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Increasing Capacity to Inform Oral Health Policy
- 1. Office of the Chief Dental Officer Increasing Capacity to Inform Oral Health Policy The National Perspective - Canada Health Measures Survey October 21-22, 2009
- 4. Direct Costs of Illness in Canada by Diagnostic Category (1993 vs. 1998) (CIHI,1999; Leake & Kalyani, 2001)
- 6. Health Canada - Branches and Agencies http://hc-sc.gc.ca/ahc-asc/branch-dirgen/index_e.html
- 11. Population of Canada Compared to other countries Sri Lanka 20M India 1,080.3M Bangladesh 144.3M Nigeria 128.8M Turkey 69.7M Costa Rica 4M Spain 40.3M France 60.7M Germany 82.4M United Kingdom 60.4M Trinidad & Tobago 1.1M Thailand 65.4M Uganda 27.3M Jamaica 2.7M Netherlands 16.4M Dominican Republic 9M Haiti 8.14M Japan 127.4M Vietnam 85.5M Italy 58.1M Greece 10.7M Cuba 11.3M South Korea 48.4M Ireland 4M Taiwan 22.9M Canada Population 31.9 million Other Countries Total Population 2.2 billion
- 22. Selecting the Respondent Select sampling frame Select site Select household Select person in the household Household Interview Clinic visit http://www.statcan.ca/english/freepub/82-003-/SIE/2007000/article/10363-en.pdf
- 46. Dental Professional and Family Physician Visits Statistics Canada, Health Division, Health Reports, Winter 1999 http://www.statcan.ca/english/ads/82-003-XPE/index.htm
- 53. Self Report (Proxy) / Clinical Comparison of Dental Treatment needs in First Nations Children 1 First Nations Regional Health Survey Report; First Nations Centre, Laurier Ave. Ottawa, 2002/03. 2 Report on the 1996/97 Oral Health Survey of First Nations and Inuit Children in Canada - Aged 6 and 12. Health Canada 2000. Study Age of Children % in need of Restorative Care % in need of Urgent Care 1 Regional Health Survey 0 ->11 years 27 2 2 Oral Health Survey 6 & 12 years 63 8.4
- 90. Validity and Reliability Valid Yes Reliable Yes Valid No Reliable Yes Valid no Reliable No Unbiased Valid No Reliable No Biased
- 101. Questions/Discussion
Editor's Notes
- -available electronically; -free to interrupt; -time at end for discussion. -Appreciate that new members here so will do a quick backgrounder for them.
- This table reflects only direct costs (the value of goods and services for which payment were made, and measures used in treatment, care, and rehabilitation). Indirect costs (the value of economic output lost due to illness) are not included here. The direct costs for dental disorders in 1993 ranked third, after cardiovascular diseases and mental disorders. However, its rank moved to second place after accounting for surface costs from mental disorders in 1998.
- Web – where we fit in.
- Public health Count Dentists, Dental Hygienists, Dental Assistants, Dental Therapists, others Health Promotion/ Disease Prevention / Health Protection All would be (Community/Targeted);
- Bangladesh population density ->6.4 B population into Canada. Nunavut 1/70 sq. Km.
- CHMS covers approximately 97% of Canadians Misses First nations on Reserve Residents of Institutions Canadian Forces full time members Since most of the Inuit do not live in areas with 10,000 within 100 km radius they were missed Yellowknife was the only North of 60 community to qualify National Needs Assessment to: Determine burden of illness Identify inequalities Inform policies Assess current delivery systems Determine health promotion strategies
- This is difference between a treatment plan and disease surveillance
- Pop = population
- I will talk more later about indexes during the section on examiner calibration
- The development of the CHMS survey was recognized to be a complex undertaking that needed to consider broad issues. The CHMS therefore established a Steering Committee that brought together expertise, both national and international, from a wide variety of areas to determine the specific health measures to be included in the CHMS. The Steering Committee was tasked with considering the current available health information and identifying the health issues and indicators that would be included in the CHMS.
- Once the health issues to be studied were identified, subject matter specialists were brought together to consider these issues which would determine: which measurements would be utilized how the measurement would be taken (indices training requirements for each measures best equipment, tools etc to be utilized Blood pressure Resting blood pressure Would it be taken manually or using automated BP machines How many times would the BP be taken – once twice, three time? What is the resting period between BP Should the examiner talk to the respondent between measurements What will the rate be measured against? What is normal?
- US – Lead; Australia – Diabetes. Canada – Health Information Roadmap Initiative, Budget 2003. (Dental Confirmed 2005). #1 Priority OCDO #1 Priority FPTDD Federal “Here to help”.
- Treating heart disease is costly to the health care system. If we make assumptiongs about the number of individuals requiring by-pass surgery each year for example: To stay the same, means the same number of cases each year We know the baby boomer population is aging and the number within the population group is larger than the generation before Will they have the same number proportion of cases? If they do the real number will go up 10% of 1000 = 100 cases each year 10% of 2000 = 200 cases per year 20% of 2000 = 400 cases per year
- Why is knowing the health of Canadians so important? The objective here is to establish a baseline on the health of the average Canadian Interview questions will provide self reported information: context Physical measures are identified: Actually measuring physical attributes We’ll have the ability to compare actual physical measures to self reported questions. This bit is important as it we will be able to have a correction factor that can be applied to other existing surveys
- Three (3) Phases: 1-Planning (2003-2007) Survey Development -questionnaire -Clinical Instruments -Consents -Ethics -Privacy Commissioner -In home visits -Communications -Data processing 2-Data Collection (2007-2009) Operations -Interviewers -Methodology -Computer application -Clinic Operations (trailers etc.) 3-Outputs (2008-2011) -Information dissemination -Research community
- The survey design is complex and multi-staged Start with Canada as whole Uses census subdivisions as basis Defined sampling frame Population of 10,000 minimum (Labour Force Survey) Urban area within 50km; Rural areas within 100km Originally 257 sites representing 97% of population; reduced to 30 and finally reduced to 15 sites Objective was to ensure that there were enough children in the survey Identified household by the age of residents Whenever possible within the site a household is selected based on one child (aged 6-12) and one adult Then randomly selected the respondent 1 respondent per household; 2 if a child aged 6-12 was present Household interview then clinic visit
- 7 days a week Hours 7 – 3 and 7 – 9 days Overlapping shifts Dentists are actually Captains from the Canadian Forces (CF) Unique partnership between HC/STC and CF Anyone working for the survey, needs to be either a STC employee or deemed to be STC employee. CF are sworn in. I was sworn in as a STC employee as I wanted to observe dentally related processes All the survey staff receive initial and ongoing training: Background on Statistics Canada and their responsibilities as a STC employee – Protection of personal information is paramount Training in safety measures – CPR first aid Training on specific tests and measures How to use the computerized data collection application Interviewers are experienced STC employees but required specific training on asking health questions some of which can be very sensitive
- MOU with DND; 2 dentists/team; 7 days/week (3 with 2 + 2); Lifeline retrofitting -> “-40 ◦ C”, 4 in total Advanced arrangements team: Parking lots University Hotel Hospital (Calgary problems) Walmart Order: Screen (smoke–cotinine; eat-fasting glucose, have medications changed) B.P. Urine Blood 2 super-rooms: sit, reach, curl, dynamometer, steps. 1 oral room Never done in cold in the US.
- Need to quantify the problem; Last national baseline epidemiological information 1970 – 1972; National Needs Assessment to: Quantify the burden of illness; Identify inequalities; Assess current oral health delivery systems; Form policies.
- 46 questionnaire modules containing 722 questions Approximately 50 physical measures variables Over 120 biospecimen analytes About a dozen Environment Canada weather / pollution indicators Potential linkage to health records Household questionaire link Look at: 45 minute interview – oral health is about 3 minutes Interview questions must relate to the clinical questions Limitations of self-report data: Social desirability trends. (PEI Height/Weight Studies) Respondent recall ability Reporting bias Knowledge of conditions (Australian Diabetes Studies, STI’s Calgary) Learned from CCHS (Mental Health) as interviewers trained well (Calgary example) 4 sensitive areas: Drugs Sexual behaviour Pregnancy (alcohol) Income (hardest to obtain) Face to face works, parent out (mother…. Cross Tabs: Income – Oral Health Status Tobacco/alcohol – Perio Urine Inorganic Hg – Amalgams Preventive practices Health Human Resources Oral Health – we’ll go into the oral health questions in a few moments
- Consent is explained during the household interview and reconfirmed at the time of the clinic visit Consent can be revoked at any time during the process. General consent for adults Proxy consent for children aged 6 -12 Children may decline Reconsent for children for biological material De-identified data sharing with partners Data linking with provincial health programs
- This list of topics was generated through multiple consultations with the PHAC, Health Canada and Statistics Canada. A much larger list was pilot tested to create this final list. Any modules that were difficult to ask (i.e. too sensitive of material- social networks) or were too long or too complicated to ask were either edited or removed.
- Look at: Income, Chronic, Soft Drink consumption, Medications, Smoke etc. Limitations of self-report data: Social desirability trends. (PEI Height/Weight Studies) Respondent recall ability Reporting bias Knowledge of conditions (Australian Diabetes Studies, STI’s Calgary) Learned from CCHS (Mental Health) as interviewers trained well (Calgary example) 4 sensitive areas: Drugs Sexual behaviour Pregnancy (alcohol) Income (hardest to obtain) Face to face works, parent out (mother…. Cross Tabs: Income – Oral Health Status Tobacco/alcohol – Perio Urine Inorganic Hg – Amalgams Preventive practices Health Human Resources Oral Health: Perceived status Appearance Treatment needs Pain Bad Breath Time for dental care Dental visits Insurance
- NHANES- National Health and Nutrition Examination Survey
- For example, a respondent questioned what a Stimudent was and if that counted toward flossing if they used one everyday. As a result, there was a note added to the interviewer manual that Stimudent is a type of toothpick and does not qualify as flossing. The interview guide was developed as an adjunct to the household survey to help the interviewer if a question was asked to which they did not know the answer.
- This slide has a list of the health issues that will be studied under the CHMS. Additionally, the interrelationship between the issues can also be investigated. For example, oral health could be assessed in relationship to diabetes where we already know this is relationship The relationship between oral health and heart disease could be investigated .
- Blood: Cholesterol, glucose etc, cotinine. Urine: Diabetes, kidney function, (HPV’s off).
- As research has evolved and continued, over the last 20 years it has become very clear that we cannot have good general health without good oral health. This list outlines the common areas of linkage but the obvious connections of periodontal disease and diabetes, aspiration pneunomia and dental plaque bacteria and viruses and problems associated with oral cancer are now well established in the scientific literature.
- Oral health can have a major impact on an individuals ability to communicate, their self-esteem, employability, and social contacts (impact of halitosis)
- Approximately 20% may be problematic; Importance of oral health: Caries ECC Perio Growth & Development (cleft lip/cleft palate after Down’s) Xerostomia Viral infections Neoplasms Local impact on life (eating, chewing, pain, social acceptability, aesthetics, neuromuscular component) Linkages: now accepted (Diabetes, Pneumonias, Cancers) Work continues (Cardiovascular, Adverse pregnancy etc).
- Seniors: Teeth / feet / bowels. Risk Factor: Nutrition, Tobacco, Alcohol.
- This is an important step for guiding the development of the survey, implementation through to the analysis. The steering committee is now involved in advising on the 2010 Oral Health Report Consideration Bring together researchers, regulators, professional and government officials from the outset. This is an important step for guiding the development of the survey, the implementation through to the analysis. Dr. Jean-Marc Brodeur- Professeur , Département de médecine sociale et préventive Dr. James L Leake - Professor Emeritus, Faculty of Dentistry, University of Toronto Dr. Patricia A Main - Chair, Federal Dental Care Advisory Committee Dr. Euan Swan - Manager Dental Programs, Canadian Dental Association Dr. Gordon Thompson - Canadian Dental Regulatory Authorities Federation Dr. Sandy Bennett - Chair Federal/Provincial/Territorial Dental Working Group Ms. Andrea Richard - Dental Hygienist (On Executive of CAPHD) Colonel SA Becker - Director Dental Services, Canadian Forces Peter V. Cooney (Chair) OCDO Harry Ames OCDO Amanda Gillis OCDO
- Determining the objectives of the oral health component Collecting and reviewing oral health surveys from other countries i.e. National Health and Nutrition Examination Survey (NHANES)/ Australia/ World Health Organization (WHO) Developing the household, the clinical survey questions and the protocol manual Choosing dental instruments according to the indices in the clinical survey Providing ongoing advice to the Office of the Chief Dental Officer throughout the survey collection period Act as peer review group for the Oral Health Report Dr. Jean-Marc Brodeur- Professeur , Département de médecine sociale et préventive Dr. James L Leake - Professor Emeritus, Faculty of Dentistry, University of Toronto Dr. Patricia A Main - Chair, Federal Dental Care Advisory Committee Dr. Euan Swan - Manager Dental Programs, Canadian Dental Association Dr. Gordon Thompson - Canadian Dental Regulatory Authorities Federation Dr. Sandy Bennett - Chair Federal/Provincial/Territorial Dental Working Group Ms. Andrea Richard - Dental Hygienist (On Executive of CAPHD) Colonel SA Becker - Director Dental Services, Canadian Forces Peter V. Cooney (Chair) OCDO Harry Ames OCDO Amanda Gillis OCDO
- There are 15 questions in total Taking about 5 minutes to complete See section 2 for the oral health household survey Complete household Areas Health Status: General Health, Height and Weight, Weight Change, Health Utility Index, Chronic Conditions, Family Medical History, Oral Health Nutrition and Food Consumption Fruit and Vegetable, Meat and Fish, Dietary Fat, Salt and Other Food, Water and Soft Drink, Milk Medication Use Medications, Other Health Products and Herbal Remedies Health Behaviours Physical Activities, Sedentary Activities, Smoking, Alcohol Use, Illicit Drugs, Sexual Behaviour, Sleep Childhood Development Pregnancy, Birth and Breastfeeding Information Environmental Factors Exposure to Second-Hand Smoke, Housing Characteristics, Exposure to Toxic Chemicals, Sun exposure Socio-Economic Information Socio-Demographic Characteristics, Education, Labour Force Activity, Income
- Tooth Surface Index of Fluorosis ( TSIF ).
- Block testing with fictional cases Pretest with 10 per age group - summer 2006 (time estimates, suitability of survey, equipment (including computer application). Now into the calibration over next few months with inter and intra examiner reliability. Current bisphenol A issues. Cross Tabs: -Insurance -Tobacco -Health Human Resources -Research Needs
- An adjustment was made max value in the amalgam count question- needed to include count on wisdom teeth in the question. Amalgam question Max was 5X the number of teeth in chart with a code of 12. eg. 4 teeth with a code of 12 yields a maximum of 20 But the 8’s could have amalgam so could exceed the original count.
- Amalgam count and wisdom teeth Recession Attachment Loss
- An OCDO staff person has been available by phone/ email during the hours of the MEC to address any issues. This led to having one recorder becoming the head recorder to ensure all were kept in the loop as changes developed.
- 2 monitors – 1 for the dental recorder and one for the dentist so that they both can see the entry screen simutaneously
- During February and March 2007, Statistics Canada held a one month dress rehearsal on the entire CHMS. All seven of the Canadian Forces dentists and the two backup dentists/trainers participated in the dress rehearsal. This dress rehearsal was designed to ensure that the timing and the flow of both the respondents and the information worked and provided the CF dentists and clinic coordinators (dental recorders) an opportunity to work together.
- I will discuss each of these briefly but these items were common to both the First Nations and Inuit National versus regional or community level data Collecting regional or community level data would require a massive financial and logistical undertaking FNOHS data will be national level for on-reserve only IOHS data will be national Survey timing and completion Completion should be closely timed to completion of CHMS data collection (March 31/09) Timing is very tight but doable with HC regions help IOHS will likely get underway in April/08 FNOHS will likely get underway in Sept/08 Data comparability to CHMS data Both surveys will utilize the CHMS clinical exam as is and the oral health interview questions as the basis of their questionnaire Inclusion of children under the age of 6 Will Include children under the age of 6 being proposed as 3 – 5 years olds - Tailor approach
- Staff concerns about sterilizer new to them noises, residues, corrosion of instruments, spore testing OCDO staff member available by telephone at all times the MEC was operating. It alienated staff concerns to know if any question just call. Usually it was to just confirm that everything was ok and they had not destroyed the sterilizer.
- Obtaining accurate lists of respondents Use existing lists if rules allow – rules may not allow you to see the full list but may allow those who have the authority to select respondents off the list for you Make your own list – door to door name collection etc. Advertisements asking to call and put name on list Attracting respondents participation Incentives Convenience Schools Daycares Elder facilities Stores North Mart
- Aim for an “Oral Health in Canada” document in 2009 (10). Other areas have published similar documents US Surgeon General Australia Analysis Planning underway Experienced researcher to assist with writing Federal Dental Care Advisory Committee to act as peer review group Public friendly document and technical report – highlight best practices
- CDA well positioned as having solved 80% of Canadians oral health issues and now has the opportunity to facilitate/promote solutions for the access to the same oral health standards for the remaining 20%
- Dr. Patricia Main, Chairperson Dr. Howard Tenenbaum , Vice-Chair - University of Toronto Faculty of Dentistry, Periodontology Dr. William A. MacInnis - Nova Scotia Provincial Dental Board Ms. Lynda McKeown , RDH, HBA, MA Mr. Tony Sarrapuchiello - Denturist Association of Canada Dr. George H. Sweetnam – A Past President of the CDA Dr. Michael l. MacEntee - Professor of Prosthodontics and Dental Geriatrics, ELDERS Research Group, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia MANDATE The mandate of the FDCAC is to advise the Office of the Chief Dental Officer and the federal departments on oral health policy, on best practices and evidence based oral health as well as on specific clinical issues, including current issues, new technologies and procedures, complimentary issues that will impact on the oral and dental health and needs of their clients. The Committee provides current advice on oral health as it impacts on general health and on dental health, on program delivery as well as on third party insurance and dental benefits in order that the departments can improve and maintain the oral and general health and well-being of their clients. RESPONSIBILITIES The FDCAC: will establish and maintain evidence based and best practice criteria for consideration by the Office of the Chief Dental Officer (OCDO) and the Departments, that guide the inclusion and the exclusion of dental benefits, provided through the federal programs; will advise on current and emerging oral health issues either identified by the Committee, by the Office of the Chief Dental Officer (OCDO) or by the federal departments; will advise on the trends, information and statistics on access to care, needs and utilization presented in reports for the purpose of policy and program development and evaluation will advise on the program delivery, including establishment of federal dental facilities and on the purchase of dental services and supply will advise on the need for and implementation of educational programs for dental providers and clients will conduct or ensure the conduct of reports/ studies necessary to the provision of advice in areas of oral health that are of immediate concern or policy development. will as needed, recommend appropriate funding for studies of the client populations that could lead to changes and improvements in oral healthcare delivery
- We do not want the Oral Health report card to overwhelm the importance of the sub group reports so are planning separate publication dates. and surveyed seniors oral health living in community and in Long term Care facilities. Note dates of completion Inuit should have been completed initially Dec 31, 2008 delayed to March 31, 2009 and completed June 15 2009 First Nation Survey Dec 31, 2008 March 31, 2009 June 30, 2009 Currently set to take place fall 2009 with first site scheduled for September 14 (8 sites to complete) completion date to be October 31, 2009
- For our Inuit and First Nation Surveys we have had 4 calibrations and 11 examiners. Calibration for seniors survey Homeless survey BC immigrant survey – hygienists and therapists
- Does your dog bite no you get bitten not my dog
- Not all item are possible to analyze using statistics. Bleeding changes, debris reduces etc.