Att B - Asthma Supplement

Attachment B: 2012 Asthma Supplement Questions
OMB No. 0920-0234 Exp. Date 2/28/2013

FORM NAMCS-91 (9-29-2011)

U.S. DEPARTMENT OF COMMERCE

12. Below are strategies that could be used to help patients control their asthma. Please specify whether you use each
strategy. If you do not use a strategy specify the most important barrier (if any) that you face to using that strategy.
You may also indicate that you face no barrier or that you view that strategy as not effective).
Do you use this
strategy? If no,
please indicate one
barrier listed to
the right.
Mark (X) one
Yes
No

Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Health Statistics

Mark (X) one box for each "NO" response.
No
barrier

Not
effective

Poor
patient
adherence

Low
patient
health
literacy

NATIONAL AMBULATORY MEDICAL CARE SURVEY

Lack of
Lack of Lack Lack of
staff/
equipment training of time payment

(a) Written asthma
action plans

1

2

1

2

3

4

5

6

7

8

(b) A control assessment
tool (e.g., ACT or
similar tool)

1

2

1

2

3

4

5

6

7

8

(c) Home peak flow
monitors

1

2

1

2

3

4

5

6

7

8

(d) In-office spirometry

1

2

1

2

3

4

5

6

7

8

2012 ASTHMA SUPPLEMENT
NOTICE – Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the 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
Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0234).
Assurance of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment will be held confidential;
will be used for statistical purposes only by NCHS staff, contractors; and agents only when required and with necessary controls, and will not be disclosed or
released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC
242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

BACKGROUND INFORMATION
(e) Educating patients to
recognize symptoms

1

2

1

2

3

4

5

6

7

8

(f) Educating patients to
avoid risk factors

1

2

1

2

3

4

5

6

7

8

1

2

1

2

3

4

5

6

7

8

(h) Observe inhaler
use by patients

1

2

1

2

3

4

5

6

7

8

(i) Advise patients to
change their home
environment

1

2

1

2

3

4

5

6

7

8

1

2

2

3

4

5

6

7

8

1

2

2

3

4

5

6

7

8

1

1

1

13. How often do you encounter these patient concerns or misunderstandings
about asthma therapies?
(a) Misunderstanding of medication risks or side effects, or belief in
myths (e.g., muscle development, addiction)

2

Never
(0%)
1

Sometimes
(1–24%)

2

Often
(25–74%)

3

Almost
always
(75–100%)

2

3

4

(c) Concern about long-term side effects of inhaled corticosteriods
(e.g., delayed growth in children)

1

2

3

4

(d) Confusion between symptom relief medications and daily control medications

1

2

3

4

3

Closing Statement – Thank you for completing this special survey. We appreciate your time and cooperation.
Page 4

FORM NAMCS-91 (9-29-2011)

4

Pediatrics
CHC Mid–level Provider

5

Other–Specify

The National Institutes of Health, Centers for Disease Control and Prevention, and the US Environmental
Protection Agency are conducting a special survey on asthma care provided in community health centers
and physician office settings. We are interested in the clinical decisions you make about asthma in every
day practice and not what may be ideal or best practice. Your answers will remain anonymous.For all the
following questions, please answer only for patients you personally see. Do not include patients seen by
or clinical decisions made by other practitioners at your site.

2.

Which type of system, if any, do you use to track and manage your patients with asthma
(e.g., schedule regular follow-up visits)?
1
2

Physician to whom this survey was addressed
Other clinical role (e.g., PA, NP, RN)
Other office staff

3

Which of the following patient age groups do you see?
Mark (X) all that apply.
1
0–11 years
12–17 years
2
18–24 years
3
25–64 years
4
65 years and above
5

3

Electronic medical record-based system
An electronic system separate from medical records
Paper reminder/recall system

4
5
6

Other type of system
No system
Don’t know

3.

How frequently do you use an asthma-specific structured encounter form (i.e., an asthma template or an asthma
visit checklist) when asthma is the primary reason for the visit?
1
No form available
4
Often (25–74%)
Never (0%)
2
Almost always (75–100%)
5
Sometimes (1–24%)
3

4.

During your last normal week of practice, approximately how many visits did you have with patients who have
asthma regardless of the reason for the visit?

14. Please indicate your role?
2

Area code Number
D. Census
contact
telephone

1.

4

1

General/Family Practice
Internal Medicine

INTRODUCTION

Mark (X) one box in each row.

(b) Concern about short-term side effects from inhaled corticosteroids
(e.g., thrush)

1

C. Census contact name

B. Provider’s specialty (Mark (X) only ONE.)

(g) Involve patients
in treatment
decision-making

(j) Advise employed
patients to seek
changes in the work
environment
(k) Schedule routine
follow-up visits to
assess asthma
control

A. Provider’s serial number

Number of visits

5.

For each of the following statements, please indicate whether
you agree or disagree:
a. Spirometry is an essential component of a clinical evaluation
for an asthma diagnosis in patients able to perform it (spirometry
does not include peak flow monitoring)
b. Inhaled corticosteroids are the most effective medications
to control persistent asthma

Mark (X) one box in each row.
Strongly
agree

Agree

Strongly
Neutral Disagree disagree

1

2

3

4

5

1

2

3

4

5

c. Asthma action plans are an effective tool to guide patient
self-management efforts

1

2

3

4

5

d. Patients with persistent asthma should have follow-up visits
at least every 6 months to assess control

1

2

3

4

5

e. Assessing asthma severity is necessary to determine
initial therapy

1

2

3

4

5

6.

Please rate your confidence in using the following actions

Mark (X) one box in each row.
Very
confident

Somewhat
confident

Not all
confident

N/A (do not
perform)

1

2

3

4

b. Assessing underlying asthma severity using standard criteria

1

2

3

4

c. Prescribing the appropriate dose of inhaled corticosteroids

1

2

3

4

d. Evaluating the need to step up controller therapy

1

2

3

4

1

2

3

4

FOR QUESTIONS 7–10, PLEASE RESPOND REGARDING VISITS MADE SPECIFICALLY
FOR ASTHMA (INCLUDING ROUTINE AND ACUTE VISITS).
7.

For what percent of asthma visits do you document overall asthma control?
1
2
3
4

8.

0% (Never)
1–24% (Sometimes)
25–74% (Often)
75–100% (Almost always)

For what percent of asthma visits do you ask about the following items
or perform the following tests to assess current asthma control?

Mark (X) one box in each row.
0%
(Never)

1–24%
25–74%
(Sometimes) (Often)

e. Assessment by history of triggers at the workplace (e.g., dust,
fumes, chemicals) Skip to 9f if you do not see adults
f. Testing for allergic sensitivity via skin or allergen-specific IgE
(e.g., RAST) testing
g. Assessment of daily use of controller medication (e.g., inhaled
corticosteroids) for patients with persistent asthma
h. Repeated assessment of inhaler technique

Mark (X) one box in each row.
0%
(Never)

1–24%
(Sometimes)

75–100%
(Almost
always)

25–74%
(Often)

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

10. Under which circumstances do you make the following recommendations about
environmental exposures?

Mark (X) one box in each row.
For most
asthma
patients

Only for patients
with sensitivity
to this trigger

Rarely or
never
recommend

a. Using dust mite control measures (e.g., mattress covers)

1

2

3

b. Controlling household mold and pests (e.g., cockroaches)

1

2

3

c. Removing pets from the home

1

2

3

d. Avoiding pollen (e.g., limit outdoor time, close windows)

1

2

3

e. Avoiding air pollution (e.g., ozone warnings)

1

2

3

f. Making changes to cooking appliances (e.g., exhaust vents)

1

2

3

g. Avoiding second-hand tobacco smoke

1

2

3

11. How do you use the following medications?
Mark (X) ALL that apply on each row.

Mark (X) ALL that apply on each row.
Daily long
Add on
For difficult
Symptom
relief/acute term control daily control to control
therapy
asthma
exacerbation therapy

75%–100%
(Almost
always)

Do
not
use

a. Short acting beta agonists (e.g., Albuterol)

1

2

3

4

5

b. Inhaled corticosteroids (ICS)
c. Long acting beta agonists (LABA) (e.g., Serevent/salmeterol,
Foradil/formoterol)
d. Combination medication that includes both LABA
and ICS (e.g., Advair)

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

4

e. Leukotriene modifiers (e.g., Singulair/montelukast)

1

2

3

4

5

3

4

f. Anticholinergics (e.g., ipatropium, tiotropium)

1

2

3

4

5

2

3

4

g. Methylxanthines (e.g., theophylline)

1

2

3

4

5

h. Omalizumab/Xolair

1

2

3

4

5

1

2

3

4

i. Short course of oral/injectable corticosteroids

1

2

3

4

5

i. Peak flow results from home

1

2

3

4

j. Spirometry (include only visits with patients able to perform it)

1

2

3

4

j. Long course of oral corticosteroids (>10 days)

1

2

3

4

5

a. Ability to engage in normal daily activities

1

2

3

4

b. Frequency of daytime symptoms

1

2

3

4

c. Frequency of nighttime awakening

1

2

3

4

d. Patient perception of symptom control

1

2

3

4

e. Control assessment tool (e.g., Asthma Control Test, Asthmas Control
Questionnaire, Asthma Therapy Assessment Questionnaire, or similar tool)

1

2

3

f. Frequency of rescue inhaler use (e.g., Albuterol)

1

2

g. Frequency of exacerbations requiring oral steroids

1

h. Frequency of patient report of emergency department
or urgent visit for asthma

Page 2

a. Provide a new or review an existing written asthma action plan
outlining medications, triggers, and when to seek emergency care.
b. Assessment by history of triggers at home (e.g.,
pets, mold, tobacco smoke)
c. Assessment by history of triggers at school (e.g., mold,
dust, exhaust) Skip to 9d if you do not see children
d. Ask adult patients about their occupation and place of
employment Skip to 9f if you do not see adults

i. Referral to a specialist Skip to 10 if you are an
asthma/allergy specialist

a. Using spirometry data as a component of a clinical evaluation for an
asthma diagnosis in patients able to perform it

e. Evaluating when to step down controller therapy

9. For what percent of asthma visits do you use each of the following
strategies to help patients control and manage their asthma?

FORM NAMCS-91 (9-29-2011)

FORM NAMCS-91 (9-29-2011)

Page 3