Preventive Service Usage and New Chronic Disease Diagnoses: Using PCORnet Data to Identify Emerging Trends, United States, 2018-2022.

Background: Data modernization efforts to strengthen surveillance capacity could help assess trends in use of preventive services and diagnoses of new chronic disease during the COVID-19 pandemic, which broadly disrupted health care access. Methods: This cross-sectional study examined electronic health record data from US adults aged 21 to 79 years in a large national research network (PCORnet), to describe use of 8 preventive health services (N = 30,783,825 patients) and new diagnoses of 9 chronic diseases (N = 31,588,222 patients) during 2018 through 2022. Joinpoint regression assessed significant trends, and health debt was calculated comparing 2020 through 2022 volume to prepandemic (2018 and 2019) levels. Results: From 2018 to 2022, use of some preventive services increased (hemoglobin A1c and lung computed tomography, both P < .05), others remained consistent (lipid testing, wellness visits, mammograms, Papanicolaou tests or human papillomavirus tests, stool-based screening), and colonoscopies or sigmoidoscopies declined (P < .01). Annual new chronic disease diagnoses were mostly stable (6% hypertension; 4% to 5% cholesterol; 4% diabetes; 1% colonic adenoma; 0.1% colorectal cancer; among women, 0.5% breast cancer), although some declined (lung cancer, cervical intraepithelial neoplasia or carcinoma in situ, cervical cancer, all P < .05). The pandemic resulted in health debt, because use of most preventive services and new diagnoses of chronic disease were less than expected during 2020; these partially rebounded in subsequent years. Colorectal screening and colonic adenoma detection by age group aligned with screening recommendation age changes during this period. Conclusion: Among over 30 million patients receiving care during 2018 through 2022, use of preventive services and new diagnoses of chronic disease declined in 2020 and then rebounded, with some remaining health debt. These data highlight opportunities to augment traditional surveillance with EHR-based data.

The cost burden of metastatic prostate cancer in the US populations covered by employer-sponsored health insurance.

BACKGROUND: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance. METHODS: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars. RESULTS: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars. CONCLUSIONS: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

Human papilloma virus vaccination and cervical cancer screening coverage in managed care plans - United States, 2018.

Human papilloma virus (HPV) vaccination for adolescents aged 11-12 years and cervical cancer screening for women aged 21-65 years are recommended to help prevent cervical cancer. The purpose of this study was to describe 2018 National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data for the United States on HPV vaccination and cervical cancer screening from 275 commercial preferred provider organizations (PPOs), 219 commercial health maintenance organizations (HMOs), and 204 Medicaid HMOs. The Centers for Disease Control and Prevention and NCQA analyzed the data in 2021. The HEDIS® measure for HPV vaccination was the percentage of male and female adolescents aged 13 years who completed HPV immunization (2- or 3-dose series) on or before their 13th birthday. The measure for cervical cancer screening was the percentage of women screened either with cervical cytology within the last 3 years for women aged 21-64 years or with cervical cytology/HPV co-testing within the last 5 years for women aged 30-64 years. Nationally, the mean rate for HPV vaccination in 2018 was 37.8% in Medicaid HMOs, 30.3% in commercial HMOs, and 24.9% in commercial PPOs. The mean rate for cervical cancer screening was 75.9% in commercial HMOs, 72.6% in commercial PPOs, and 60.3% among Medicaid HMOs. Medicaid HMOs reported higher HPV vaccination rates but lower cervical cancer screening rates than commercial plans. These differences raise questions about explanatory factors and how to improve prevention performance by plan category.

The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control.

INTRODUCTION: State cancer prevention and control programs rely on public health surveillance data to set objectives to improve cancer prevention and control, plan interventions, and evaluate state-level progress towards achieving those objectives. The goal of this project was to evaluate the validity of using electronic health records (EHRs) based on common data model variables to generate indicators for surveillance of cancer prevention and control for these public health programs. METHODS: Following the methodological guidance from the PRISMA Extension for Scoping Reviews, we conducted a literature scoping review to assess how EHRs are used to inform cancer surveillance. We then developed 26 indicators along the continuum of the cascade of care, including cancer risk factors, immunizations to prevent cancer, cancer screenings, quality of initial care after abnormal screening results, and cancer burden. Indicators were calculated within a sample of patients from the New York City (NYC) INSIGHT Clinical Research Network using common data model EHR data and were weighted to the NYC population using post-stratification. We used prevalence ratios to compare these estimates to estimates from the raw EHR of NYU Langone Health to assess quality of information within INSIGHT, and we compared estimates to results from existing surveillance sources to assess validity. RESULTS: Of the 401 identified articles, 15% had a study purpose related to surveillance. Our indicator comparisons found that INSIGHT EHR-based measures for risk factor indicators were similar to estimates from external sources. In contrast, cancer screening and vaccination indicators were substantially underestimated as compared to estimates from external sources. Cancer screenings and vaccinations were often recorded in sections of the EHR that were not captured by the common data model. INSIGHT estimates for many quality-of-care indicators were higher than those calculated using a raw EHR. CONCLUSION: Common data model EHR data can provide rich information for certain indicators related to the cascade of care but may have substantial biases for others that limit their use in informing surveillance efforts for cancer prevention and control programs.

Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity - United States, 2001-2017.

Among U.S. men, prostate cancer is the second leading cause of cancer-related death (1). Past studies documented decreasing incidence of prostate cancer overall since 2000 but increasing incidence of distant stage prostate cancer (i.e., signifying spread to parts of the body remote from the primary tumor) starting in 2010 (2,3). Past studies described disparities in prostate cancer survival by stage, age, and race/ethnicity using data covering ≤80% of the U.S. population (4,5). To provide recent data on incidence and survival of prostate cancer in the United States, CDC analyzed data from population-based cancer registries that contribute to U.S. Cancer Statistics (USCS).* Among 3.1 million new cases of prostate cancer recorded during 2003-2017, localized, regional, distant, and unknown stage prostate cancer accounted for 77%, 11%, 5%, and 7% of cases, respectively, but the incidence of distant stage prostate cancer significantly increased during 2010-2017. During 2001-2016, 10-year relative survival for localized stage prostate cancer was 100%. Overall, 5-year survival for distant stage prostate cancer improved from 28.7% during 2001-2005 to 32.3% during 2011-2016; for the period 2001-2016, 5-year survival was highest among Asian/Pacific Islanders (API) (42.0%), followed by Hispanics (37.2%), American Indian/Alaska Natives (AI/AN) (32.2%), Black men (31.6%), and White men (29.1%). Understanding incidence and survival differences by stage, race/ethnicity, and age can guide public health planning related to screening, treatment, and survivor care. Future research into differences by stage, race/ethnicity, and age could inform interventions aimed at improving disparities in outcomes.

Screening for Lung Cancer - 10 States, 2017.

Lung cancer is the leading cause of cancer death in the United States; 148,869 lung cancer-associated deaths occurred in 2016 (1). Mortality might be reduced by identifying lung cancer at an early stage when treatment can be more effective (2). In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with low-dose computed tomography (CT) for adults aged 55-80 years who have a 30 pack-year* smoking history and currently smoke or have quit within the past 15 years (2).† This was a Grade B recommendation, which required health insurance plans to cover lung cancer screening as a preventive service.§ To assess the prevalence of lung cancer screening by state, CDC used Behavioral Risk Factor Surveillance System (BRFSS) data¶ collected in 2017 by 10 states.** Overall, 12.7% adults aged 55-80 years met the USPSTF criteria for lung cancer screening. Among those meeting USPSTF criteria, 12.5% reported they had received a CT scan to check for lung cancer in the last 12 months. Efforts to educate health care providers and provide decision support tools might increase recommended lung cancer screening.

Lung cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study.

BACKGROUND: Results from the second CONCORD study (CONCORD-2) indicated that 5-year net survival for lung cancer was low (range, 10%-20%) between 1995 and 2009 in most countries, including the United States, which was at the higher end of this range. METHODS: Data from CONCORD-2 were used to analyze net survival among patients with lung cancer (aged 15-99 years) who were diagnosed in 37 states covering 80% of the US population. Survival was corrected for background mortality using state-specific and race-specific life tables and age-standardized using International Cancer Survival Standard weights. Net survival was estimated for patients diagnosed between 2001 and 2003 and between 2004 and 2009 at 1, 3, and 5 years after diagnosis by race (all races, black, and white); Surveillance, Epidemiology, and End Results Summary Stage 2000; and US state. RESULTS: Five-year net survival increased from 16.4% (95% confidence interval, 16.3%-16.5%) for patients diagnosed 2001-2003 to 19.0% (18.8%-19.1%) for those diagnosed 2004-2009, with increases in most states and among both blacks and whites. Between 2004 and 2009, 5-year survival was lower among blacks (14.9%) than among whites (19.4%) and ranged by state from 14.5% to 25.2%. CONCLUSIONS: Lung cancer survival improved slightly between the periods 2001-2003 and 2004-2009 but was still low, with variation between states, and persistently lower survival among blacks than whites. Efforts to control well established risk factors would be expected to have the greatest impact on reducing the burden of lung cancer, and efforts to ensure that all patients receive timely and appropriate treatment should reduce the differences in survival by race and state. Cancer 2017;123:5079-99. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

A qualitative analysis of smokers' perceptions about lung cancer screening.

BACKGROUND: In 2013, the US Preventive Services Task Force (USPSTF) began recommending lung cancer screening for high risk smokers aged 55-80 years using low-dose computed tomography (CT) scan. In light of these updated recommendations, there is a need to understand smokers' knowledge of and experiences with lung cancer screening in order to inform the design of patient education and tobacco cessation programs. The purpose of this study is to describe results of a qualitative study examining smokers' perceptions around lung cancer screening tests. METHODS: In 2009, prior to the release of the updated USPSTF recommendations, we conducted 12 120-min, gender-specific focus groups with 105 current smokers in Charlotte, North Carolina and Cincinnati, Ohio. Focus group facilitators asked participants about their experience with three lung cancer screening tests, including CT scan, chest x-ray, and sputum cytology. Focus group transcripts were transcribed and qualitatively analyzed using constant comparative methods. RESULTS: Participants were 41-67 years-old, with a mean smoking history of 38.9 pack-years. Overall, 34.3% would meet the USPSTF's current eligibility criteria for screening. Most participants were unaware of all three lung cancer screening tests. The few participants who had been screened recalled limited information about the test. Nevertheless, many participants expressed a strong desire to pursue lung cancer screening. Using the social ecological model for health promotion, we identified potential barriers to lung cancer screening at the 1) health care system level (cost of procedure, confusion around results), 2) cultural level (fatalistic beliefs, distrust of medical system), and 3) individual level (lack of knowledge, denial of risk, concerns about the procedure). Although this study was conducted prior to the updated USPSTF recommendations, these findings provide a baseline for future studies examining smokers' perceptions of lung cancer screening. CONCLUSION: We recommend clear and patient-friendly educational tools to improve patient understanding of screening risks and benefits and the use of best practices to help smokers quit. Further qualitative studies are needed to assess changes in smokers' perceptions as lung cancer screening with CT scan becomes more widely used in community practice.

Racial and Ethnic Differences in Health Behaviors and Preventive Health Services Among Prostate Cancer Survivors in the United States.

INTRODUCTION: Little is known about how health behaviors and receipt of preventive health care differ by race and ethnicity among prostate cancer survivors. The purpose of this study was to identify differences in the prevalence of 7 modifiable factors related to prostate cancer: smoking, alcohol consumption, physical inactivity, weight, colorectal cancer screening, influenza vaccination, and pneumococcal vaccination. METHODS: We used data from the 2010 Behavioral Risk Factor Surveillance System to calculate the racial/ethnic prevalence of sociodemographic and health-related characteristics, health behaviors, and preventive health care among prostate cancer survivors. Adjusted prevalence estimates were calculated by using multivariable logistic regression. RESULTS: We identified 8,016 men with a history of prostate cancer. Multivariable analyses indicated that more black men reported being obese (29.9%; 95% confidence interval [CI], 24.5%-35.9%) than white men (22.8%; 95% CI, 21.1%-24.6%). More white men (3.6%; 95% CI, 2.9%-4.5%) reported consuming more than 2 alcoholic drinks per day than black men (0.9%; 95% CI, 0.4%-2.0%). More white men aged 65 or older reported receiving pneumococcal vaccine (74.2%; 95% CI, 72.2%-76.1%) than black men of the same age (63.2%; 95% CI, 54.8%-70.8%).We did not observe any differences in the prevalence of health behaviors and preventive health care between white men and men in Hispanic or other race categories. CONCLUSION: Differences in alcohol consumption, obesity, and receipt of pneumococcal vaccination existed only between black and white prostate cancer survivors. These differences underscore the need to develop culturally appropriate, evidence-based interventions to reduce excessive alcohol consumption, maintain a healthy weight, and promote pneumococcal vaccination among prostate cancer survivors.

Comorbidities, smoking status, and life expectancy among individuals eligible for lung cancer screening.

BACKGROUND: Lung cancer screening recommendations are based on results from the National Lung Screening Trial (NLST). The authors determined how the screening-eligible US population differs from NLST participants in terms of characteristics that affect their ability to benefit from screening. METHODS: The authors identified respondents to the 2012 Health and Retirement Study (HRS), a national survey of individuals aged ≥50 years who are eligible for screening based on US Preventive Services Task Force and Centers for Medicare and Medicaid Services criteria. Comorbidities, life expectancy, smoking history, and other characteristics were compared between the screening-eligible population and NLST participants. RESULTS: The authors estimated that in 2013, 8.4 million individuals (95% confidence interval, 7.9-8.9 million individuals) would have met the eligibility criteria for lung cancer screening established by the US Preventive Services Task Force. Compared with NLST participants, HRS screening-eligible respondents were older, more likely to be current smokers, and more likely to have been diagnosed with comorbidities. The 5-year survival rate was 87% in the HRS screening-eligible individuals versus 93% in the NLST participants (P<.001, based on a 2-sided test). Life expectancy was 18.7 years in the HRS screening-eligible individuals versus 21.2 years in the NLST participants. CONCLUSIONS: The US population eligible for lung cancer screening is probably less likely to benefit from early detection than NLST participants because they face a high risk of death from competing causes. The results of the current study highlight the need for smoking cessation interventions targeting those patients eligible for screening and tools to help clinicians determine the potential benefits of screening in individual patients.

CDC Grand Rounds: the future of cancer screening.

Cancer is the second leading cause of death in the United States, with 52% of deaths caused by cancers of the lung and bronchus, female breast, uterine cervix, colon and rectum, oral cavity and pharynx, prostate, and skin (melanoma). In the 1930s, uterine cancer, including cancer of the uterine cervix, was the leading cause of cancer deaths among women in the United States. With the advent of the Papanicolaou (Pap) test in the 1950s to detect cellular level changes in the cervix, cervical cancer death rates declined significantly. Since this first cancer screening test, others have been developed that detect the presence of cancer through imaging procedures (e.g., mammography, endoscopy, and computed tomography) and laboratory tests (e.g., fecal occult blood tests).

Decreasing trend in tobacco-related cancer incidence, United States 2005-2009.

More than 1 in 3 cancer-related deaths are associated with tobacco use; these include cancers of the lung and bronchus, oral cavity and pharynx, larynx, esophagus, stomach, pancreas, kidney and renal pelvis, urinary bladder, and cervix, and acute myeloid leukemia. In order to characterize the current cancer burden due to tobacco use, this study provides recent trends in tobacco-related cancer incidence across the US. We analyzed data from CDC's National Program of Cancer Registries and NCI's Surveillance, Epidemiology and End Results Program, covering 100% of the US population during 2005-2009. Age-adjusted incidence rates, 95% confidence intervals and annual percent change were calculated for each state, the District of Columbia, and the US. Tobacco-related cancer incidence in the US decreased significantly from 152.9 (per 100,000 persons) in 2005 to 145.8 in 2009. Men had higher incidence rates, but a greater decrease in tobacco-related cancers per year over the 5-year time period (-1.4% in men, compared to -0.8% in women). Incidence rates decreased the most per year for larynx (-2.4%), lung and bronchus (-1.9%) and stomach (-1.5%) cancers during the study period. Tobacco-related cancer incidence trends varied by state. While tobacco-related cancer incidence in the United States decreased overall from 2005 to 2009, tobacco continued to account for a large cancer burden. Our findings suggest that continued efforts in tobacco prevention and control are needed to further reduce tobacco-related cancer burden in general and among targeted sub-populations in the US.

Methods for improving the quality and completeness of mortality data for American Indians and Alaska Natives.

OBJECTIVES: We describe methods used to mitigate the effect of race misclassification in mortality records and the data sets used to improve mortality estimates for American Indians and Alaska Natives (AI/ANs). METHODS: We linked US National Death Index (NDI) records with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN deaths. Analyses excluded decedents of Hispanic origin and focused on Contract Health Service Delivery Area (CHSDA) counties. We compared death rates for AI/AN persons and Whites across 6 US regions. RESULTS: IHS registration records merged to 176,137 NDI records. Misclassification of AI/AN race in mortality data ranged from 6.3% in the Southwest to 35.6% in the Southern Plains. From 1999 to 2009, the all-cause death rate in CHSDA counties for AI/AN persons varied by geographic region and was 46% greater than that for Whites. Analyses for CHSDA counties resulted in higher death rates for AI/AN persons than in all counties combined. CONCLUSIONS: Improving race classification among AI/AN decedents strengthens AI/AN mortality data, and analyzing deaths by geographic region can aid in planning, implementation, and evaluation of efforts to reduce health disparities in this population.

Lung cancer incidence trends among men and women--United States, 2005-2009.

Lung cancer is the leading cause of cancer death and the second most commonly diagnosed cancer (excluding skin cancer) among men and women in the United States. Although lung cancer can be caused by environmental exposures, most efforts to prevent lung cancer emphasize tobacco control because 80%-90% of lung cancers are attributed to cigarette smoking and secondhand smoke. One sentinel health consequence of tobacco use is lung cancer, and one way to measure the impact of tobacco control is by examining trends in lung cancer incidence rates, particularly among younger adults. Changes in lung cancer rates among younger adults likely reflect recent changes in risk exposure. To assess lung cancer incidence and trends among men and women by age group, CDC used data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the period 2005-2009, the most recent data available. During the study period, lung cancer incidence decreased among men in all age groups except <35 years and decreased among women aged 35-44 years and 54-64 years. Lung cancer incidence decreased more rapidly among men than among women and more rapidly among adults aged 35-44 years than among other age groups. To further reduce lung cancer incidence in the United States, proven population-based tobacco prevention and control strategies should receive sustained attention and support.

Patterns of Care for Medicare Beneficiaries With Metastatic Prostate Cancer.

INTRODUCTION: Therapeutic options for men with metastatic prostate cancer have increased in the past decade. We studied recent treatment patterns for men with metastatic prostate cancer and how treatment patterns have changed over time. METHODS: Using the Surveillance, Epidemiology, and End Results‒Medicare database, we identified fee-for-service Medicare beneficiaries who either were diagnosed with metastatic prostate cancer or developed metastases following diagnosis, as indicated by the presence of claims with diagnoses codes for metastatic disease, between 2007 and 2017. We evaluated treatment patterns using claims. RESULTS: We identified 29,800 men with metastatic disease, of whom 4721 (18.8%) had metastatic disease at their initial diagnosis. The mean age was 77 years, and 77.9% of patients were non-Hispanic White. The proportion receiving antineoplastic agents within 3 years of the index date increased over time (from 9.7% in 2007 to 25.9% in 2017; P < .001). Opioid use within 3 years of prostate cancer diagnosis was stable during 2007 to 2013 (around 73%) but decreased through 2017 to 65.5% (P < .001). Patients diagnosed during 2015 to 2017 had longer median survival (32.6 months) compared to those diagnosed during 2007 to 2010 (26.6 months; P < .001). CONCLUSIONS: Most metastatic prostate cancer patients do not receive life-prolonging antineoplastic therapies. Improved adoption of effective cancer therapies when appropriate may increase length and quality of survival among metastatic prostate cancer patients.

Use Trends and Recent Expenditures for Cervical Cancer Screening-Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years.

Importance: Since 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening-associated services in this age group. Objective: To examine annual use trends in cervical cancer screening-associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019. Design, Setting, and Participants: This population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022. Main Outcomes and Measures: Proportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019. Results: There were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019. Conclusions and Relevance: The results of this cross-sectional study suggest that while annual use of cervical cancer screening-associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.

Multilevel Small Area Estimation for County-Level Prevalence of Mammography Use in the United States Using 2018 Data.

Background: The U.S. Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50-74 years. We aim to generate county-level prevalence estimates for mammography use to examine disparities among counties. Materials and Methods: We used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 111,902 women) and linked them to county-level data from the American Community Survey. We defined two outcomes: mammography within the past 2 years (current); and mammography 5 or more years ago or never (rarely or never). We poststratified the data with U.S. Census estimated county population counts, ran Monte Carlo simulations, and generated county-level estimates. We aggregated estimates to state and national levels. We validated internal consistency between our model-based and BRFSS state estimates using Spearman and Pearson correlation coefficients. Results: Nationally, more than three in four women [78.7% (95% confidence interval {CI}: 78.2%-79.2%)] were current with mammography, although with large variations among counties. Also, nationally, about one in nine women [11% (95% CI: 10.8%-11.3%)] rarely or never had a mammogram. County estimates for being current ranged from 60.4% in New Mexico to 86.9% in Hawaii. Rarely or never having a mammogram ranged from 6% in Connecticut to 23.0% in Alaska, and on average, almost one in eight women in all the counties. Internal consistency correlation coefficient tests were ≥0.94. Conclusions: Our analyses identified marked county variations in mammography use across the country among women aged 50-74 years. We generated estimates for all counties, which may be helpful for targeted outreach to increase mammography uptake.