Form #8 Form #8 Physician survey

ATTACHMENT J:

PHYSICIAN SURVEY

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Standardizing Antibiotic Use in Long-Term Care, SAUL Study

Physician Survey

The first set of survey questions provides background information about your training and your experience.

1. What is your title?

2. What is your specialty?

3. How long have you been in practice?

4. How long have you been providing care for patients in [INSERT NAME OF FACILITY]?

5. Do you have a geriatric certification?

6. Are you a certified medical director?

7. How many patients do you currently have in [INSERT NAME OF FACILITY]?

8. What percent of your patient visits involve:

   1. Patients ages 65 and older?

   2. Patients who reside in nursing home?

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

This questionnaire has eight questions, all related to infections and antibiotic prescribing for your patients who live in [INSERT NAME OF FACILITY]. The first four are general questions, and the second four are specific to one or more of your patients. No identifying information is asked regarding any of your patients.

GENERAL QUESTIONS

1. In general, when a facility nurse calls about a patient, what information do you need before ordering an antibiotic for a suspected urinary tract infection?

2. In general, when a facility nurse calls to report a suspected skin/soft tissue infection, what information do you need before ordering an antibiotic?

3. In general, when a facility nurse calls to report a suspected respiratory infection, what information do you need before ordering an antibiotic?

4. In general, when a facility nurse calls to report a suspected fever of unknown origin, what information do you need before ordering an antibiotic?

PATIENT-SPECIFIC QUESTIONS

The next questions refer to specific conditions for which you recently ordered an antibiotic for one or more of your patients who live in [INSERT NAME OF FACILITY] (urinary tract infection, skin/soft tissue infection, respiratory infection, fever of unknown origin). For each condition for which you prescribed an antibiotic in the last 60 days, you will be asked to describe the factors that you considered when deciding to prescribe the antibiotic.

All questions refer to your patients who live in [INSERT NAME OF FACILITY] and for whom you wrote a prescription for an antibiotic for that condition in the last 60 days. If this situation did not occur, check that response “a” and move onto the next condition.

1. Please consider a recent prescription for antibiotics that you wrote for a resident with a urinary tract infection. To what extent did each of the following items factor into your decision? For each factor, rate its importance in making the decision to prescribe an antibiotic on a scale of 0 to 4 where 0 means it played no role at all in the decision and 4 means it was of overriding importance. Please note that only one item can be assigned 4, of overriding importance.

[For each response that is greater than 0, the user will be prompted to provide additional details.]

1. Did not write an antibiotic prescription for a UTI in the last 60 days (skip to Question 2).

2. Family request  Please describe the family’s argument/justification for their request.

3. Nursing request  Please describe the information that the nurse communicated to justify his/her request.

4. Resident symptoms  Please describe the symptoms as observed or communicated by the requesting nurse.

5. Resident history  Please describe the features of the resident’s history that factored into your decision.

6. Facility characteristics  Please describe any policies or characteristics of this facility that were a factor in your decision.

7. Other situational factors (e.g. time of day, day of week)

8. Additional comments

9. Please describe your rationale for ordering this specific antibiotic for this specific case.

2. Please consider a recent prescription for antibiotics that you wrote for a resident with a skin/soft issue infection. To what extent did each of the following items factor into your decision? For each factor, rate its importance in making the decision to prescribe an antibiotic on a scale of 0 to 4 where 0 means it played no role at all in the decision and 4 means it was of overriding importance. Please note that only one item can be assigned 4, of overriding importance.

[For each response that is greater than 0, the user will be prompted to provide additional details.]

1. Did not write an antibiotic prescription for a skin/soft tissue infection in the last 60 days (skip to Question 3).

2. Family request  Please describe the family’s argument/justification for their request.

3. Nursing request  Please describe the information that the nurse communicated to justify his/her request.

4. Resident symptoms  Please describe the symptoms as observed or communicated by the requesting nurse.

5. Resident history  Please describe the features of the resident’s history that factored into your decision.

6. Facility characteristics  Please describe any policies or characteristics of this facility that were a factor in your decision.

7. Other situational factors (e.g. time of day, day of week)

8. Additional comments

9. Please describe your rationale for ordering this specific antibiotic for this specific case.

3. Please consider a recent prescription for antibiotics that you wrote for a resident with a respiratory infection. To what extent did each of the following items factor into your decision? For each factor, rate its importance in making the decision to prescribe an antibiotic on a scale of 0 to 4 where 0 means it played no role at all in the decision and 4 means it was of overriding importance. Please note that only one item can be assigned 4, of overriding importance.

[For each response that is greater than 0, the user will be prompted to provide additional details.]

1. Did not write an antibiotic prescription for a respiratory infection in the last 60 days (skip to Question 4).

2. Family request  Please describe the family’s argument/justification for their request.

3. Nursing request  Please describe the information that the nurse communicated to justify his/her request.

4. Resident symptoms  Please describe the symptoms as observed or communicated by the requesting nurse.

5. Resident history  Please describe the features of the resident’s history that factored into your decision.

6. Facility characteristics  Please describe any policies or characteristics of this facility that were a factor in your decision.

7. Other situational factors (e.g. time of day, day of week)

8. Additional comments

9. Please describe your rationale for ordering this specific antibiotic for this specific case.

4. Please consider a recent prescription for antibiotics that you wrote for a resident with a fever of unknown origin. To what extent did each of the following items factor into your decision? For each factor, rate its importance in making the decision to prescribe an antibiotic on a scale of 0 to 4 where 0 means it played no role at all in the decision and 4 means it was of overriding importance. Please note that only one item can be assigned 4, of overriding importance.

[For each response that is greater than 0, the user will be prompted to provide additional details.]

1. Did not write an antibiotic prescription for a fever of unknown origin in the last 60 days (skip remaining items).

2. Family request  Please describe the family’s argument/justification for their request.

3. Nursing request  Please describe the information that the nurse communicated to justify his/her request.

4. Resident symptoms  Please describe the symptoms as observed or communicated by the requesting nurse.

5. Resident history  Please describe the features of the resident’s history that factored into your decision.

6. Facility characteristics  Please describe any policies or characteristics of this facility that were a factor in your decision.

7. Other situational factors (e.g. time of day, day of week)

8. Additional comments

9. Please describe your rationale for ordering this specific antibiotic for this specific case.

Thank your for taking the time to participate in this survey.