1. National Health and Nutrition Examination Survey – Oral Health Components Laurie Barker, MSPH Mathematical Statistician Surveillance, Investigation and Research Team Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion Office of Noncommunicable Diseases, Injury and Environmental Health lub2@cdc.gov

2. Workshop Overview Lecture I.Introduction II.NHANES Overview III.NHANES Data Resources IV.Future Developments in NHANES Hands-on Workshop V.Orientation to NCHS NHANES Web site VI.Orientation to DRC tutorial materials VII.Practice Examples (in SAS and SUDAAN)

3. I. Introduction – CDC’s organization (oral health, NHANES) and relationship to NIDCR and other Federal agencies, and to universities and state governments – Surveillance vs. Research

4. I. Introduction: CDC organization – Within CDC DOH – located within the National Center for Chronic Disease Prevention and Health Promotion – Funds 19 states to build oral health infrastructure – Funds part of NHANES, along with NIDCR Division of HANES – located within the National Center for Health Statistics – Designs, manages contract to operate NHANES – produces public and restricted data sets – Collaborates with other NCHS divisions to link NHANES to other data sets – Publishes a wide variety of reports on NHANES

5. I. Introduction: CDC organization – Outside of CDC Department of Health and Human Services – NIH/NIDCR – CDC – CMS – HRSA – IHS – SAMSHA – …

6. I. Introduction – Surveillance vs. Research Main purpose of surveillance is to monitor trends in – known public health problems and related risk factors – Identify emerging problems – Broad picture of trends in national populations – Sentinel surveillance » monitors rarer problems in higher risk populations » Or problems in populations representative of a smaller area (county, city or specific population) Survey-based Surveillance at the national level is constrained by costs and burden to participants

7. I. Introduction – Surveillance vs. Research Changes in trends or new problems identified through surveillance ideally trigger focused research to explain the observed change Surveillance data sets are often cross-sectional – Few truly longitudinal surveys – Limitations in the types of research that can be conducted with surveillance data – New developments linkage among surveys, linkage with external data (CMS, environmental) may support more research Match rate could be a limiting issue

8. II. NHANES overview – History of NHANES – NHANES compared to other national surveys – NHANES Oral Health Components 2009-2010 Previous NHANES and precursor National Health Examination Survey – Survey design and analysis considerations Statistical methods Software

9. II. NHANES Overview: History of NHANES National Health Examination Surveys – 1959-62, 1963-65, 1966-1970 National Health and Nutrition Examination Surveys – 1971-1974, 1988-1995 – 1999+ Continuous NHANES Hispanic HANES 1986-1987

10. National Health Survey NHES I 1959-1962 – 18-79y NHES II 1963-1965 – 6-11y NHES III 1966-1970 – 12-17y NHANES I 1971-1974 – 1-74y NIDR/OHSC I 1979-1980 5-17y HHANES 1982-1984 6m-74y NIDR/OHSC II 1986-1987 5-17y NHANES III 1988-1994 2m+ NHANES 1999-2004 2y+ NHANES 2005-2008 5y+ NHANES 2009-2010 3-19y, 30y+ NHIS 1963-2010 NHAMCS 1992-2007 MEPS 1996-2008 State-based Health Survey BSS - 3 rd grade, K,1,2, HeadStart, older adults BRFSS 1999, 2002, 2004, 2006, 2008, 2010 – 18y+ Some states in other years from 1995 PRAMS 1990-1995, 1996-1999, 2000-2003, 2004- 2008, 2009+ NSCH 2003, 2007, 2011 – 0-17y NSCSHCN 2001, 2005-2006, 2009-2010 – 0-17y YRBSS 1991-2009, odd years

11. II. NHANES Overview: NHANES compared to other national surveys NHANES – National Household - questionnaire, exam, lab NHIS – National Household – questionnaire MEPS – National Household – questionnaire focused on costs BRFSS – State Telephone (multimodal now) – questionnaire – National estimates from combined states YRBSS – Paper survey – Separate National and State samples

12. II. NHANES Overview: NHANES Oral Health Components – 2009-2010 – dental hygienist raters Caries – tooth surface level, limited age range Periodontal disease – full mouth – 2005-2008 – medical technician raters Caries – person level, limited age range – 1999-2004 – dentist raters Caries and sealants - Tooth surface level Root caries, Fluorosis - Tooth level Periodontal disease – 2 quadrants, facial/buccal sites – Previous NHANES and precursor National Health Examination Survey – dentist raters Caries, other measures of oral health, some out-of-date

13. II. NHANES Overview:Survey design and analysis considerations Statistical methods Software

14. II. NHANES Overview:Survey design and analysis considerations Statistical methods – Complex sample survey design requires methods that account for clustering due to survey design, in addition to any other clustering Typically, design-based analyses have been recommended – parameter estimation limited by PSUs (~15 per 2 years) NCHS (and others) exploring other methods to account for clustering, increase yield of information from survey data – Sampling fraction, oversampling, non-response NCHS provides weights that should be used Little information to construct special weights due to disclosure protections

15. II. NHANES Overview:Survey design and analysis considerations Software – SUDAAN (or WESVAR), historically the recommended software due to limited procedures for complex samples in other software – SAS, Stata, SPSS, R All now have procedures to account for survey design Point estimates should be the same from all packages Variance estimates may differ due to choices each package has made in methods to account for clustering – Differences probably less than 0.01?

16. II. NHANES Overview:Survey design and analysis considerations Key references – Heeringa, Steven G, Brady T. West and Patricia Berglund. 2010. Applied Survey Data Analysis. Chapman & Hall, CRC, New York. – Korn, Edward L. and Barry Graubard. 1999. Analysis of Health Surveys. John Wiley, New York. – Groves, Robert M., Floyd J. Fowler, Jr., Mick P. Cooper, James M. Lepkowski, Eleanor Singer, Roger Tourangeau. 2004. Survey Methodology, 2 nd edition. John Wiley, New York, 2009.

17. III. NHANES data resources – NCHS NHANES Tutorial – Dental, Oral and Craniofacial Data Resource Center (CDC and NIDCR funded project) Current online resources Tutorial materials in development – Restricted data, linked data and Research Data Centers operated by NCHS or Census

18. III. NHANES data resources – NCHS NHANES Tutorial http://www.cdc.gov/nchs/tutorials/index.htm http://www.cdc.gov/nchs/tutorials/index.htm Excellent tutorial, materials being added regularly Not specific to oral health, but good resources for – Dietary interview data – Environmental chemical data – Variable crosswalks Cross year variable table http://www.cdc.gov/nchs/nhanes/variable_tables/cross_year_vari ables_list.htm http://www.cdc.gov/nchs/nhanes/variable_tables/cross_year_vari ables_list.htm Not for oral health yet, but many others – Demographics, dietary recall, C-reactive protein, smoking, reproductive health – Q-Bank – question evaluation reports http://wwwn.cdc.gov/qbank/Home.aspx

19. III. NHANES data resources – Dental, Oral and Craniofacial Data Resource Center (CDC and NIDCR funded project) Current online resources – Data Query System, some publications, survey questions inventory, Catalog of Surveys and Archive of Methods Related to Oral Health (400+ surveys listed) Tutorial materials in development – Will cover this in hands-on workshop » Basic info on key data sets with oral health, linked to source » Expanded documentation of oral health components » Variable crosswalks » Code for creating analytic data sets » “clean” oral health data sets

20. III. NHANES data resources – Restricted data, linked data and Research Data Centers operated by NCHS or Census – Research Data Centers http://www.cdc.gov/rdc/http://www.cdc.gov/rdc/ – Linked data – national surveys linked to CMS, mortality, air quality, Social Security Benefit history http://www.cdc.gov/nchs/data_access/data_linkage_ac tivities.htm http://www.cdc.gov/nchs/data_access/data_linkage_ac tivities.htm

21. Hands-on workshop V.Orientation to NCHS NHANES Web site VI.Orientation to DRC tutorial materials VII.Practice examples (in SAS and SUDAAN)

22. Hands-on Workshop V.Orientation to NCHS NHANES Web site – Locating and downloading files Demographics Questionnaire – Oral health – Oral health referral and recommendations – Household and other files Examination – Oral health examination – Dietary interview files Laboratory – Tobacco – C-Reactive Protein – Vitamin D

23. Hands-on workshop VI.Orientation to DRC tutorial materials

24. Hands-on workshop VII.Practice examples (in SAS and SUDAAN) – Setting up an analytic data set with questionnaire items – Preparing an analytic data set with oral health examination items and dental indices – Preparing an analytic data set with laboratory items – Producing national estimates for Healthy People objectives

25. Hands-on workshop VII.Practice examples (in SAS and SUDAAN) – Setting up an analytic data set with questionnaire items

26. Hands-on workshop VII.Practice examples (in SAS and SUDAAN) – Preparing an analytic data set with oral health examination items and dental indices

27. Hands-on workshop VII.Practice examples (in SAS and SUDAAN) – Preparing an analytic data set with laboratory items

28. Hands-on workshop VII.Practice examples (in SAS and SUDAAN) – Producing national estimates for Healthy People objectives Tracking Healthy People 2010 CDC WONDER/Data2010