended to facilitate the implementation of such systems within individual clinics as well as on broader national and international scales.

In vivo assessment of retinal neuronal layers in multiple sclerosis with manual and automated optical coherence tomography segmentation techniques.

Macular optical coherence tomography (OCT) segmentation, enabling quantification of retinal axonal and neuronal subpopulations, may help elucidate the neuroretinal pathobiology of multiple sclerosis (MS). This study aimed to determine the agreement, reproducibility, and visual correlations of retinal layer thicknesses measured by different OCT segmentation techniques, on two spectral-domain OCT devices. Macular scans of 52 MS patients and 30 healthy controls from Spectralis OCT and Cirrus HD-OCT were segmented using fully manual (Spectralis), computer-aided manual (Spectralis and Cirrus), and fully automated (Cirrus) segmentation techniques. Letter acuity was recorded. Bland-Altman analyses revealed low mean differences across OCT segmentation techniques on both devices for ganglion cell + inner plexiform layers (GCIP; 0.76-2.43 µm), inner nuclear + outer plexiform layers (INL + OPL; 0.36-1.04 µm), and outer nuclear layers including photoreceptor segment (ONL + PR; 1.29-3.52 µm) thicknesses. Limits of agreement for GCIP and ONL + PR thicknesses were narrow. Results of fully manual and computer-aided manual segmentation were comparable to those of fully automated segmentation. MS patients demonstrated macular RNFL, GCIP, and ONL + PR thinning compared to healthy controls across OCT segmentation techniques, irrespective of device (p < 0.03 for all). Low-contrast letter acuity in MS correlated significantly and more strongly with GCIP than peripapillary RNFL thicknesses, regardless of the segmentation method or device. GCIP and ONL + PR thicknesses, measured by different OCT devices and segmentation techniques, are reproducible and agree at the individual and cohort levels. GCIP thinning in MS correlates with visual dysfunction. Significant ONL + PR thinning, detectable across OCT segmentation techniques and devices, strongly supports ONL pathology in MS. Fully automated, fully manual and computer-assisted manual OCT segmentation techniques compare closely, highlighting the utility of accurate and time-efficient automated segmentation outcomes in MS clinical trials.

Assessment of uncertainty in functional-structural plant models.

BACKGROUND AND AIMS: Constructing functional-structural plant models (FSPMs) is a valuable method for examining how physiology and morphology interact in determining plant processes. However, such models always have uncertainty concerned with whether model components have been selected and represented effectively, with the number of model outputs simulated and with the quality of data used in assessment. We provide a procedure for defining uncertainty of an FSPM and how this uncertainty can be reduced. METHODS: An important characteristic of FSPMs is that typically they calculate many variables. These can be variables that the model is designed to predict and also variables that give indications of how the model functions. Together these variables are used as criteria in a method of multi-criteria assessment. Expected ranges are defined and an evolutionary computation algorithm searches for model parameters that achieve criteria within these ranges. Typically, different combinations of model parameter values provide solutions achieving different combinations of variables within their specified ranges. We show how these solutions define a Pareto Frontier that can inform about the functioning of the model. KEY RESULTS: The method of multi-criteria assessment is applied to development of BRANCHPRO, an FSPM for foliage reiteration on old-growth branches of Pseudotsuga menziesii. A geometric model utilizing probabilities for bud growth is developed into a causal explanation for the pattern of reiteration found on these branches and how this pattern may contribute to the longevity of this species. CONCLUSIONS: FSPMs should be assessed by their ability to simulate multiple criteria simultaneously. When different combinations of parameter values achieve different groups of assessment criteria effectively a Pareto Frontier can be calculated and used to define the sources of model uncertainty.

Common mental disorders, unemployment and welfare benefits in England.

OBJECTIVES: Individuals who are out of work have a higher rate of common mental disorders (CMD) than individuals who are employed. People who are unemployed in the UK are entitled to welfare benefits to alleviate financial strain. This study examined rates of CMD in individuals who were employed, unemployed and receiving various UK benefits. It also investigated associations between duration of unemployment, gender and CMD. STUDY DESIGN: An analysis of 5090 working-age participants from the Adult Psychiatric Morbidity Survey 2007, a stratified probability sample survey conducted among adults aged 16 years and over living in private households in England. METHODS: CMD was assessed using the Clinical Interview Schedule (Revised). Information was gathered on sociodemographics, employment, income, benefits and debt. Data were analysed using logistic regression. RESULTS: Risk of CMD was significantly greater in individuals classified as: unemployed; economically inactive; not working due to physical health reasons; unable to find a suitable job; receiving housing, care or sickness benefit; and receiving income support. However, risk of CMD was not significantly greater in individuals receiving jobseeker's allowance. Individuals unemployed for less than 1 year or more than 3 years had a higher risk of CMD. Some interactions with gender were significant, with associations being greater in men than women. CONCLUSIONS: Job loss events are not the only reason for unemployed people to develop CMD. The state of unemployment itself may be detrimental to mental health. Risk of CMD is increased in those who have been out of work for 3 years or more. Associations between benefits and mental health are likely to be due to social, health or economic circumstances associated with benefit eligibility.

Defining how aging Pseudotsuga and Abies compensate for multiple stresses through multi-criteria assessment of a functional-structural model.

Many hypotheses have been advanced about factors that control tree longevity. We use a simulation model with multi-criteria optimization and Pareto optimality to determine branch morphologies in the Pinaceae that minimize the effect of growth limitations due to water stress while simultaneously maximizing carbohydrate gain. Two distinct branch morphologies in the Pareto optimal space resemble Pseudotsuga menziesii (Mirb.) Franco and Abies grandis (Dougl. ex D. Don) Lindl., respectively. These morphologies are distinguished by their performance with respect to two pathways of compensation for hydraulic limitation: minimizing the mean path length to terminal foliage (Pseudotsuga) and minimizing the mean number of junction constrictions to terminal foliage (Abies). Within these two groups, we find trade-offs between the criteria for foliage display and the criteria for hydraulic functioning, which shows that an appropriate framework for considering tree longevity is how trees compensate, simultaneously, for multiple stresses. The diverse morphologies that are found in a typical old-growth conifer forest may achieve compensation in different ways. The method of Pareto optimization that we employ preserves all solutions that are successful in achieving different combinations of criteria. The model for branch development that we use simulates the process of delayed adaptive reiteration (DAR), whereby new foliage grows from suppressed buds within the established branch structure. We propose a theoretical synthesis for the role of morphology in the persistence of old Pseudotsuga based on the characteristics of branch morphogenesis found in branches simulated from the optimal set. (i) The primary constraint on branch growth for Pseudotsuga is the mean path length; (ii) as has been previously noted, DAR is an opportunistic architecture; and (iii) DAR is limited by the number of successive reiterations that can form. We show that Pseudotsuga morphology is not the only solution to old-growth constraints, and we suggest how the model results should be used to guide future empirical investigation based on the two contrasting morphologies and how the morphological contrast may relate to physiological processes. Our results show that multi-criteria optimization with Pareto optimality has promise to advance the use of models in theory development and in exploration of functional-structural trade-offs, particularly in complex biological systems with multiple limiting factors.

Statistical inference using the g or K point pattern spatial statistics.

Spatial point pattern analysis provides a statistical method to compare an observed spatial pattern against a hypothesized spatial process model. The G statistic, which considers the distribution of nearest neighbor distances, and the K statistic, which evaluates the distribution of all neighbor distances, are commonly used in such analyses. One method of employing these statistics involves building a simulation envelope from the result of many simulated patterns of the hypothesized model. Specifically, a simulation envelope is created by calculating, at every distance, the minimum and maximum results computed across the simulated patterns. A statistical test is performed by evaluating where the results from an observed pattern fall with respect to the simulation envelope. However, this method, which differs from P. Diggle's suggested approach, is invalid for inference because it violates the assumptions of Monte Carlo methods and results in incorrect type I error rate performance. Similarly, using the simulation envelope to estimate the range of distances over which an observed pattern deviates from the hypothesized model is also suspect. The technical details of why the simulation envelope provides incorrect type I error rate performance are described. A valid test is then proposed, and details about how the number of simulated patterns impacts the statistical significance are explained. Finally, an example of using the proposed test within an exploratory data analysis framework is provided.

Health departments' implementation of public health's core functions: an assessment of health impacts.

OBJECTIVES: The purpose of this article was to investigate the relationship between state health agencies' adherence to the recommendations of the United State's Institute of Medicine's (IOM) report, "The Future of Public Health", and changes in their populations' health. STUDY DESIGN: Data were abstracted from agencies' plans, budgets, annual reports, etc. spanning a 5-year period. A comprehensive change in population health measure over the same period was drawn from the UnitedHealth Group's annual survey. METHODS: Configurations, based on public health core functions, were established using linear regression and qualitative comparative analysis. The dependent variable was a holistic measure of change in a state population's health status. RESULTS: State agencies that most completely adopted a public health model emphasizing assessment, assurance and policy development also experienced significant improvements in their population health measures. CONCLUSIONS: State agencies that more completely adopted the IOM's public health core functions had a concomitant improvement in their populations' health statuses. Further research to explore if there is a causal link between adoption of the core functions and positive health impacts is warranted.

Healthy Eating Index and C-reactive protein concentration: findings from the National Health and Nutrition Examination Survey III, 1988-1994.

OBJECTIVE: To examine whether diet quality is associated with C-reactive protein concentration. DESIGN: Cross-sectional study using data from the Third National Health and Nutrition Examination Survey (1988-1994). SETTING: Representative sample of the US population. SUBJECTS: A total of 13 811 men and women aged >/=20 y. INTERVENTIONS: We examined the cross-sectional associations between the Healthy Eating Index (HEI), a measure of diet quality according to the Dietary Guidelines for Americans, and serum C-reactive protein concentration. Dietary information was assessed using a 24-h recall. RESULTS: After adjustment for age, sex, race or ethnicity, education, smoking status, cotinine concentration, body mass index, waist-hip-ratio, aspirin use, alcohol use, physical activity level, and energy intake, HEI score was inversely associated with an elevated C-reactive protein concentration in logistic regression analysis (odds ratio per 10 unit change: 0.92; 95th confidence interval (CI): 0.86-0.99). Among the components, only the score for grain consumption was inversely associated with an elevated C-reactive protein concentration. Compared with participants in the lowest quintile of number of servings of grain consumption, the adjusted odds ratios of having an elevated C-reactive protein concentration for participants in the second, third, fourth, and fifth quintiles were 0.87 (95th CI: 0.67, 1.12), 0.85 (95th CI: 0.69, 1.06), 0.79 (95th CI: 0.65, 0.96), and 0.68 (95th CI: 0.52, 0.88), respectively. CONCLUSIONS: Grain consumption may reduce inflammation. Our findings require confirmation.

Self-reported body mass index and health-related quality of life: findings from the Behavioral Risk Factor Surveillance System.

OBJECTIVE: To examine the relationship between self-reported body mass index (BMI) and health-related quality of life in the general adult population in the United STATES: RESEARCH METHODS AND PROCEDURES: Using data from 109,076 respondents in the 1996 Behavioral Risk Factor Surveillance System, we examined how self-reported BMI is associated with five health-related quality of life measures developed by the Centers for Disease Control and Prevention for population health surveillance. RESULTS: After adjusting for age, gender, race or ethnicity, educational attainment, employment status, smoking status, and physical activity status, participants with a self-reported BMI of <18.5 kg/m(2) and participants with a self-reported BMI of > or =30 kg/m(2) reported impaired quality of life. Compared with persons with a self-reported BMI of 18.5 to <25 kg/m(2), odds ratios (ORs) of poor or fair self-rated health increased among persons with self-reported BMIs of <18.5 (1.57, 95% confidence interval [CI]: 1.31 to 1.89), 25 to <30 kg/m(2) (1.12, 95% CI: 1.04 to 1.20), 30 to <35 kg/m(2) (1.65, 95% CI: 1.50 to 1.81), 35 to <40 kg/m(2) (2.58, 95% CI: 2.21 to 3.00), and > or =40 kg/m(2) (3.23, 95% CI: 2.63 to 3.95); ORs for reporting > or =14 days of poor physical health during the previous 30 days were 1.44 (95% CI: 1.21 to 1.72), 1.04 (95% CI: 0.96 to 1.14), 1.32 (95% CI: 1.19 to 1.47), 1.80 (95% CI: 1.52 to 2.13), and 2.37 (95% CI: 1.90 to 2.94), respectively; ORs for having > or =14 days of poor mental health during the previous 30 days were 1.18 (95% CI: 0.97 to 1.42), 1.02 (95% CI: 0.95 to 1.11), 1.22 (95% CI: 1.10 to 1.36), 1.68 (95% CI: 1.42 to 1.98), and 1.66 (95% CI: 1.32 to 2.09), respectively. DISCUSSION: In the largest study to date, low and increased self-reported BMI significantly impaired health-related quality of life. Particularly, deviations from normal BMI affected physical functioning more strongly than mental functioning.

Serum alpha-tocopherol status in the United States population: findings from the Third National Health and Nutrition Examination Survey.

Despite the role vitamin E may have in protecting against various chronic conditions, little is known about vitamin E status in the US population. Using data from the Third National Health and Nutrition Examination Survey (1988-1994), the authors examined the distribution and correlates of serum alpha-tocopherol among 16,295 US adults aged 18 or more years. The mean concentration of alpha-tocopherol was 26.8 micromol/liter (geometric mean, 25.0 micromol/liter). The 25th, 50th, and 75th percentiles were 19.6, 24.1, and 30.4 micromol/liter, respectively. The mean alpha-tocopherol/cholesterol ratio was 5.1 (geometric mean, 4.9); the 25th, 50th, and 75th percentiles were 4.1, 4.7, and 5.5 (10(-3)), respectively. About 27% of the US population had a low alpha-tocopherol concentration (<20 micromol/liter). After age standardization, 29% of the men, 28% of the women, 26% of the Whites (men, 27%, and women, 26%), 41% of the African Americans (men, 42%, and women, 40%), 28% of the Mexican Americans (men, 29%, and women, 27%), and 32% of the other participants (men, 36%, and women, 29%) had this low concentration. For all participants, age, educational attainment, serum cholesterol, and several serum vitamins and carotenoids were directly related to and high density lipoprotein cholesterol was inversely related to serum alpha-tocopherol concentration in multiple linear regression analysis. Men had a higher concentration than did women, and African Americans had the lowest concentration of any racial or ethnic group. These results show that important proportions of US adults have a low serum alpha-tocopherol concentration, which may increase their risk for chronic diseases in which low dietary intake or blood concentration of alpha-tocopherol have been implicated.

Attitudes of organized labor officials toward health care issues: an exploratory survey of Alabama labor officials.

Delegates to the Alabama AFL-CIO Convention were surveyed concerning their attitudes toward their health benefits and various options for health care reform. Most are satisfied with their current health care coverage, but dissatisfied with its high costs. Participants attribute the high costs to providers' pricing policies and insurance companies' overhead.

Radon and lung cancer: a cost-effectiveness analysis.

OBJECTIVES: This study examined the cost-effectiveness of general and targeted strategies for residential radon testing and mitigation in the United States. METHODS: A decision-tree model was used to perform a cost-effectiveness analysis of preventing radon-associated deaths from lung cancer. RESULTS: For a radon threshold of 4 pCi/L, the estimated costs to prevent 1 lung cancer death are about $3 million (154 lung cancer deaths prevented), or $480,000 per life-year saved, based on universal radon screening and mitigation, and about $2 million (104 lung cancer deaths prevented), or $330,000 per life-year saved, if testing and mitigation are confined to geographic areas at high risk for radon exposure. For mitigation undertaken after a single screening test and after a second confirmatory test, the estimated costs are about $920,000 and $520,000, respectively, to prevent a lung cancer death with universal screening and $130,000 and $80,000 per life-year for high risk screening. The numbers of preventable lung cancer deaths are 811 and 527 for universal and targeted approaches, respectively. CONCLUSIONS: These data suggest possible alternatives to current recommendations.

Serum and red blood cell folate concentrations, race, and education: findings from the third National Health and Nutrition Examination Survey.

BACKGROUND: Little is known about the relations between race or ethnicity, educational attainment, and serum and red blood cell folate concentrations. OBJECTIVE: We examined the relation between educational attainment and serum and red blood cell folate concentrations in 8457 white, African American, and Mexican American men and women aged > or = 17 y. DESIGN: We performed a cross-sectional analysis using data from Phase 1 of the third National health and Nutrition Examination Survey (1988-1991). RESULTS: White men had significantly higher adjusted serum and red blood cell folate concentrations (16.9 and 502.6 nmol/L, respectively) than did African American men (15.6 and 423.3 nmol/L, respectively) or Mexican American men (16.0 and 457.0 nmol/L, respectively); white women had significantly higher concentrations (18.4 and 515.9 nmol/L, respectively) than did African American women (16.3 and 415.4 nmol/L, respectively) or Mexican American women (15.9 and 455.7 nmol/L, respectively). For the entire sample, rank correlation coefficients between educational attainment and serum and red blood cell folate were 0.11 and 0.12, respectively, and were larger in white participants than in other participants. No significant linear trends between adjusted serum or red blood cell folate and educational attainment were found. Among participants with > 12 y of education, the mean adjusted concentrations of serum folate were 15% and 18% lower and those of red blood cell were 18% and 22% lower in African American men and women than in white men and women, respectively. CONCLUSIONS: African Americans and Mexican Americans could benefit most from public health programs to boost folate intakes by encouraging increased intake of folate-rich foods and vitamin supplements.

Health insurance status and cardiovascular disease risk factors among 50-64-year-old U.S. women: findings from the Third National Health and Nutrition Examination Survey.

To examine the cardiovascular disease risk factors profile and use of preventive health services for cardiovascular disease among uninsured women aged 50-64 years, we studied data from the National Health and Nutrition Examination Survey III (NHANES III), conducted from 1988 to 1994. Insured women (n = 1308) and uninsured women (n = 303) had similar levels of blood pressure and lipids, but uninsured women were more likely to be current smokers, sedentary, and overweight and to consume less fiber, vitamin C, folate, calcium, and potassium than insured women. Compared with insured women, uninsured women were less likely to have had their blood pressure checked during the previous 6 months, to have had their cholesterol level checked, and to be aware of hypercholesterolemia. Insured women (24.9%) were three times more likely to use estrogen replacement therapy than uninsured women (7.9%). NHANES III data suggest that women without health insurance have a worse cardiovascular disease risk factor profile and use healthcare services less frequently than women with health insurance.

Race, education, and dietary cations: findings from the Third National Health And Nutrition Examination Survey.

Hypertension, which has been associated with high intake of sodium and low intake of calcium, magnesium, and potassium, is highly prevalent among African Americans. To examine differences in dietary intakes of calcium, magnesium, and potassium between whites and African Americans, and the effect of education on these differences, the author analyzed data from a nationally representative sample that participated in the first phase of the National Health and Examination Survey III from 1988-1991. The analytic sample included 6,046 white participants and 2,226 African-American participants with complete information for age, race, education, and diet. Dietary information was collected from a single 24-hour dietary recall. African Americans consumed less calcium, magnesium, and potassium than whites regardless of educational achievement. Sodium intakes from diet were similar between the two groups. Among whites, intakes of calcium, magnesium, and potassium were positively related to educational attainment. Among African Americans, only magnesium intake was positively related to educational attainment. Because the prevalence of hypertension among African Americans exceeds that among whites, increases in the consumption of calcium, magnesium, and potassium could help to prevent and control excess hypertension among African Americans.

Characteristics of survey participants with and without a telephone: findings from the third National Health and Nutrition Examination Survey.

This study examines the potential coverage bias in telephone surveys. Data were analyzed from the first phase of the third National Health and Nutrition and Examination Survey conducted from 1988 to 1991. In that survey, 10,120 persons 17 years and older were interviewed and 9034 were examined. About 2.7% of respondents reported not having a telephone. Differences in demographic and lifestyle variables, but not physiological or anthropometric variables, existed between persons with a telephone and those without one. Respondents without a telephone were more likely to report that an impairment or health problems limited their work or activities. Compared with respondents with a telephone, those without one were more likely to be current smokers, to be less physically active, to never have had their blood pressure checked or have had it checked more than 5 years ago, and to never have had their cholesterol checked. Based on data from a 24-hour dietary recall, persons without a telephone consumed less vitamin A, vitamin C, vitamin E, and carotene than did respondents with a telephone. However, prevalence estimates of health characteristics obtained from telephone surveys in populations with high telephone coverage are unlikely to be seriously affected by coverage bias nor are conclusions of comparisons involving populations with low telephone coverage.

Knowledge about indoor radon in the United States: 1990 National Health Interview Survey.

The Year 2000 objectives for environmental health include radon testing in 40% of residences overall and in 50% of residences that house a smoker, former smoker, or a child. Baseline data about radon and radon testing were determined by questions included in the 1990 Health Promotion and Disease Prevention supplement for the National Health Interview Survey. Minorities and individuals with low income or minimal education were significantly less likely to have heard of indoor radon than were whites and those with more education or income. In this survey, only 3%-5% of residences had been tested for radon. A substantial increase above the rate of testing noted for 1990 will be needed to achieve the Year 2000 objectives for indoor radon.