Request for Approval of A Non-Substantive Change to the:
National Ambulatory Medical Care Survey
OMB No. 0920-0234
(Expires 12/31/2014)
Contact Information:
Donald Cherry, M.S.
Lead Statistician, Ambulatory Care Team
Ambulatory and Hospital Care Statistics Branch
Division of Health Care Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention
3311 Toledo Road, Room 3333
Hyattsville, MD 20782
301-458-4762
301-458-4032 (fax)
October 25, 2013
National Ambulatory Medical Care Survey (NAMCS)
This request is for a nonsubstantive change to an approved data collection - the National Ambulatory Medical Care Survey (NAMCS) (OMB No. 0920‑0234) (expires 12/31/2014). On December 13, 2011, OMB approved the NAMCS including the shift from a paper-based survey to electronic data collection in 2012. The approved supporting statement included permission to modify selected sections of the 2012-2014 surveys through a nonsubstantive change clearance request. Some questions change on a periodic basis to collect new and/or updated information as needed.
This document proposes some new, modified, and deleted questions to the prior approved NAMCS data collection content for two specific survey forms -- Physician Induction Interview and Patient Record form. Changes to the content for 2014 are presented in the included attachments, highlighted below, and described in more detail in section A2. In addition, the lookback module has been discontinued for 2014 due to funding issues (described in more detail in section A2).
Concurrent to this submission, the National Hospital Ambulatory Medical Care Survey (NHAMCS, OMB No. 0920-0278, expiration 12/31/2014) is also requesting nonsubstantive changes. A majority of the requested data changes in this request apply to both surveys, and represents an attempt to maintain data collection consistency across ambulatory care settings.
All respective changes are documented within each of the two nonsubstantive submissions.
Physician Induction Interview (NAMCS-1)
The Physician Induction Interview collects a variety of information, including physician and practice information. This form is used for both office-based physicians and providers in community health centers. Attachments A1-A3 contain the modifications and additions to the 2014 Physician Induction Interview (NAMCS-1). As in 2013, the 2014 NAMCS-1 questions will be collected on a computer-assisted interviewing instrument. Changes include the following:
Modify the survey eligibility question series for both office-based physicians and community health center (CHC) providers to reduce possible misclassification of providers (Attachment A1)
Include phlebotomy as a possible answer choice for activities performed in a particular office, and include additional text that defines lab testing (Attachment A1)
Modify questions in the electronic health records (EHR) section (Attachment A2)
Modify two questions and add a new workforce question related to written protocols for providing chronic care services (Attachment A3)
Patient Record Form (PRF)
Minor changes are proposed for the 2014 NAMCS PRF. Attachment B provides an itemized summary of the proposed changes. All proposed question changes are highlighted in the attachment. As in 2013, the 2014 PRF questions will be collected on a computer-assisted PRF instrument. A general summary of the PRF changes are highlighted below:
Add/modify answer choices for selected items examining payment, tobacco use, major reason for visit, injury, and visit disposition
Add a follow-up question if the visit was for an injury, to assess timing of injury
Re-order answer choices and slightly modify text related to intentionality of injury
Add new/modify number of look-up and linked verbatim items in the following sections: reason for visit, cause of injury, diagnosis, and medications
Add/modify various check-boxes related to a patient’s chronic conditions and medical services
Slightly modify the question assessing duration of patient interaction with the physician
The following section highlights modifications to the NAMCS-1. Note that the induction interview is used for both office-based physicians and providers in community health centers. Changes by section of the induction form are shown in attachments A1-A3.The questions in the attachments are numbered; however, this was done purely as a guide to follow skip patterns. The computerized instrument is not numbered. The full induction interview for 2014 is shown in Attachment C1 and the related burden notice and confidentiality statement that will appear on the computerized instrument are shown in Attachment C2.
The first modifications to the NAMCS-1 are of a general nature and are shown in Attachment A1. Specifically, these changes relate to the eligibility criteria for NAMCS. A new trend in the health care arena is hospital ownership of private physician practices, which are in-scope, but may potentially be lost due to how the current eligibility questions are structured. A new question that explicitly captures this new type of practice has been added. Specifically, for office-based physicians, if they report that they care for ambulatory patients and do not work in a federally-operated setting, then a direct question has been added that asks them if they work in an office-based practice owned by a hospital.
The second modification involves the eligibility questions for sampled providers practicing in community health centers (CHCs). Typically, federally-operated settings are out-of-scope for NAMCS participants; however, we explicitly sample federally-funded community health centers. Recently, we have found that providers were incorrectly classifying their CHC as ineligible for NAMCS participation because they were confusing their center’s in-scope federally-funded status with the eligibility wording that stated “Do you work as an employee or a contractor in a federally-operated patent care setting…” In short, CHC providers thought that because their CHC was funded by federal grants they were also working at a federally-operated CHC; this assumption was incorrect, and classified the provider as out-of-scope for the NAMCS. In order to reduce potential misinterpretation, we dropped any mention of the concept “working in a federally operated setting” on the NAMCS-1 for CHC providers.
A general question on tests performed is the next modification. In previous versions of the NAMCS-1, we simply asked if lab testing was done in the office. This item has been determined to be too general, so a more specific definition of lab testing was added for the Census field representatives (FRs) to explain to sampled providers. Specifically, we are requesting that lab testing should not include urine dipstick, urine pregnancy, fingerstick blood glucose, or rapid swab testing for infectious diseases. NCHS also expanded the list of medical procedures performed at an in-scope office to include phlebotomy.
Another section of the interview relates to the use of Electronic Health Records (EHRs). Small modifications are also proposed to this section to either increase or decrease the specificity of the information being requested in a given question. For instance, modifications 1, 2, 9, and 10 (in Attachment A4) add questions on EHR privacy issues and sharing of clinical data; modification 4 allows the responder to differentiate between Stage 1 and Stage 2 EHR incentive programs; and modification 8 adds a few brief “follow up” questions. Modifications 5, 6 and 7 are of similar scope.
The following section highlights proposed changes to the PRF and can be reviewed in Attachment B. It should be noted that the proposed changes described below follow sequentially how the changes will be ordered on the 2014 PRF, and thus are organized similarly in the attachment. Although not discussed in detail below, numerous section headings were modified to be more descriptive of the medical information contained within each group. A copy of the full computerized 2014 Patient Record form is shown in Attachment D.
First, the Medicaid answer choice will be expanded to include “other state-based programs.” After examining the payment item, it was determined that we were potentially misclassifying payments by state-based programs as “other” because of the limited scope of the current check-boxes.
Second, two tobacco check-boxes will be added for patients who indicate they are not currently smoking and include “never” and “former.” Given the long latent period for smoking-induced illnesses, there is research value in knowing more specifics about past smoking behavior.
A review of the computer-assisted PRF revealed that (a) changing the section headings and ordering of some questions, (b) expanding and adding new answer choice categories, and (c) increasing the number of verbatim (and subsequent look-up tables) would improve the flow of data collection, and enhance the richness of data collected at each visit. Specifically, we are proposing to expand selected verbatim items so the physician or Census abstractor can record up to 5 patient’s reasons for visit and diagnoses. Historically, NAMCS has only included space to write in 3 diagnoses and the patient’s reason for visit. Various other small modifications in these sections include: (a) expanding the single checkbox “Pre/Post surgery” under the major reason section into two distinct answer choices: “Pre-surgery” and “Post-surgery,” (b) adding additional text to the injury checkbox question to identify if the visit was due to an adverse effect of medical/surgical care, or adverse effect of medicinal drug, (c) adding a follow-up question when the visit was for an injury to determine if the cause occurred within 72 hours, and (d) changing the wording of the intentionality question identifying an injury and poisoning to include “overdose.”
There have been several modified and new checkboxes added to the collection of underlying chronic conditions, housed within the “Diagnosis” section of the computer-assisted PRF. These specific conditions were added after consultation with clinicians on staff, subject matter experts within the National Center for Health Statistics (NCHS), and a review of AHRQ’s recommendations found in “The Guide to Clinical Preventive Services, 2012.” The NAMCS has always had the ability to collect the chronic conditions listed below in write-in fields; however, adding these check-boxes will reduce burden substantially, and should increase reporting accuracy. There were eleven specific modified/new chronic condition check-boxes; a few are shown below, but the complete list is shown in Attachment B.
Alcohol misuse, abuse, or dependence
Alzheimer's disease/Dementia
HIV Infection/AIDS
Obstructive sleep apnea (OSA)
NCHS is also proposing to make several changes to the medical services section of the computer-assisted PRF. As with the new patient chronic conditions, the NAMCS has always had the ability to collect the newly proposed services listed below from write-in fields, and adding these check-boxes should make data collection easier and more accurate. Some modified/new medical services are listed below; a complete list with highlighted changes is included in Attachment B.
Domestic violence screening
Comprehensive metabolic panel
Creatinine /Renal function panel
Hepatitis testing/Hepatitis panel
Vitamin D test
Genetic counseling
Lookback Module Removal
The lookback module was added in 2012 and collected additional information from the 12 month period prior to the sampled visit on risk factors and clinical management of patients with conditions that put people at high risk for heart disease and stroke. The module recorded medications prescribed, changes in medications, family history, and contraindications to certain medications. The intent of the lookback module was 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 lookback module was funded from prevention funds from the Patient Protection and Affordable Care Act (ACA) of 2010. Funding from ACA was removed and a decision was made to remove the module in 2014, with the possibility of a re-emergence in 2015.
A8. Consultation Outside the Agency
Andrew Bindman, MD
Senior Advisor
HHS/ASPE/Health Policy
200 Independence Ave, SW
Washington, DC 20201
(202) 401-8398
Caroline Taplin
HHS/ASPE
Acting Director, Division of Public Health Services
200 Independence Ave, SW
Washington, DC 20201
(202) 690-6870
Jennifer King, PhD
Office of Economic Analysis, Evaluation and Modeling
Office of the National Coordinator for Health IT (ONC)
200 Independence Avenue, SW, Suite 729-D
Washington, DC 20201
202-260-6347
Vaishali Patel, MPH, PhD
Office of Economic Analysis, Evaluation and Modeling
Office of the National Coordinator for Health IT (ONC)
200 Independence Avenue, SW, Suite 729-D
Washington, DC 20201
202-690-3912
A12. Estimates of Annualized Burden Hours and Costs
The lookback module has been deleted and the line in the burden table removed. The total burden has been reduced by 2,980 hours, from 50,923 to 47,943 hours.
Table of Estimated Annualized Burden Hours
Type of Form |
Type of Respondent
|
Form Name |
Number of Respondents |
Number of Responses per Respondent |
Hours per Response |
Total Burden (Hours) |
Core NAMCS Forms |
Office-based physicians/CHC providers |
Physician Induction Interview (NAMCS-1) |
17,034 |
1 |
35/60 |
9,937 |
Community Health Center Directors |
Community Health Center Induction Interview (NAMCS-201) |
2,008 |
1 |
20/60 |
669 |
|
Office-based physicians/CHC providers |
Patient Record form (NAMCS-30) |
3,407 |
30 |
14/60 |
23,849 |
|
Office/CHC staff |
Pulling, re-filing medical record forms |
13,627 |
30 |
1/60 |
6,814 |
|
Office-based physicians/CHC providers |
Asthma Supplement |
11,072 |
1 |
20/60 |
3,691 |
|
National Electronic Health Records Survey (NEHRS) |
Office-based physicians |
NEHRS form |
4,344 |
1 |
20/60 |
1,448 |
Physician Workflow Survey (PWS) |
Office-based physicians |
PWS form |
2,645 |
1 |
30/60 |
1,323 |
Pretest NAMCS Forms |
Office-based physicians |
Physician Induction Interview (NAMCS-1) |
17 |
1 |
35/60 |
10 |
Office-based physicians |
Patient Record form (NAMCS-30) |
17 |
30 |
14/60 |
119 |
|
Re-abstraction Study |
Office/CHC staff |
Pulling, re-filing medical record forms |
500 |
10 |
1/60 |
83 |
|
Total |
|
|
|
|
47,943 |
A15. Explanation for Program Changes or Adjustments
The current approved burden is 50,923 hours. The proposed changes to the 2013 survey, including removing the Lookback Module, will reduce the burden to the respondent by 2,980 hours, resulting in a final burden of 47,943 hours.
Supporting Statement
List of Attachments
A1. National Ambulatory Medical Care Survey 2014: NAMCS-1 General Changes
A2. National Ambulatory Medical Care Survey 2014: NAMCS-1 Electronic Health Record (EHR) Changes
A3. National Ambulatory Medical Care Survey 2014: NAMCS-1 Workforce Changes
A4. National Ambulatory Medical Care Survey 2014: NAMCS-1 Electronic Health Record (EHR) Changes
B. National Ambulatory Medical Care Survey 2014: Patient Record Form (PRF) Changes
C1. National Ambulatory Medical Care Survey 2014: NAMCS-1 Induction Interview
C2. National Ambulatory Medical Care Survey 2014: Notice and Confidentiality Statement
D. National Ambulatory Medical Care Survey 2014: PRF
| File Type | application/msword |
| File Modified | 2013-10-28 |
| File Created | 2013-10-28 |