2008 virginia elder oral health survey logistics & lessons learned elizabeth barrett, dmd, msph...
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2008 Virginia Elder Oral Health Survey
Logistics & Lessons Learned
Elizabeth Barrett, DMD, MSPH
Virginia Department of Health
August 18, 2009
Logistics
Why do a Statewide Survey?Purpose of SurveyPopulations SurveyedSurvey Design & AdministrationAnalysis (pending)
Why Do a Statewide Survey?
Minimal national and Virginia-specific oral health data regarding older adults
Limitations to Virginia BRFSS Limited number and type of dental indicators Limited ability to reach all elder populations
Inadequate data regarding homebound or high-risk elders of low SES
Virginia has not addressed oral health issues among the elderly or the need to increase access to dental services through improved dental coverage
Purpose of Survey
To collect specific oral health indices and information about self-care, medical conditions, access and utilization of oral health services
To document the oral health status of several elder sub-populations across the state, including Nursing Home (NH) residents and homebound seniors
To utilize results for policy and program planning purposes to address disparities in access to dental care and oral health outcomes among the elderly
Study Population Virginia elders (65+ years)
Nursing home residents Homebound Attendees of senior meal congregates
Sample estimates calculated for each category based on statewide population estimates to obtain significant results at the state level 3-5% error and a 95% confidence level were used
For NHs, used total bed capacity as a proxy to estimate this population in Virginia
Did not anticipate any problems obtaining a significant sample size within each category
Sampling: Nursing Home Residents
274 facilities Stratified population by health planning region
to ensure geographic representation Sample size calculated to reflect proportion of
NH beds by region Within each region, NHs stratified according to
facility payment type and randomly selected from each category
NHs selected using this sampling scheme until an adequate sample size was obtained for each region
Sample Size: Estimates of NH residents
Health Planning Regions Proportion
Sample (3% error)
Sample (4% error)
Sample (5% error)
Region 1 0.15 155 88 57
Region 2 0.14 144 82 53
Region 3 0.28 289 165 106
Region 4 0.20 206 118 76
Region 5 0.23 237 135 87
Statewide (sample size) 1.00 1032 589 380
Sampling: Well Elders at Congregate Centers
Used a sampling scheme to select senior groups across the state
Stratified population by the 5 health planning regions
Sample size calculated from the statewide estimate of attendees to reflect the proportion of enrolled seniors by region
Senior congregates then randomly selected within each region until an adequate sample size had been obtained for each area
Sampling: Homebound Elders
Identified from a private corporation that provides home care for adults 9 locations across the Commonwealth
providing care to homebound individuals Due to the smaller population, surveyed
all seniors (no sampling)
Survey Design
Based on Kentucky Elder Oral Health Survey Two components: Questionnaire and Clinical Questionnaire variables
Demographics, risk factors, oral hygiene habits, access to dental services, oral health conditions
Clinical variables Modified Basic Screening Survey (BSS)
Caries, soft tissue and gum disease, tooth loss, denture use Oral Hygiene Index (OHI)
Questionnaire Variables
Demographics: age, sex, race, education, income
Health conditions: paralysis/stroke, diabetes, heart problems, dementia
Demonstration of dexterity/mobility Tobacco and alcohol use
Questionnaire (continued)
Daily care: brushing, flossing, dentures
Satisfaction with oral health: ability to chew, speak, appearance
Presence of pain Dental services: visited a dentist in
past year (if no, why not; if yes, why)
Adult BSS with Additions
Denture BSS
Oral Hygiene Index
Survey Administration
Survey conducted primarily by 3 hygienists 2 public health dentists – congregate meal sites in
their localities A nurse, trained to recognize oral health indicators,
surveyed the homebound population Trained and calibrated
One full day of training provided followed by calibration in facilities on survey participants
Anticipated 6 months for data collection
Survey Administration
Contacted facility administrators and group directors for approval
Written individual informed consent required
Each participant assigned an ID number No names recorded except on consent
form
Survey Administration Supplies needed for clinical survey
Headlamp, mirror, tongue depressor, gauze and floss
All examiners wore masks and gloves and were instructed to hand sanitize before and after each exam
Residents were given OH supplies tailored to their specific needs upon completion of the survey
Analysis (pending)
Clean and weight data across each subgroup
Analyze data separately for each elder subgroup Descriptive statistics Bi-variable analyses to determine associations
between demographic predictors/risk factors and specific oral health outcomes
Multi-variable analyses to assess the predictive capability of known demographics and risk factors with regard to oral health outcomes
Lessons Learned
What Worked?
What Didn’t Work?
Lessons Learned What Worked?
Exceeded our expectation in numbers Surveyed 1448 seniors
Clinical exam was easy to use Worked well for the surveyors Obtained the most valuable information
Selection process was clear Epidemiologist’s sample process and lists for
contacting facilities were easy to follow and made planning more efficient
Lessons Learned What Worked?
Congregate Meal Sites wanted to participate No problem with getting approval to participate Sites not selected called us to see if they could
participate Able to provide educational program during visit
Homebound interested in improved oral care Stated many times to surveyor that they were
grateful to know the status of their oral health Many were unable to get to the dentist for exams Grateful for hygiene supplies we provided
Lessons Learned What Didn’t Work?
Difficulty gaining approval in NHs Facilities not interested in survey Concern that the “state” would be in the facility
Questionnaire for NH Residents Residents unable or unwilling to answer the
questions in the survey Family members not available to answer questions Facility staff too busy to answer questions Limited access to charts to obtain information
Lessons Learned What Didn’t Work?
Collecting data from homebound individuals took a lot of resources Examiner averaged about 5 exams per 8 hour day
in areas that were geographically challenging Some homebound individuals were reluctant to let
examiners in and answer questions The examiner found it hard to leave because they
wanted to talk to someone (loneliness)
Lessons Learned What Didn’t Work?
Initial estimate of congregate site participation was inflated Each individual counts as a participant even if they
attend just 1 day per year Had to go to more congregate meal sites than initially
anticipated Project took a lot of coordination
A lot of time on calls to facilities Preparing and approving travel for multiple individuals Filling requests for supplies to examiners Tracking and monitoring surveys Scheduling support staff to record for examiners
Lessons Learned What Didn’t Work?
No identifying information on forms Made it impossible to go back and obtain
missing information after the survey Consistent monitoring of multiple examiners
Although examiners were calibrated and forms were reviewed for completeness, final cleaning of data indicated that some questions were consistently missed as time progressed
Need to maintain ongoing monitoring of examiners
Lessons Learned What Didn’t Work?
Contracting for examiners Process was long and tedious Using an agency is extremely costly Hard to manage examiners that are not
compliant to procedures and deadlines set by survey coordinator
If possible, use existing staff
Conclusions Survey method is a viable way to reach our target
senior populations In future, continue to use clinical component with
slight changes and simplify questionnaire particularly with respect to NH residents
Survey took a lot of coordination, money, and other resources but it was worth it
Survey will provide valuable data regarding oral health status of Virginia elders
We look forward to analyzing the data and using it to develop new programs for Virginia’s seniors
