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Oral Health Surveillance in the US & States. Mike Manz, DDS, MPH University of Michigan and ASTDD Consultant Texas Oral Health Summit: Advocacy, Equity & Access Austin, Texas September 9-10, 2004. Oral Health Surveillance – State of the States . Mike Manz, DDS, MPH

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oral health surveillance in the us states

Oral Health Surveillance in the US & States

Mike Manz, DDS, MPH

University of Michigan

and ASTDD Consultant

Texas Oral Health Summit: Advocacy, Equity & Access

Austin, Texas

September 9-10, 2004

oral health surveillance state of the states

Oral Health Surveillance – State of the States

Mike Manz, DDS, MPH

University of Michigan

and ASTDD Consultant

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Great (Lake) State

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surveillance

Surveillance

My definition: What you want to know about who(m?) and what you do with it.

surveillance defined
Surveillance Defined
  • Surveillance vs. Surveys vs. Screening
  • Surveillance in public health is “the ongoing systematic collection, analysis and interpretation of outcome-specific data for use in the planning, implementation and evaluation of public health practice.”

Thacker SB, Berkelman RL. Public health surveillance in the United States. Epidemiol Rev 1988;10:164-90.

specific oral health surveillance aims
Specific Oral Health Surveillance Aims
  • Address problems described in Report of the Surgeon General on Oral Health at state (Texas) level www.surgeongeneral.gov/library/oralhealth/
  • And… A National Call to Action to Promote Oral Health www.nidcr.nih.gov/sgr/CallToAction.asp
  • Assess progress toward Healthy People 2010 objectives (HHS- Office of Disease Prevention and Health Promotion) www.healthypeople.gov
report of the surgeon general on oral health
Report of the Surgeon General on Oral Health
  • Purpose of reports: “frame the science on vital health issues in a way that have helped educate, motivate and mobilize the public to more effectively deal with those issues”
  • Emphasized racial and socio-economic disparities particularly in children
hp 2010 oral health
HP 2010 - Oral Health
  • Goal : Prevent and control oral and craniofacial diseases, conditions, and injuries and improve access to related services.
  • Objectives: 17, including oral health status, individual and population preventive exposure, and access to care
  • Age groups:
    • Caries: 2-4, 6-8, 15, adults
    • Sealants: 8, 14
    • Edentulism: 65-74
    • Periodontal Disease: 35-44
    • Oral Cancer Screening: ge 40
existing data sources
Existing Data Sources
  • National Level
    • NCHS - NHANES, NHIS
    • Fluoridation Census
    • NIDCR
  • State Level
    • BRFSS
    • WFRS/ MWF
    • YRBS
    • PRAMS
    • Previous surveys
    • Medicaid and private insurance data (claims - no dx codes)
existing data sources13
Existing Data Sources
  • NIDCR/CDC Data Resource Center
    • Existing national survey data and OH related questions
existing oral data brfss
Existing Oral Data - BRFSS
  • Core component
  • Optional modules and
  • State added questions addressing:
    • Access to care/last dental visit
    • Teeth cleaning/oral hygiene
    • Dental insurance
    • Edentulism/missing teeth
    • Tobacco use
collecting new data filling gaps
Collecting New Data (Filling Gaps)
  • Questionnaires vs. in-mouth screening
    • Conditions assessed
    • Resources
    • Costs
    • Response
    • Who’s doing the assessing
    • Self Assessment Reliability (pending)
astdd www astdd org
ASTDD www.astdd.org
  • State Activities
  • Best Practices
  • Resources Links including state oral health programs
  • Publications
    • Basic Screening Survey (BSS)
    • Seven Step Model
    • Program Guidelines
    • Technical Assistance
best practice approaches state oral health surveillance
Best Practice Approaches – State Oral Health Surveillance
  • Characteristics/utility of a good system
  • Sources of data
  • Building an OH surveillance system
    • National Oral Health Surveillance System (NOHSS) as a basis
    • Using existing data and integrating with existing systems (YRBS, PRAMS, BRFSS)
    • In-mouth surveys as needed
best practice approaches state oral health surveillance18
Best Practice Approaches – State Oral Health Surveillance
  • Emphasis on
    • defining resources
    • use of system data for planning/decision making
    • importance of dissemination and partnering
  • CDC model cited:

resources > activities > outcomes www.cdc.gov/oralhealth/library/infrastructure.htm

best practice approaches state oral health surveillance19
Best Practice Approaches – State Oral Health Surveillance
  • Oral health surveillance system evaluation criteria
    • Impact/effectiveness – important indicators and dissemination
    • Efficiency – regular schedule, cost effective data collection, analysis, and dissemination
    • Sustainability – continuous over years to analyze trends
    • Collaboration/integration
      • Resources and partnering
      • Integrating oral health into other programs
    • Objectives/rationale – clear on why system exists and how data will be used
guidelines for state and territorial oral health programs
Guidelines for State and Territorial Oral Health Programs
  • Based on 1988 IOM Future of Public Health Report model with components:
    • Assessment
    • Policy development
    • Assurance
guidelines for state and territorial oral health programs21
Guidelines for State and Territorial Oral Health Programs
  • Specific guidelines on Assessment
    • Oral Health Status and Needs
      • Monitor oral health status and needs
      • Assess oral health in special populations
      • Document dental service needs
    • Analyze determinants of oral health (includes assessment of OH services, workforce, and knowledge/perceptions of constituents and care providers)
    • Assess state and local fluoridation
guidelines for state and territorial oral health programs22
Guidelines for State and Territorial Oral Health Programs
  • Implement OH surveillance system
    • Develop (Seven Step Model)
    • Maintain – systematic continuous collection
    • Disseminate findings
    • Support local surveillance
    • Surveillance (evaluation) of OH programs/services
    • Integrate with other state systems
    • Coordinate/collaborate with other government/industry/university etc. surveillance
    • Surveillance of potential OH hazards (radiation, amalgam (Hg), infection control, nitrous oxide…)
astdd resources
ASTDD Resources
  • Seven Step Model
  • Basic Screening Survey (BSS)
  • BSS EpiInfo program module
seven step model
Seven Step Model
  • Lays out the steps in developing a needs assessment system (simple to complex)
    • Identify partners – form advisory committee
    • Conduct a self assessment
    • Plan the needs assessment
    • Collect data
    • Organize and analyze data
    • Prioritize issues and report findings
    • Evaluate the needs assessment
objectives of bss surveys
Objectives of BSS Surveys
  • To provide information not available from existing data sources
  • Assess basic (but important) indicators - simple training for non-dental professionals
  • To provide information on:
    • Caries experience and untreated caries
    • Dental sealants
    • Can add - dental trauma, malocclusion, dental fluorosis, oral pathology, missing teeth…..
objective objectives
Objective Objectives
  • Derive population estimates from sample
  • Get good estimates - representative sample
  • Be able to estimate statistically how good these estimates are (probability sampling)
  • Avoid biases in sample (good design and following protocol)
  • Avoid biases in data collection (standardization and following protocol)
what you can get
What You Can Get
  • State estimates
  • County specific estimates for bigger counties
  • Estimates by SES (F/R lunch)
  • Estimates by urban/rural
  • Estimates by health region
what you can do with it
What You Can Do With It
  • Compare to national (NHANES) and other state (NOHSS) data / report (NOHSS, MCH)
  • Track disease trends over time/ assess progress toward Healthy People Objectives
  • Explore variations by geography, SES, etc. = disparities
  • Provide for optimal program planning for improving the oral health of the population
what s going on cdc
What’s going on? - CDC
  • Data Systems • MWF• NOHSS

• Oral Health Maps• Synopses • WFRS

national oral health surveillance system www cdc gov nohss
National Oral Health Surveillance Systemwww.cdc.gov/nohss/
  • CDC/ASTDD – monitor disease burden
  • 8 oral health indicators
    • Dental visits (NHIS, BRFSS)
    • Teeth cleaning (BRFSS)
    • Edentulism (BRFSS)
    • Fluoridation (WFRS)
    • Caries experience (BSS)
    • Untreated caries (BSS)
    • Dental sealants (BSS)
    • Oral cancer (Vital statistics, cancer registries)
national oral health surveillance system
National Oral Health Surveillance System
  • Inclusion Criteria for Caries/Sealants Data
    • Within past 10 years
    • Statewide probability sample
    • Trained/calibrated examiners (yearly)
    • NIDCR or BSS criteria used
    • SUGGEST minimally 3rd grade (K-2)
    • Stratified by grade (vs. age)
    • Submitted by school year
      • Would like nonresponse adjustment
      • % F/R lunch for sample kids, schools, and state
examples pennsylvania
Examples - Pennsylvania
  • Battery of Surveys 1998-2000
    • School – Grades 1,3,9 and 11 (caries counts)
    • Parent interview on subset (SES, insurance, perceived need, concerns, parents oral history, dental knowledge)
    • School nurses – log of emergency visits/dental
    • Fluoridation census
  • State mandated oral screenings - entry (K or 1), 3, and 7 - school summaries dmf and treatment need (since 1949 - boxed in Harrisburg) = untapped resource
illinois
Illinois
  • Just completing BSS survey / Division of Chronic Disease (CV and obesity) BMI
  • 1994 DMF survey with trauma/mouthguards info
  • BRFSS, cancer registry, PRAMS, NOSHA, MCH, Medicaid - summary of data collected/how/ and when, Illinois specific indicators
  • Communication and information to collect on regular basis from local agencies (may develop ground-up surveillance system)
  • Workforce survey (practice characteristics, retirement)
  • Fluoride survey – awareness of dentists/hygienists
kentucky
Kentucky
  • LARGE statewide surveys in 1987, 2001
  • Presently developing surveillance system
  • 3 year cycles of replicate samples conducted annually
  • State representation annually, county level after 3 years and annual surveys merged for improved state estimates
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Ohio
  • Large surveys – 87, 92-93, 98-99, 04-05
  • State to county level surveys (vs. VT)
  • Down to grade 3 and BSS indicators
  • County profiles website
  • Detailed data available to counties for monitoring, and reporting, and grant applications $$$$$
ohio cont
Ohio cont.
  • Annual data
  • 25 sentinel sites (reassessed)
  • MCH requirements
  • Need/Readiness assessment
    • Hospital data (OH Hospital Assn)
    • Workforce data
    • Census data
    • Medicaid Data
    • Ohio Family Health Survey
summary
Summary
  • Oral Health Surveillance: Past, Present, and Future Challenges. J Public Health Dent 2003;63(3):141-9.
    • Trend to state and local data collection
    • Integration with existing systems
    • Visual only simpler oral indicators
    • Variety of conditions/behaviors (vs. DMF)
    • Timely analysis and dissemination
summary logical conclusion
Summary – Logical Conclusion

The better you can define the problem, the better your chances of obtaining resources and addressing the problem.

bonus time sampling issues
Bonus Time - Sampling Issues
  • Representative of Who?
  • Precision of population estimates
  • Level of Estimates
    • State
    • Region
    • County
    • (Small Area Estimation)
  • Subpopulations of interest
methods
Methods
  • Representative PPS (probability proportional to size) sampling of schools to produce state and subpopulation estimates
  • Systematic Selection from an ordered list to achieve “implicit stratification” on region, urban/rural, and free/reduced lunch eligibility, …. your choice
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Sampled School Districts

and Regions

Pittsburgh

Philadelphia

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Sampled School Districts and

County Populations

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sampling terms
Sampling Terms
  • Probability Sampling
  • Purposive (“Expert Choice”) Sampling
  • Simple Random Sampling
  • Cluster Sampling
  • Stratification and Stratified Random Sampling
  • Systematic Sampling (Implicit Stratification)
  • Probability Proportional to Size (PPS)
  • Weights
  • Oversampling
  • Nonresponse (BAD)
but how many kids should we screen
But how many kids should we screen???????
  • Simple but unsatisfying answer – how many can you screen?
  • Certain % of the population? - nope
  • Real first question - how much precision do you want (or will settle for) at what level?
  • Second question – do you have other data for sample size calculation
  • Third question – what’s your sample design?
sample size effects of sample design
Sample Size –Effects of Sample Design
  • Stratification – small gains in precision
  • Clustering – potentially big loss in precision
  • Main variable(s) of interest
  • Design Effect – practical definition
  • Expected Non-response
sample size effects of sample design49
Sample Size –Effects of Sample Design
  • In our case (BSS) – proportions
  • Simpler formula than continuous variables:
  • v(p0) = (1-f) p0 q0 / n-1
  • Conservatively use p0 = 50%
  • For 95% CI = +/- 10% n = 97
  • For 95% CI = +/- 5% n = 384
  • For 95% CI = +/- 3% n = 1,066
sample size effects of sample design50
Sample Size –Effects of Sample Design
  • Then multiply by estimated design effect
  • Remember basically the same calculations are appropriate for the designated population level, e.g.
    • If want this precision for regional level estimates and have 5 regions, then X 5
    • If want this precision for county level estimates and have 35 counties, then X 35
surveillance recommendations
Surveillance Recommendations
  • Follow probability sampling protocol
  • Keep screeners standardized
  • Start slow – when people are involved, they always create new and innovative problems.
  • Make sure everyone knows and follows the study protocol
school aged surveillance tips
School-Aged Surveillance Tips
  • School Nurses
  • Selection of Classes
  • Nonresponse at Student level
    • Motivated Teachers / Random Sampling
    • Incentives Grade 3 vs. HS
  • Nonresponse at Cluster (school) level
    • Replacement method (no, not the next one on the list)