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National Health and Nutrition Examination Survey – Oral Health Components
Laurie Barker, MSPHMathematical StatisticianSurveillance, Investigation and Research TeamDivision of Oral HealthNational Center for Chronic Disease Prevention and Health PromotionOffice ofNoncommunicableDiseases, Injury and Environmental Healthlub2@cdc.gov
Workshop Overview
LectureIntroductionNHANES OverviewNHANES Data ResourcesFuture Developments in NHANESHands-on WorkshopOrientation to NCHS NHANES Web siteOrientation to DRC tutorial materialsPractice Examples (in SAS and SUDAAN)
I. Introduction
CDC’s organization (oral health, NHANES) and relationship to NIDCR and other Federal agencies, and to universities and state governmentsSurveillance vs. Research
I. Introduction: CDC organization
Within CDCDOHlocated within the National Center for Chronic Disease Prevention and Health PromotionFunds 19 states to build oral health infrastructureFunds part of NHANES, along with NIDCRDivision of HANESlocated within the National Center for Health StatisticsDesigns, manages contract to operate NHANESproduces public and restricted data setsCollaborates with other NCHS divisions to link NHANES to other data setsPublishes a wide variety of reports on NHANES
I. Introduction: CDC organization
Outside of CDCDepartment of Health and Human ServicesNIH/NIDCRCDCCMSHRSAIHSSAMSHA…
I. Introduction
Surveillance vs. ResearchMain purpose of surveillance is to monitor trends inknown public health problems and related risk factorsIdentify emerging problemsBroad picture of trends in national populationsSentinel surveillancemonitors rarer problems in higher risk populationsOr 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
I. Introduction
Surveillance vs. ResearchChanges in trends or new problems identified through surveillance ideally trigger focused research to explain the observed changeSurveillance data sets are often cross-sectionalFew truly longitudinal surveysLimitations in the types of research that can be conducted with surveillance dataNew developmentslinkage among surveys, linkage with external data (CMS, environmental) may support more researchMatch rate could be a limiting issue
II. NHANES overview
History of NHANESNHANES compared to other national surveysNHANES Oral Health Components2009-2010Previous NHANES and precursor National Health Examination SurveySurvey design and analysis considerationsStatistical methodsSoftware
II. NHANES Overview:History ofNHANES
National Health Examination Surveys1959-62, 1963-65, 1966-1970National Health and Nutrition Examination Surveys1971-1974, 1988-19951999+ Continuous NHANESHispanic HANES 1986-1987
II. NHANES Overview:NHANES compared to other nationalsurveys
NHANESNational Household - questionnaire, exam, labNHISNational Household – questionnaireMEPSNational Household – questionnaire focused on costsBRFSSState Telephone (multimodal now) – questionnaireNational estimates from combined statesYRBSSPaper surveySeparate National and State samples
II. NHANES Overview:NHANES Oral HealthComponents
2009-2010 – dental hygienist ratersCaries – tooth surface level, limited age rangePeriodontal disease – full mouth2005-2008 – medical technician ratersCaries – person level, limited age range1999-2004 – dentist ratersCaries and sealants - Tooth surface levelRoot caries,Fluorosis- Tooth levelPeriodontal disease – 2 quadrants, facial/buccalsitesPrevious NHANES and precursor National Health Examination Survey – dentist ratersCaries, other measures of oral health, some out-of-date
II. NHANESOverview:Surveydesign and analysisconsiderations
Statistical methodsSoftware
II. NHANESOverview:Surveydesign and analysisconsiderations
Statistical methodsComplex sample survey design requires methods that account for clustering due to survey design, in addition to any other clusteringTypically, 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 dataSampling fraction, oversampling, non-responseNCHS provides weights that should be usedLittle information to construct special weights due to disclosure protections
II. NHANESOverview:Surveydesign and analysisconsiderations
SoftwareSUDAAN (or WESVAR), historically the recommended software due to limited procedures for complex samples in other softwareSAS,Stata, SPSS, RAll now have procedures to account for survey designPoint estimates should be the same from all packagesVariance estimates may differ due to choices each package has made in methods to account for clusteringDifferences probably less than 0.01?
II. NHANESOverview:Surveydesign and analysisconsiderations
Key referencesHeeringa, Steven G, Brady T. West and Patricia Berglund. 2010.Applied Survey Data Analysis.Chapman & Hall, CRC, New York.Korn, Edward L. and BarryGraubard. 1999.Analysis of Health Surveys.John Wiley, New York.Groves, Robert M., Floyd J. Fowler, Jr., Mick P. Cooper, James M.Lepkowski, Eleanor Singer, RogerTourangeau. 2004.Survey Methodology, 2ndedition. John Wiley, New York, 2009.
III. NHANES data resources
NCHS NHANES TutorialDental, Oral and Craniofacial Data Resource Center (CDC and NIDCR funded project)Current online resourcesTutorial materials in developmentRestricted data, linked data and Research Data Centers operated by NCHS or Census
III. NHANES data resources
NCHS NHANES Tutorialhttp://www.cdc.gov/nchs/tutorials/index.htmExcellent tutorial, materials being added regularlyNot specific to oral health, but good resources forDietary interview dataEnvironmental chemical dataVariable crosswalksCross year variable tablehttp://www.cdc.gov/nchs/nhanes/variable_tables/cross_year_variables_list.htmNot for oral health yet, but many othersDemographics, dietary recall, C-reactive protein, smoking, reproductive healthQ-Bank – question evaluation reportshttp://wwwn.cdc.gov/qbank/Home.aspx
III. NHANES data resources
Dental, Oral and Craniofacial Data Resource Center (CDC and NIDCR funded project)Current online resourcesData Query System, some publications, survey questions inventory, Catalog of Surveys and Archive of Methods Related to Oral Health (400+ surveys listed)Tutorial materials in developmentWill cover this in hands-on workshopBasic info on key data sets with oral health, linked to sourceExpanded documentation of oral health componentsVariable crosswalksCode for creating analytic data sets“clean” oral health data sets
III. NHANES data resources
Restricted data, linked data and Research Data Centers operated by NCHS or CensusResearch Data Centershttp://www.cdc.gov/rdc/Linked data – national surveys linked to CMS, mortality, air quality, Social Security Benefit historyhttp://www.cdc.gov/nchs/data_access/data_linkage_activities.htm
Hands-on workshop
Orientation to NCHS NHANES Web siteOrientation to DRC tutorial materialsPractice examples (in SAS and SUDAAN)
Hands-on Workshop
Orientation to NCHS NHANES Web siteLocating and downloading filesDemographicsQuestionnaireOral healthOral health referral and recommendationsHousehold and other filesExaminationOral health examinationDietary interview filesLaboratoryTobaccoC-Reactive ProteinVitamin D
Hands-on workshop
Orientation to DRC tutorial materials
Hands-on workshop
Practice examples (in SAS and SUDAAN)Setting up an analytic data set with questionnaire itemsPreparing an analytic data set with oral health examination items and dental indicesPreparing an analytic data set with laboratory itemsProducing national estimates for Healthy People objectives
Hands-on workshop
Practice examples (in SAS and SUDAAN)Setting up an analytic data set with questionnaire items
Hands-on workshop
Practice examples (in SAS and SUDAAN)Preparing an analytic data set with oral health examination items and dental indices
Hands-on workshop
Practice examples (in SAS and SUDAAN)Preparing an analytic data set with laboratory items
Hands-on workshop
Practice examples (in SAS and SUDAAN)Producing national estimates for Healthy People objectivesTracking Healthy People 2010CDC WONDER/Data2010

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