Justification for Change

4/27/2011

Justification for Change:

National Hospital Ambulatory Medical Care Survey
OMB No. 0920-0278
(Expires 08/31/2012)

This is a justification to conduct a small pretest for the automation of the 2012 National Hospital Ambulatory Medical Care Survey (OMB No. 0920-0278). The pretest will test:

• the feasibility of converting paper-based survey forms to computer-based instruments,

• minor content changes to approved Patient Record forms,

• a lookback module associated with the outpatient department Patient Record form, and

• an asthma management supplement.

In our current approved full clearance, we stated “Additionally, we request approval of slight modifications to our data collection forms based on past performance and recommendations from consultants.” Much of the work will be completed by Census Bureau field representatives, keeping the burden change to a minimum. All pretest activities, if successful, will appear for approval in the full revision to be submitted later in 2011.

1. Pretest of Automated Survey Instruments

A pretest will be conducted to test the conversion of paper forms into a computer-based instrument. Field representatives will conduct the induction interviews using a computer-based instrument on their laptops and will then abstract patient record information from the medical record using a separate instrument on the same laptop. The pretest will be used to determine the feasibility and usability of using computer-based instruments for NHAMCS. Recruitment and abstraction procedures for the pretest are identical to the currently approved protocol, except that answers will be recorded on the laptop instrument instead of on paper.

Our plan is to first conduct the NHAMCS facility induction interviews at 12 hospitals and 8 freestanding ambulatory surgery centers (Attachments A, B). The hospital induction will take one hour and the freestanding ambulatory surgery center induction will take 90 minutes. The facility induction interviews will be conducted between the field representative and a facility administrator and the answers will be recorded on the computer. For the hospitals, a one-hour induction ambulatory unit interview (Attachment C) will be conducted at 1 emergency service area, 2 outpatient department (OPD) clinics (at least 1 will have a specialty of either general medicine or obstetrics/gynecology), and 1 ambulatory surgery location (n=48), and the answers will also be recorded on the computer. The following asthma screening question will be asked of each of the 2 OPD clinics selected for the pretest “Does this clinic see any patients who have an asthma diagnosis or who receive asthma education and/or ongoing clinical management?” At each hospital, a physician from one eligible OPD clinic will be asked to complete a 15-minute asthma supplement (Attachment D).

Once the ambulatory units are inducted, the field representatives will take a convenience sample of records from which patient record data will be abstracted. Data will be collected on 10 patient visits from each participating emergency department, outpatient department, and ambulatory surgery location (Attachments E, F, G). The field representative will abstract the relevant patient record data directly into the laptop. For patients with diagnoses that match the requirements for the lookback module, additional data will be collected on past visits during the previous 12 months on a paper form (Attachment H). The only burden to the facility for the Patient Record form abstraction is to have a medical record clerk pull and refile records (Attachment I). The overall burden for the pretest is 82 hours.

2. Minor Modification of Survey Forms

Minor modifications to the approved survey instruments will be included in the automation pretest.

1. For the ambulatory unit induction form (NHAMCS-101(U), Attachment C), a screener question (“Does this clinic see any patients who have an asthma diagnosis or who receive asthma education and/or ongoing clinical management?”) was added to assess whether the OPD clinic sees asthma patients thereby determining if the physician is eligible to receive the asthma supplement.

2. For the Outpatient Department Patient Record form (OPD PRF; NHAMCS-100(OPD), Attachment E), checkboxes were added that are related to the asthma supplement assessing the patient’s asthma severity and control practices. The checkboxes in Item 7-Diagnostic/Screening Services, Item 8-Health Education, and Item 9-Non-medication treatment were combined into one new item entitled Item 7-Services to eliminate confusion in the classification of certain services. The following checkboxes were replaced with write-in fields at the end of the item: “other blood test,” “other imaging,” and “other health education.” Checkboxes were added based on services that are commonly written into blank spaces on the form to save the abstractor from having to enter the name of the service.

3. For the Ambulatory Surgery PRF (NHAMCS-100(ASC), Attachment F), Item 3-External Cause of Injury was deleted and checkboxes were added in Item 2 for additional diagnoses that could impact the surgery. The ”oxygen administered during this visit” item was deleted and checkboxes for the most commonly administered drugs and anesthetics were added in Item 4 to reduce the time and effort needed to enter the names. Additional checkboxes were added to Item 7-Disposition in order to get a more accurate response to the item. For the Emergency Department (ED) PRF (NHAMCS-100(ED), Attachment G), the Glasgow Coma scale item was deleted due to poor item response and checkboxes were added to Item 6b - the patient’s current conditions , Item 7 - Diagnostic Services, and Item 8 - Procedures.

3. Lookback Module

The intent of the lookback module is to improve the nation’s ability to monitor and evaluate the quality of clinical care to prevent heart disease and stroke as health reform proceeds. The feasibility of obtaining information from the 12-month period prior to the sampled visit on risk factors for heart disease and stroke and the clinical management of patients with hypertension, hyperlipidemia, and diabetes will be tested (Attachment H). For example, the module includes items related to family history, lab tests, health education, and medications, including changes in dosage and contraindications.

Since NHAMCS already collects selected intermediate outcomes, including blood pressure and cholesterol levels, combining currently collected OPD PRF data with the additional lookback items will permit the evaluation and monitoring of the appropriateness of clinical management and the relationship to these outcomes.

The lookback module will be funded from prevention funds from the Patient Protection and Affordable Care Act of 2010, and has already been approved for pretesting in the physician’s office in the National Ambulatory Medical Care Survey (NAMCS, OMB No. 0920-0234).

Testing this module will not add an additional burden to the facility, since the medical records will have already been pulled for completion of the OPD PRF.

4. Pretest of Asthma Management Supplement

The feasibility of conducting an asthma management supplement in outpatient clinics will be tested. At each hospital, no more than one OPD physician will be asked to complete a short questionnaire assessing the clinic’s asthma management practices. The supplement will take approximately 15 minutes per respondent, and a total of 12 respondents is expected (Attachment D).

Table 12-A. Annualized Burden to Respondents

Type of Respondent		No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Response Burden (in hours)
	Form Name
Hospital CEO/CFO	Hospital Induction (NHAMCS-101)	12	1	1	12
Ancillary Service Executive	Freestanding ASC Induction (NHAMCS-101FS)	8	1	1.5	12
Ancillary Service Executive	Ambulatory Unit Induction (NHAMCS-101U)	48	1	1	48
Physician	Asthma Management Supplement Pretest	12	1	15/60	3
Medical Record Clerk	Pulling and re-filing Patient Records (ED, OPD, and ASC) Pretest	40	10	1/60	7
Total					82

Attachments

1. NHAMCS-101 Hospital Induction form

2. NHAMCS-101(FS) Freestanding Ambulatory Surgery Center Induction form

3. NHAMCS-101(U) Ambulatory Unit Induction form

4. NHAMCS-908 Asthma Management Supplement Pretest

5. NHAMCS-100(OPD) Outpatient Department Patient Record form Pretest

6. NHAMCS-100(ASC) Ambulatory Surgery Center Patient Record form Pretest

7. NHAMCS-100(ED) Emergency Department Patient Record form Pretest

8. NHAMCS-910 Lookback module Pretest

9. Pulling and Refiling Records Pretest

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