Survey of Primary Care Physicians Practices Regarding Pr

Attachment 4

Data Collection Instrument

Form Approved

OMB Control No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Physicians’ Practices Regarding Prostate Cancer Screening

The Centers for Disease Control and Prevention (CDC) is inviting you to participate in a national survey of physicians being conducted for CDC by the Battelle Centers for Public Health Research and Evaluation.

CDC is interested in your practices and opinions regarding prostate cancer screening. Your opinions will guide CDC and other organizations that develop new clinical training materials, clinical decision support tools, and materials physicians use to counsel and educate patients. Therefore, the input of practicing physicians is very important.

This survey includes questions about your demographic, practice and patient characteristics. Then, we ask about your practices and opinions about prostate cancer screening. Finally, we seek your opinions about your management of prostate-specific antigen (PSA) screening for prostate cancer in your practice under various clinical scenarios.

The survey asks your opinions about a range of PSA screening practices and screening guideline information that has changed rapidly over the last few years and includes questions about practices that may not be the standard of care in your community or may not be endorsed by clinical guidelines.

• 3,000 randomly selected primary care physicians have been sent this survey. We need the response of every physician to make this important study valid and representative of diverse practice styles of U.S. primary care physicians.

• Your responses will be treated in a secure manner.

• Battelle must maintain the link between names and participant ID numbers for tracking survey mailings. While Battelle will have the capability to link responses to individual participants, this capability will only be present until data collection is completed. At that point, the tracking file will be destroyed and there will be no way to link responses to you.

• Survey reports will present all findings in aggregate so individual responses cannot be identified.

• On average, the survey will take about 30 minutes to complete.

• Some questions about your provision of advice to patients about prostate cancer screening, or about your practices that may differ from institutional clinical practice recommendations may cause you discomfort.

• Your participation in this survey is voluntary. You may choose to withdraw from the study or to skip any questions that you do not want to answer.

Public reporting burden of this collection of information varies from 20 to 40 minutes with an estimated average of 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Section I: Physician and Practice Characteristics

This part of the survey asks questions that will let us describe the participants who respond to the survey. Please write in or check () the best answer.

1. What is your age? _________________

2. What is your sex?  Male  Female

3. Are you of Hispanic or Latino origin?  Yes  No

4. What is your race or racial heritage? Check all that apply.

 American Indian or Alaska Native  Native Hawaiian or other Pacific Islander

 Asian  White

 Black or African American

5. What year did you graduate from medical school?________(enter year)

6. Since completing your medical training (including residency and fellowship), how long have you been practicing medicine? ____________Years

7. Where did you complete your residency training?____________________(enter state).

 Not applicable, I did not complete residency training

8. What is your primary clinical specialty? (Please only one)

 Family Practice

 General Practice

 Internal Medicine

 Other __________________________________________________(Please specify)

9. What is your clinical sub-specialty, if any? ________________________________(Please specify)

10. Do you currently (last 2 months) practice in an outpatient setting?

 Yes Continue

 No STOP and return the survey at this point

Please answer the remainder of the survey based on your “primary practice site,” the location where you spend most of your outpatient care practice time.

11. On average, how many hours per week do you spend on direct patient care at your primary practice site?

Average number of hours per week_______________

If you spend less than 8 hours per week at your primary practice site, please

STOP and return the survey in the postage-paid envelope.

12. Do you provide health maintenance exams to any of your patients at this site?

 Yes (Continue with the survey)  No

If you do not provide health maintenance exams or routine checkups to any of your patients at this site, STOP and return the survey in the postage-paid envelope.

Please answer the remainder of the questionnaire about your Primary Practice Site.

13. Where is this practice located? Is it within a(an): (Please  only one)

 Private practice office	 Hospital emergency department
 Ambulatory care clinic of hospital/medical center	 Institutional setting/clinic (e.g., correctional, nursing home)
 Urgent care clinic	 Clinic that is part of a Health Maintenance Organization
 Community health center	 Academic or teaching hospital
 Public health clinic
 Other type of clinic____________________(specify)

14. Is this practice a: (Please  only one)

 Solo practice?

 Single-specialty group practice?

 Multi-specialty group practice?

 Other type of practice (please specify)___________________________?

15. Does your practice participate in any of the following types of Managed Care Contracts (MCO)?

(Please  all that apply)

 Staff-model HMO (e.g., Kaiser)

 Group-model HMO

 Network-model HMO (e.g., need an example)

 Independent-Practice Association (IPA)

 Preferred Provider Organization (PPO)

 Point-of-Service Plan (POS)

 Other type of MCO (please specify)___________________________?

16. Zip code of this practice (first 5 digits only): ___ ___ ___ ___ ___

17. Please indicate which of the following best describes the size of the community in which your primary practice is located (Please  only one)

 A community of fewer than 2,500 people

 Small town of 2,501 to 10,000 people

 Medium-sized town of 10,001 to 25,000 people

 Large town of 25,001 to 50,000 people

 A small city of 50,001 to 100,000 people

 City of 100,001 to 250,000 people

 Large city of 250,000+ people

18. Please indicate which of the following best describes the community setting in which your primary practice is located (Please  only one)

 Rural

 Suburban

Urban  Inner city

 Not inner city

19. Do you practice in a federally qualified health manpower shortage area?

 Yes  No  Don’t know

Section II: Patient Characteristics

Please give us your best estimates for the following questions about characteristics of the patients you see in your primary practice site. Please write in or check () your response. Your best estimate is all we need.

1. On average, how many patients do you see in a typical week? ______________

2. Approximately what percent of your patients are male?_______ %

3. Approximately what percent of your male patients are over age 40?_______ %

4. How many health maintenance exams do you perform on males over age 40 per week? ______________

5. Approximately what percent of your male patients are:

White _______ %

Black, African or African American _______ %

Native American or Alaska Native _______ %

Asian _______ %

Native Hawaiian or Pacific Islander _______ %

Other (including multiracial) _______ %

Total 100%

6. Approximately what percent of your male patients are of

Hispanic or Latino origin _______ %

7. Please estimate what percentage of your patients use the following primary payment methods:

Self pay _______ %

Private Managed Care (HMO, MCO, PPO, IPA, POS) _______ %

Other private medical insurance _______ %

Medicaid, including Medicaid Managed Care _______ %

Medicare, including Medicare Managed Care _______ %

Other Government (e.g., CHAMPUS, HRSA) _______ %

Charity care (no fee charged) _______ %

Other insurance type or payor (specify) ________________ _______ %

Total 100%

Section III: Clinical Practice

Please provide the following answers based on your routine practices during health maintenance exams (HME) with male patients 40 and older.

Prostate Cancer Screening Practices

1. Do you routinely perform Digital Rectal Examination (DRE) on asymptomatic patients as part of their HME?

 Yes  No (If NO, Go to Question 8)

2. What percent of your patients visiting for an HME do you offer DRE?__________________%

3. What percent of your HME patients get DRE? _________________%

4. Please check the reason you perform DRE? (Please  all that apply)

 To palpate prostate

 To check anus and rectum for abnormalities

 To get an in-office specimen for FOBT

 Other___________________________________________________________________(Please specify)

5. At what age do you begin to offer routine DRE to the following types of patients? If you do not see such patients or offer DRE for such patients, please check () ”I do not offer DRE to these patients”.

Type of Patient	Age	I do not offer DRE to these patients
Asymptomatic White males	____	
Asymptomatic White males with a family history of prostate cancer	____	
Asymptomatic African American males	____	
Asymptomatic African American males with a family history of prostate cancer	____	
Asymptomatic Asian American males	____	
Asymptomatic Asian American males with a family history of prostate cancer	____	
Asymptomatic Hispanic or Latino males	____	
Asymptomatic Hispanic or Latino males with a family history of prostate cancer	____	
Asymptomatic Native American or Alaskan males	____	
Asymptomatic Native American or Alaskan males with a family history of prostate cancer	____	

6. Do you ever stop performing routine DRE on asymptomatic male patients?

 Yes (If YES, Go to Question 7)  No (If NO, Go to Question 8)

7. Please specify why you stop performing routine DRE? (Please  all that apply)

Reasons for discontinuing DRE
	Advanced age
	Existing co-morbid conditions
	Debilitated health status

8. Do you routinely offer Prostate Specific Antigen (PSA) testing for asymptomatic male patients as part of their HME?

 Yes  No

Why not?  Organizational practice policy

 National guidelines do not support offering

 Insufficient evidence to demonstrate impact on mortality

 Other__________________________________________(Please specify)

Go to Question 21

9. What percent of your male patients visiting for an HME are offered PSA? ___________________%

10. What percent of your HME patients receive PSA? _________________%

11. Relative to the DRE, when do you routinely draw blood for PSA?

 Before DRE  After DRE  Both before and after DRE  I do not do routine DRE

12. At what age do you begin to routinely offer the PSA test to the following types of patients? If you do not see such patients or offer PSA for such patients, please check () ”I do not offer PSA to these patients”.

Type of Patient	Age	I do not offer PSA to these patients
Asymptomatic White males	____	
Asymptomatic White males with a family history of prostate cancer	____	
Asymptomatic African American males	____	
Asymptomatic African American males with a family history of prostate cancer	____	
Asymptomatic Asian American males	____	
Asymptomatic Asian American males with a family history of prostate cancer	____	
Asymptomatic Hispanic or Latino males	____	
Asymptomatic Hispanic or Latino males with a family history of prostate cancer	____	
Asymptomatic Native American or Alaskan males
Asymptomatic Native American or Alaskan males with a family history of prostate cancer

13. Do you ever stop offering routine PSA to asymptomatic patients?

 Yes (If YES, Go to Question 14)  No (If NO, Go to Question 15)

14. Please specify why you stop offering PSA? (Please  all that apply)

Reasons for discontinuing PSA
	Advanced age
	Existing co-morbid conditions
	Debilitated health status

15. What percent of PSA tests you order are performed on men who are asymptomatic? __________%

16. What percent of PSA tests you order are performed on men who experience non-specific lower urinary tract symptoms? __________%

17. What percent of your patients are screened for prostate cancer under the following conditions?

Type of Patient	%
Health maintenance exam (HME)	____
Routine scheduled check-up other than HME (e.g., chronic problem)	____
Acute problem visits	____
Other	____

18. How often do you screen for prostate cancer in your asymptomatic male patients?

 Once a year

 Every two years

 When the patient comes in for a periodic HME

 Other_______________(Please specify)

19. How often do you screen for prostate cancer in your high risk (e.g., patients with a family history or African American) male patients?

 Once a year

 Every two years

 When the patient comes in for a periodic HME

 Other_______________(Please specify)

20. If a PSA is higher than the expected normal range, what do you generally do next?

	Never	Sometimes	Half the time	Usually	Always
a. Repeat the PSA test					
b. Order a more specific PSA (e.g., complex PSA)					
c. Use free/total PSA estimations…………………..					
d. Refer to a urologist					
e. Check for infection					

20. Please indicate how often you do any of the following

	Never	Sometimes	Half the time	Usually	Always
a. Provide written information (i.e., pamphlets, guides), videos, or other educational materials on PSA screening in your office or clinic for patients to browse or take home					
b. Refer patients to any type of educational materials about prostate cancer screening					
c. Screen men age 75 and older who have no significant health or medical problems …………					
d. Screen men with significant co-morbid conditions					

20. Do you routinely discuss prostate cancer screening with your male patients to involve the patient in the decision about screening? (Please check () only one)

	Yes, with all patients
	Yes, with patients who decline the test
	Yes, with patients who had a previous elevated PSA
	Yes, with patients who request PSA test
	No (If NO, Go to Question 26)

20. What is your usual policy when discussing PSA testing with patients?

	I try to talk the patient into getting the test
	I try to talk the patient out of getting the test
	I remain neutral

20. At what age do you begin discussing prostate cancer screening with the following types of patients: If you do not see or discuss prostate cancer with such patients, please check () ”I do not discuss with these patients”.

Type of Patient	Age	I do not discuss with these patients
Asymptomatic White males	____	
Asymptomatic White males with a family history of prostate cancer	____	
Asymptomatic African American males	____	
Asymptomatic African American males with a family history of prostate cancer	____	
Asymptomatic Asian American males	____	
Asymptomatic Asian American males with a family history of prostate cancer	____	
Asymptomatic Hispanic or Latino males	____	
Asymptomatic Hispanic or Latino males with a family history of prostate cancer	____	
Asymptomatic Native American or Alaskan males
Asymptomatic Native American or Alaskan males with a family history of prostate cancer

20. Approximately how much time is usually involved in the discussion? _____________minutes.

20. Do you require an informed consent prior to performing a PSA test for screening purposes?

	Yes, verbal consent
	Yes, written consent
	No

20. Have you heard of informed or shared decision making?

 Yes  No (If NO, Go to Question 30)

20. Have you incorporated informed or shared decision making into your practice?

 Yes  No (If NO, Go to Question 30)

20. Have you been satisfied with the results?

 Yes  No

20. In general, who decides whether a patient should have prostate cancer testing (Please only one)?

 I decide

 I mostly decide

 I decide together with the patient and/or his family member(s)

 The patient and/or his family member(s) mostly decides

 The patient and/or family member(s) decides

Screening Efficacy and Beliefs

Please check () how strongly you agree or disagree with each statement below.

1. My performing Digital Rectal Exam in average risk patients:

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Permits me to use a reliable tool for cancer detection					
Helps men live longer through early detection and treatment of prostate cancer					
Does more good than harm					
Helps protect me from malpractice claims					
Results in no or low reimbursement					
Is unwanted by most of my male patients					
Will result in uncertainty about the meaning of the test result due to test inaccuracies (e.g. false positives)					
Is difficult due to my embarrassment or discomfort					
Is difficult due to patient embarrassment or discomfort with DRE					
Is difficult because the patient does not perceive prostate cancer to be a serious health threat					
Is difficult due to patient’s beliefs that screening is not effective					
Is difficult due to patient fears of potential side effects of treatment					
Is difficult due to my belief that screening is not effective
Is difficult due to patient myths and misconceptions					
Is difficult due to a lack of scientific evidence of survival benefit					
Is difficult due to a lack of consensus regarding DRE screening guidelines					
Allows me to assess other health problems (CRC, hemorrhoids, etc)					
Helps reduce prostate cancer mortality in average risk patients age 50 years and older					
Is difficult due to patient cultural barriers					
Is difficult due to a lack of confidence in my DRE skills					

2. My discussing prostate cancer screening:

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. Is helpful because my male patients need to be informed about this topic					
b. Is easy because I feel confident I know enough about the benefits of screening to give patients adequate information					
c. Is easy because I feel confident I know enough about the possible risks of screening outcomes to give patients adequate information regarding prostate cancer					
d. Is something most patients are comfortable making an informed decision about screening					
e. Does not allow me the time to discuss the advantages/disadvantages of screening					
f. Results in lack of or low reimbursement					
g. Is too complex to cover in a limited amount of time					
h. Takes too much time					
i. Is challenging because patients are unwilling to discuss					
j. Is challenging because patients are not interested in topic					
k. Is difficult due to patient cultural or language barriers					
l. Is difficult because topic is too complex, for most patients to understand					
m. Is uncomfortable for patients					

3. My providing PSA testing to average risk patients:

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Permits me to use a reliable tool for cancer detection					
Helps men live longer through early detection and treatment of prostate cancer					
Does more good than harm					
Helps protect me from malpractice claims					
Results in lack of or low reimbursement					
Costs me money					
Coincides with the standard of care in my community					
Will result in the uncertainty about the meaning of the test result (false positives?)					
Is difficult due to patient fear of finding cancer					
Is difficult due to patient not perceiving prostate cancer to be a serious health threat					
Is difficult due to patient beliefs that screening is not effective					
Is difficult due to patient fears of potential side effects of treatment					
Is difficult due to patient myths and misconceptions					
Is difficult due to lack of scientific evidence of survival benifit					
Is difficult due to lack of consensus regarding screening guidelines					
Is something I do because the patient demands it					
Helps reduce prostate cancer mortality in average risk patients age 50 years and older					
Is difficult due to a lack of confidence in test accuracy					

Social Influences and Social Support

1. Does your practice have formal written guidelines for prostate cancer screening?

 Yes  No  Don’t Know

2. Does your practice have informal or unwritten guidelines or policies for prostate cancer screening?

 Yes  No  Don’t Know

3. Please indicate whether you follow prostate cancer screening recommendations from any of the following organizations.

(Please  all that apply)

	American Academy of Family Physicians (AAFP)
	American Cancer Society (ACS)
	American College of Preventive Medicine (ACPM)
	American College of Physicians (ACP)/ASIM
	American Urological Association (AUA)
	United States Preventive Services Task Force (USPSTF)
	Other_____________________(Specify)
	Not applicable

4. Please check () your opinion about how much each of the following individuals or entities encourages or discourages your current practices or beliefs about

DRE:

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
American Academy of Family Physicians (AAFP)					
American Cancer Society (ACS)					
American College of Preventive Medicine (ACPM)					
American College of Physicians (ACP)/ASIM					
American Urological Association (AUA)					
United States Prevention Services Task Force (USPSTF)					
Medical school attended/ residency training					
Professional organization(s) guidelines					
Medical literature (e.g., JAMA, NEJM, Cochran Collaborative)					
Practice setting philosophy					
Community influences. Community influences					
Personal practice experiences. Personal practice experiences					
Community practice standard					
Patient or family requests					
Other_____________________(Specify)					

PSA Testing:

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
American Academy of Family Physicians (AAFP)					
American Cancer Society (ACS)					
American College of Preventive Medicine (ACPM)					
American College of Physicians (ACP)/ASIM					
American Urological Association (AUA)					
United States Prevention Services Task Force (USPSTF)					
Medical school attended/ residency training					
Professional organization(s) guidelines					
Medical literature (e.g., JAMA, NEJM, Cochran Collaborative)					
Practice setting philosophy					
Community influences. Community influences					
Personal practice experiences. Personal practice experiences					
Community practice standard					
Patient or family requests					
Other_____________________(Specify)					

Discussing Prostate Cancer Screening:

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
American Academy of Family Physicians (AAFP)					
American Cancer Society (ACS)					
American College of Preventive Medicine (ACPM)					
American College of Physicians (ACP)/ASIM					
American Urological Association (AUA)					
United States Prevention Services Task Force (USPSTF)					
Medical school attended/ residency training					
Professional organization(s) guidelines					
Medical literature (e.g., JAMA, NEJM, Cochran Collaborative)					
Practice setting philosophy					
Community influences. Community influences					
Personal practice experiences. Personal practice experiences					
Community practice standard					
Patient or family requests					
Other_____________________(Specify)					

Physician Perceptions and Behaviors

1. For the next set of questions, please indicate how often:

	Never	Sometimes	Half the time	Usually	Always
a. Wives, partners, or significant others of your male patients influence the men to come in for the screening tests					
b. Men provide information about their family history of prostate cancer					
c. Your patients bring up prostate cancer related issues during their office visit					
d. Your patients ask about the PSA test					
e. You discuss the possible benefits of prostate-specific antigen (PSA) screening with your age-appropriate patients before ordering the test					
f. You discuss the possible risks of PSA screening with your age-appropriate patients before ordering the test					
g. You discuss diet and its possible link to prostate cancer					
h. Your patients bring up prevention related questions regarding prostate cancer					
i. Paying for the screening tests is an issue with your patients					
j. Performing the digital rectal examination (DRE) is a barrier for your patients					
k. You use educational tools or decision guides on prostate cancer (pamphlets, anatomical models) to share with your patients					
l. You keep abreast of the scientific literature on prostate cancer					

2. How knowledgeable are your male patients concerning prostate cancer screening issues?

 No knowledge at all

 A little knowledge

 A moderate amount of knowledge

 A great deal of knowledge

3. How knowledgeable are you on prostate cancer screening guidelines?

 No knowledge at all

 A little knowledge

 A moderate amount of knowledge

 A great deal of knowledge

Patient Scenarios

The next few questions are about your management of prostate-specific antigen (PSA) screening for prostate cancer in your primary practice site. Below we present you with hypothetical patients that we ask you to respond to. Please respond regardless of whether or not you may see these types of patients.

Patient scenario 1: A 55 year old White male, who has no current prostate-related symptoms, with no family history of prostate cancer and has no serious co-morbidities.

1. For this type of patient, I generally (Please only one):

	Refer to a urologist for screening.
	Order the PSA test without discussing the possible benefits and risks with the patient.
	Discuss the possible benefits and risks of PSA screening with the patient, then recommend the test.
	Discuss the possible benefits and risks of PSA screening with the patient, then let him decide whether or not to have the test.
	Discuss the possible benefits and risks of PSA screening with the patient, and then recommend against the test.
	Do not order the PSA test or discuss the possible benefits and risks with the patient unless the patient asks.
	Other:

2. If you offer the PSA test and the patient declines, would you try to persuade him to have the test?

 Yes  No  Don’t Know

3. Approximately what percent of your patients with the above characteristics actually get a PSA test done in your practice?____________%

4. Approximately what percent of your patients with the above characteristics have their blood work including PSA done before seeing you for a health maintenance exam? _____________________%

Patient scenario 2: A 45 year old African American male, who has no current prostate-related symptoms, with no family history of prostate cancer and has no serious co-morbidities.

1. For this type of patient, I generally (Please only one):

	Refer to a urologist for screening.
	Order the PSA test without discussing the possible benefits and risks with the patient.
	Discuss the possible benefits and risks of PSA screening with the patient, then recommend the test.
	Discuss the possible benefits and risks of PSA screening with the patient, then let him decide whether or not to have the test.
	Discuss the possible benefits and risks of PSA screening with the patient, and then recommend against the test.
	Do not order the PSA test or discuss the possible benefits and risks with the patient unless the patient asks..
	Other:

2. If you offer the PSA test and the patient declines, would you try to persuade him to have the test?

 Yes  No  Don’t Know

3. Approximately what percent of your patients with the above characteristics actually get a PSA test done in your practice?_____________%

4. Approximately what percent of your patients with the above characteristics have their blood work including PSA done before seeing you for a health maintenance exam? _________________%

Patient scenario 3: A 50 year old male, who has no current prostate-related symptoms, who has a family history of prostate cancer and has no serious co-morbidities.

1. For this type of patient, I generally (Please only one):

	Refer to a urologist for screening.
	Order the PSA test without discussing the possible benefits and risks with the patient.
	Discuss the possible benefits and risks of PSA screening with the patient, then recommend the test.
	Discuss the possible benefits and risks of PSA screening with the patient, then let him decide whether or not to have the test.
	Discuss the possible benefits and risks of PSA screening with the patient, and then recommend against the test.
	Do not order the PSA test nor discuss the possible benefits and risks with the patient unless the patient asks..
	Other:

2. If you offer the PSA test and the patient declines, would you try to persuade him to have the test?

 Yes  No  Don’t Know

3. Approximately what percent of your patients with the above characteristics actually get a PSA test done in your practice?_____________%

4. Approximately what percent of your patients with the above characteristics have their blood work including PSA done before seeing you for a health maintenance exam?__________________%

Thank you for your participation in this survey.

Comments: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________