Screener

Attachment 3 – Cognitive interviewing eligibility screener

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). 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).

Public reporting burden for this collection of information is estimated to average 5 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 (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

Sample screening script for respondent contact by CQDER Laboratory Recruiter/CQDER Staff

for testing the CDC HSSC Assessment Tool

recruited through invitation letter for one-on-one cognitive interviews

Dial respondent’s telephone number [hereafter referred to as R] as indicated on audio recording.

 Note: Speak only to R. If the number is answered by an answering machine/voice mail, call back at another time.

CQDER Laboratory Recruiter/CQDER Staff: Good morning/afternoon, may I speak to [fill name]?

 If R is not available say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am following up on a letter I mailed them. I’ll try to reach them at another time.”

 If R has been successfully contacted, continue...

...Hello, my name is [CQDER Staff/CQDER Laboratory Recruiter’s name]. I am calling from the National Center for Health Statistics. You might remember receiving an invitation letter from Charlie Rothwell stating that we were looking for paid volunteers to help us evaluate a health scorecard questionnaire about topics related to the policies, practices, and systems that guide the delivery of care for adult patients with chronic disease conditions.

 If correct person has been contacted. Continue…

...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If the potential respondent has not received the invitational letter…

The Center for Questionnaire Design and Evaluation Research within the National Center for Health Statistics will be conducting a study to evaluate a health scorecard questionnaire about topics related to the policies, practices, and systems that guide the delivery of care for adult patients with chronic disease conditions. To do so, we will be conducting one-on-one interviews to get information about your experience filling out the health scorecard questionnaire, and your opinions of the health scorecard questions and the form. The one-on-one interview will last approximately 60 minutes. Respondents will receive $100.00.

...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

1. Does this practice mainly offer primary care services to ambulatory patients?

[The practice could be a single, stand-alone practice or part of a larger group of practices]

Yes

No [Refer to Exit Script 1]

2. What is your practice size (by size of the patient population served annually)?

Fewer than 500 covered lives

500 – 44,999 covered lives [Small individual providers or practices]

45,000 – 49,999 covered lives [Medium providers or practices]

50,000 or more covered lives [Large providers or practices] [Refer to Exit Script 1]

100,000 or more covered lives [Health System] [Refer to Exit Script 1]

3. What is your position in this medical practice? _____________________

Practice administrator

Practice manager or office manager

Physician practice owner or partner

Head of practice

Physician

Medical staff

Other staff member (please specify): ______________________

4. Do you have some knowledge (or can access information about)…

[R needs to have knowledge of or can access the majority of this information; if R only has knowledge of or can access information for less than three, ask for the best person who can speak about these topics]

Chronic disease management practices (high blood pressure, high cholesterol, diabetes, obesity, tobacco use, cancer) ___Yes ____No

Multi-disciplinary team approach to care ___Yes ____No

Clinical guidelines ___Yes ____No

Electronic health record system ___Yes ____No

Patient tracking systems ___Yes ____No

Clinical Decision supports and protocols ___Yes ____No

Patient Education ___Yes ____No

Self-management and care management ___Yes ____No

5. Is this practice part of or owned by any of the following?

[For representative sample, need to obtain at least one or more of each***]

Physician(s) or physician group***

Hospital or hospital system [Practice within a hospital would qualify if it mainly offers primary care services and R is someone who oversees this practice as opposed to the entire hospital system]

Health maintenance organization (HMO)***

Federally Qualified Health Center (FQHC), such as a community health center***

State or local government, such as a county clinic***

University of medical school [Refer to Exit Script 1]

Insurance company [Refer to Exit Script 1]

Other type of organization (please specify): ___________________

[If individual has not met any of the eligibility requirements go to exit script 1].

[If the recruitment needs for certain groups have been achieved, go to exit script 2].

Entry Script:

...Based on your answers to the questions, we would like you to take part in our study. An interviewer will ask you about topics related to the policies, practices, and systems that guide the delivery of care for adult patients with chronic disease conditions. The interviewer will also ask you about your opinions of the survey questions and the form. Everything you say will be kept private. Your individual responses will not be shared with anyone. Only summary reports will be available to those interested in the results of this study. With your permission, we would like to audio record your interview. The recording is a record of what we asked and what you said. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 3. Audio recording is essential for this project].

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing in your area on (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 4.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for being willing to participate and we look forward to seeing you at (LOCATION) at (DATE/TIME) Get respondent to cite date & time if possible.

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Exit script 1: I’m sorry, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.

Exit script 2: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 3: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time.

Exit script 4: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time.

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