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 Survey Populations Surveyed Survey Design & Administration Analysis (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 Region Region Region Region Statewide (sample size)

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

Questions ??? Elizabeth Barrett, DMD, MSPH (804)