What is surveillance and why is it important to oral health?
Surveillance is widely defined as the ongoing, systematic collection, analysis, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control. It is important because it identifies public health emergencies/issues; provides data that informs policy; documents the impact of interventions and progress towards specified public health targets/goals; and allows for public health officials to understand/monitor the epidemiology of a condition to set priorities and guide public health policy and strategies.
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Are states required to collect oral health surveillance data?
States are required to collect Annual Early and Periodic Screening and Diagnostic Testing (EPSDT) data to fulfill Medicaid/CHIP requirements. Otherwise, there are no nation-wide requirements placed on states to collect oral health surveillance data; however, it is not uncommon for states to be required to collect data when receiving monies via federal grants (e.g., states receiving funding from CDC’s Division of Oral Health collect surveillance data, including third-grader Basic Screening Survey (BSS) and Water Fluoridation Reporting System (WFRS) data).
Individual state requirements for collecting oral health surveillance data vary greatly from state to state.
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What are the major national oral health surveillance systems and what kinds of information are collected?
- Behavioral Risk Factor Surveillance System (BRFSS): A state-based, ongoing data collection program designed to measure behavioral risk factors in the adult, non-institutionalized population 18 years of age or older. Every month, states select a random sample of adults for a telephone interview. This selection process results in a representative sample for each state so that statistical inferences can be made from the information collected.
- National Health and Nutrition Examination Survey (NHANES I [1971-75], NHANES III [1988-94], and NHANES [1999-2004]): A national survey designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations. NHANES I used a national sample of about 28,000 persons between the ages of 1 and 74. The sampling design of NHANES I did not include persons of Hispanic/Latin origin. NHANES III included about 40,000 people selected from households in 81 counties across the United States. To obtain reliable estimates, infants and young children (aged 1 to 5 years), older persons (aged 60 years and older), Black Americans and Mexican Americans were sampled at a higher rate. The latest iteration of NHANES is a continuous survey visiting 15 U.S. locations per year. Approximately 5,000 people are surveyed annually. Oral health data from the current NHANES will be added to NOHSS when data from each phase of the survey become publicly available.
- Youth Risk Behavior Surveillance System (YRBSS): A CDC school-based survey conducted biennially to assess the prevalence of health risk behaviors among high school students. YRBSS includes national, state, territorial, and local school-based surveys of high school students. The school-based surveys employ a cluster sample design to produce a representative sample of students in grades 9–12. Survey procedures are designed to protect the students’ privacy by allowing for anonymous and voluntary participation. Current data collected relating to oral health includes tobacco-use, dietary behaviors, and behaviors that contribute to unintentional injury and violence.
- National Health Interview Survey (NHIS): A cross-sectional household interview survey on the health of the civilian non-institutionalized population of the United States. The sampling plan follows a multistage area probability design that permits the representative sampling of households. NHIS data are collected annually from approximately 43,000 households including about 106,000 persons.
- Medical Expenditure Panel Survey (MEPS): Started in 1996, MEPS is a set of large-scale surveys of families and individuals, their medical providers, and employers across the United States. MEPS collects data on the specific health services (including oral health) that Americans use, how frequently they use them, the cost of these services, and how they are paid for, as well as data on the cost, scope, and breadth of health insurance held by and available to U.S. workers.
- National Survey of Children’s Health (NSCH) and NSCH with Special Health Care Needs (NSCHSHCN) (as part of the State and Local Area Integrated Telephone Survey (SLAITS): Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCH) telephone survey includes four oral health-related questions of children ages 0-17 years. The last iteration was performed in 2007-08 and had a sample size of nearly 92,000 children.
- Dental, Oral, and Craniofacial Data Resource Center (DRC): Co-sponsored by the National Institute of Dental and Craniofacial Research (NIDCR) and CDC-DOH, the DRC conducts surveillance on dental, oral, and craniofacial conditions. The DRC is a primary resource for data for the oral health research community, clinical practitioners, public health planners and policy makers, advocates, and the general public.
- Healthy People DATA2010: An interactive database system developed by the Division of Health Promotion Statistics at the National Center for Health Statistics that contains the most recent monitoring data for tracking Healthy People 2010. Data are included for all of the 467 objectives and additional subgroups in 28 focus areas identified in the Healthy People 2010: Objectives for Improving Health. DATA2010 contains primarily national data. However, state-based data are provided as available. Data for the population-based objectives may be presented separately for select populations, such as racial, gender, educational attainment, or income groups. National data are gathered from more than 190 different data sources, from more than seven Federal Government Departments (including Health and Human Services, Commerce, Education, Justice, Labor, Transportation, and the Environmental Protection Agency), and from voluntary and private non-governmental organizations.
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What are the major state oral health surveillance systems and what kinds of information are collected?
- National Oral Health Surveillance System (NOHSS): Developed by CDC-DOH and ASTDD, NOHSS is designed to monitor the burden of oral disease, use of the oral health care delivery system, and the status of community water fluoridation on both a national and state level. NOHSS is designed to track oral health surveillance indicators based on data sources and surveillance capacity available to most states.
- Basic Screening Survey (BSS): Developed by ASTDD and CDC, BSS is a standardized set of surveys designed to collect information on the observed oral health of participants, self-report or observed information on age, gender, race and Hispanic ethnicity, and self-report information on access to care for preschool, school-age, and adult populations. The surveys are cross-sectional and descriptive. In the observed oral health survey, gross dental or oral lesions are recorded by dentists, dental hygienists, or other appropriate health care workers in accordance with state law. The examiner records presence of untreated cavities and urgency of need for treatment for all age groups. In addition, for preschool and school-age children, caries experience (treated and untreated decay) is also recorded. School-age children are also examined for presence of sealants on permanent molars.
- Pregnancy Risk Assessment Monitoring System (PRAMS): A surveillance system that collects state-specific, population-based data on maternal attitudes and experiences prior to, during, and immediately following pregnancy. The PRAMS sample of women who have had a recent live birth is drawn from the state's birth certificate records. Each participating state samples between 1,300 and 3,400 women per year. Women from some groups are sampled at a higher rate to ensure adequate data are available in smaller but higher risk populations. Information is gathered by mail and telephone. Data collection procedures and instruments are standardized to allow comparisons between states. The PRAMS allows CDC and state health officials to monitor changes in maternal and child health indicators (e.g., unintended pregnancy, prenatal care, breastfeeding, smoking, alcohol use, infant health).
- Head Start Program Information Report (PIR): Provides comprehensive data on the services, staff, children, and families served by over 2,500 Head Start and Early Head Start programs nationwide. Most data are collected annually, although grantees are required to report enrollment on a monthly basis. All grantees and delegates are required to submit Program Information Reports for each Head Start or Early Head Start program operated. The PIR data are compiled for use at the federal, regional, and local levels. The PIR includes the percent of Head Start enrolled children in need of dental treatment.
- Annual Early and Periodic Screening and Diagnostic Testing (EPSDT) Report (Form CMS-416): The CMS-416 provides basic information on participation in the Medicaid child health program. The statute requires that States provide CMS with the following: (1) the number of children provided child health screening services, (2) the number of children referred for corrective treatment, (3) the number of children receiving dental services, and (4) the State's results in attaining goals set for the state under section 1905(r) of the Act. The information is used to assess the effectiveness of State EPSDT programs in terms of the number of children (by age group and basis of Medicaid eligibility), who are provided child health screening services, are referred for corrective treatment, and the number receiving dental services.
- Water Fluoridation Reporting System (WFRS): Developed by the CDC, WFRSS provides state oral health program staff a tool for monitoring the quality of the water fluoridation program in their state. Data provided by water systems is used by state oral health program staff to recognize excellent work in water fluoridation and identify opportunities for continuous improvement in the water fluoridation program. The data are also used to develop estimates of the percentage of the population that receives fluoridated water.
- Child Health Survey (Example: Colorado): Initiated in 2004 through a state partnership, the Child Health Survey was designed to fill the health data gap in Colorado that exists for children ages 1-14. It is coupled with the BRFSS, which surveys Colorado adults via a random digit dialing telephone survey method. Once a respondent has completed the BRFSS, the interviewer inquires if they have a child in the target age range and about their willingness to complete the Child Health Survey. Approximately 10 days later, the parent is called to complete the survey on a variety of topics, including their child's access to health and dental care. Data from about 1,000 surveys are collected over each calendar year, which are cleaned and weighted to reflect the general population of children 1-14 years old.
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What is an example of a local oral health survey and what kind of information is collected?
* Hospital ER Data: Five Ambulatory Care-Sensitive (ACS) dental conditions (preventable dental conditions) were studied in California. California Health Care Foundation, “Emergency Department Visits for Preventable Dental Conditions in California” (2009).
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What impact does the federal Patient Protection and Affordable Coverage Act (ACA) have on oral health surveillance?
Section 4102 of ACA requires the Secretary of HHS to update and improve national oral health surveillance as follows:
- Requires all states to participate in NOHSS
- Requires the inclusion of oral health reporting on pregnant women through PRAMS (currently optional)
- Retains the current NHANES “tooth-level” surveillance (plans were to drop this level of measure for “person-level” analysis)
- Requires MEPS findings for dental expenditures be validated through a “look back” procedure to be in-line with current standards applied to medical expenditures.
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Where can I get more information?
* Beltrán-Aguilar ED, Malvitz DM, Lockwood SA, Rozier RG, Tomar SL. “Oral health surveillance: past, present, and future challenges.” J Public Health Dent. 2003 Summer; 63(3):141-9.
* Meriwether RA. “Blueprint for a national public health surveillance system for the 21st century.” J Public Health Management Practice 1996; 2(4):16-23.
* ASTDD. “Best Practice Approach: State-based Oral Health Surveillance System.” July 14, 2008.
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