0920-0572 Survey Instrument for Health Care Providers

Form Approved

OMB No. 0920-0572

Exp. Date 03/31/2018

Attachment C2:

Survey Instrument for

Health Care Providers

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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

1. What percentage of your patient population would you estimate is African-American/Black?

   • Don’t know

   • 0%

   • Less than 5%

   • 5%-24%

   • 25-49%

   • 50-75%

   • more than 75%

2. What percentage of your patient population would you estimate is of Ashkenazi Jewish heritage?

• Don’t know

• 0%

• Less than 5%

• 5%-24%

• 25-49%

• 50-75%

• more than 75%

3. Of all your patients, approximately what percentage are covered by: (Please provide a percentage)

• Medicare _________%

• Medicaid _________%

• Out of pocket/uninsured __________%

• Privately insured __________%

• Other (Specify) ______________________________ ________%

4. Select the three sources you find most useful in keeping up with current medical information related to well visits for women age 18-45.

   • Peer reviewed journals

   • General internet search

   • Social media

   • Mobile health apps for providers (i.e., Epocrates, UpToDate, Doximity)

   • Continuing Medical Education courses

   • Discussions with colleagues, peers

   • Conferences or presentations

   • Product theaters

   • National Guidelines

   • Medical Science Liaisons

   • Satellite Radio

   • Government health websites

   • Non-government health websites [please list the website names]

   • None of these

   • Other [please describe]

5. [For each of the top 3 sources selected in Q4] How frequently do you refer to or look at this source of information to inform your clinical practice?

• Daily

• At least once a week

• At least once a month

• Never

• Other: (please describe)

6. Which of the following do you use to seek or share information professionally: (select all that apply)

   • Facebook

   • Twitter

   • Instagram

   • Pinterest

   • Blogs

   • Reddit

   • YouTube

   • Tumblr

   • Snapchat

   • I do not use social media professionally

   • Other [please specify]

Material A

7. Do you remember seeing this graphic before? (123d.)

• Yes

• No

IF YES

1. Please indicate any actions you took after seeing this graphic (check all that apply)

• I did not take any action after seeing this graphic

• I ‘liked’ it on social media

• I shared it with others on social media

• I clicked on it

• I looked for additional information on the topic

• Other: [please describe]

2. IF NO

   1. Please indicate any actions you would take after seeing this graphic (check all that apply)

• I would not take any action after seeing this graphic

• I would ‘liked’ it on social media

• I would share it with others on social media

• I would click on it

• I would look for additional information on the topic

• Other: [please describe]

Please indicate how much you agree or disagree with the following statements about this graphic.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I am interested in this graphic’s topic (36e.)	1	2	3	4	5
It is important that clinicians see this graphic	1	2	3	4	5
I like the way this graphic looks (37e.)	1	2	3	4	5
I trust the information in this graphic (42e.)	1	2	3	4	5

12. What information would you hope to find if you clicked on this graphic?

13. How could this graphic be improved?

Material B

14. Do you remember seeing this factsheet before? (123d.)

• Yes

• No

3. IF YES

   1. Please indicate any actions you took after seeing this factsheet (check all that apply)

• I did not take any action after seeing this factsheet

• I ‘liked’ it on social media

• I shared it with others on social media

• I thought about the issue

• I talked with colleagues about this information

• I clicked on a link in the factsheet

• I looked for additional information on the topic

• I incorporated the information into my patient visits as appropriate

• Other: [please describe]

4. IF NO

   1. Please indicate any actions you would take after seeing this factsheet (check all that apply)

• I would not take any action after seeing this factsheet

• I would ‘like’ it on social media

• I would share it with others on social media

• I would think about the issue

• I would talk with colleagues about this information

• I would click on a link in the factsheet

• I would look for additional information on the topic

• I would incorporate the information into my patient visits as appropriate

• Other: (please explain)

15. What questions do you have about this factsheet or the information presented in it?

16. How could the factsheet be improved?

Please indicate how much you agree or disagree with the following statements about this factsheet.

ITEM	Strongly disagree	Somewhat disagree	Neutral	Somewhat Agree	Strongly Agree
The information is presented in a way that is easy for me to consume
I learned something new by reading this (E.55.e)
I need or want information on this topic
This is not a high priority topic in my practice or specialty
Overall, the suggestions in this factsheet are doable (F.43.f)
This factsheet leaves me with more questions than answers
After reading this, I would assess or advise some of my 18-45 year old female patients differently than before

24. How much of the factsheet would you read? Please choose all that apply. (D.37.d)

• I would not read any of it.

• I would only read the headline.

• I would only read the headlines and look at the images.

• I would read the whole thing.

• I would read the whole thing and click on some of the links.

25. Where should this information be placed to most effectively reach clinicians like you?

    • Peer reviewed journals [please specify]

    • Social media [please specify]

    • Mobile health apps for providers (ie, Epocrates, UpToDate, Doximity)

    • Continuing Medical Education courses

    • Websites [please specify]

    • Email listservs [please specify]

    • None of these

    • Other [please describe]

Factsheet Section 1: Who is at high risk for early-onset breast cancer?

26. Is assessing your patients’ medical and family history for risk of early-onset breast cancer a topic on which you need information?

• Yes

• No

	Never	Occasionally	Frequently	Always
In your well visits with 18-45 year old women, how often is the patient’s individual risk for breast cancer discussed?
When discussing 18-45 year old women’s individual risk for breast cancer, how often do you discuss the link between lifestyle behaviors and breast cancer?
When speaking with 18-45 year old female patients about breast cancer risk, how often do you encounter questions you are not confident in answering?

30. Does this factsheet provide any information that would prompt or assist you in having these early-onset breast cancer risk conversations with your 18-45 year old patients?

• Yes

• No

31. How do you collect family history information:

• Family Health Questionnaire or Checklist (Patient completes at home)

• Family Health Questionnaire or Checklist (Patient completes in office)

• Direct patient questioning (by physician, NP, or PA)

• Direct patient questioning (by other office staff – e.g., RN, CMA)

• Pedigree (completed by physician, NP, PA)

• Other [please describe]

32. Select any of the following that you collect from patients regarding their personal and family medical history.

    • Personal history of cancer

    • History of chest radiation between the ages of 10-30

    • Cancer among first-degree relatives (parents, siblings, children)

    • Cancer among second-degree relatives (grandparents, aunts, uncles)

    • Cancer among third-degree relatives (cousins, great-grandparents

    • Age of cancer diagnosis among relatives

    • Age of death of relatives with cancer

    • Results of any genetic tests performed on family members

    • Presence of Ashkenazi Jewish heritage

33. The factsheet advises using an early-onset breast cancer risk assessment tool based mainly on family history. Do you regularly use any of the following?

Screening Tool
Ontario Family History Assessment Tool
Manchester Scoring System
Referral Screening Tool
Pedigree Assessment Tool
FHS-7
The Referral Screening Tool/B-RST
Breast Cancer Surveillance Consortium Risk Calculator
Gail Model
SHARE Workbook
Your Disease Risk
Know:BRCA
Others (please describe)
I do not regularly use an HBOC risk assessment tool

34. Does this factsheet provide any information you find useful regarding conducting early-onset breast cancer risk assessments?

• Yes

• No

Factsheet Section 2: What are the current genetic counseling and testing guidelines for women at high risk for breast cancer?

In the past 3 years, have you seen an increase in the number of 18-45 year old women	Yes	No
Concerned about their risk for breast or ovarian cancer
Asking about lifestyle factors as they relate to breast or ovarian cancer
Requesting mammograms or other breast cancer screening tests
Asking about genetic testing related to hereditary breast or ovarian cancer risk

Have you ever:	Yes	No
Recommended genetic counseling to a patient based on their risk for hereditary breast or ovarian cancers
Ordered genetic tests related to hereditary breast or ovarian cancers
Interpreted the results of a genetic test related to hereditary breast or ovarian cancers

Provide your opinions on advising 18-45 year old women regarding genetic testing for early-onset breast or ovarian cancer risk	Strongly Agree	Some-what Agree	Some-what Disagree	Strongly Disagree	This isn’t something I deal with in my practice
Clear Guidelines are not available for referring to genetic counseling and testing
Genetic tests for hereditary breast or ovarian cancer risk have too many ambiguous results
Genetic tests for hereditary breast or ovarian cancer risk are too costly
My patients with positive HBOC genetic test results are at risk for health insurance discrimination

Before looking at this factsheet:
	Yes	No
It was clear to me which 18-45 year old female patients should be referred for genetic counseling and testing
After looking at this factsheet:
	Yes	No
It was clear to me which 18-45 year old female patients should be referred for genetic counseling and testing

Factsheet Section 3: What are the current screening guidelines for women at high risk for breast cancer?

Before looking at this factsheet:
	Yes	No
It was clear to me what screening recommendations to make for 18-45 year old female patients at moderate risk for breast cancer
It was clear to me what screening recommendations to make for 18-45 year old female patients at high risk for breast cancer
After looking at this factsheet:
	Yes	No
It is clear to me what screening recommendations to make for 18-45 year old female patients at moderate risk for breast cancer
It is clear to me what screening recommendations to make for 18-45 year old female patients at high risk for breast cancer

Factsheet Section 4: What are the possible next steps after screening women at high risk for early-onset breast cancer?

How easy or difficult do you find the following:	Very difficult	Somewhat difficult	Somewhat easy	Very easy	I do not do this in my practice
Managing patients who carry a genetic mutation for inherited cancer susceptibility
Counseling a patient on risk reduction actions (e.g., mammography and other screening), based on the results of a genetic test

54. Would you like additional information – beyond what is in this factsheet – regarding managing a patient with a genetic mutation related to hereditary breast and ovarian cancers?

• Yes

• No

Additional Material Needs

55. Please select any of the following HBOC topics on which you need or want information.

• What to do when a patient doesn’t know their family cancer medical history

• Exactly what family medical history information is needed to assess risk

• Scripts for communicating with patients about the evidence-base and/or guidelines you use for assessing risk and recommending appropriate screening

• Scripts for communicating about how to access genetic counseling and testing

• Scripts for communicating about the benefits of genetic counseling and testing for those at increased risk

• Tailored and culturally relevant resources and education materials to give patients

• Assistance in determining which risk assessment tool(s) to use

• Assistance in determining which screening guidelines to follow for high risk patients

• Assistance in determining which screening guidelines to follow for moderate risk patients

• Managing breast or ovarian cancer survivors once they are in remission

• Managing patients with a known BRCA or other HBOC-related genetic mutation

• Other (please elaborate)

56. In what format do you prefer to receive information about HBOC topics (as selected in the previous question)?

• CME courses

• Podcasts

• Infographics

• Presentations

• Videos

• Blogs

• Articles

• Factsheets

• Webinars

• Other (please elaborate)

57. Where would you prefer to find that information?

• Social media

• Announcements or emails from my professional organizations

• Conferences or meetings

• Professional organization websites

• Government websites

• Research literature

• Professional publications/journals

• Internal communication channels within my healthcare organization

• Other

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