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The respondent universe for this information collection consists of a total of 48 state government staff and their delegates in 6 selected states (Georgia, Louisiana, Missouri, Rhode Island, South Carolina and Wyoming). Respondents acting in their official capacities include 6 State Health Department staff (one from each selected state), 6 state EMS Task Force Directors, 6 state EMS data managers, 12 state EMS/Stroke Task Force Members, and 18 delegates (Please see Attachment A: Respondent Breakdown). The delegates included in this information collection are acting on behalf of the state health agency by performing stroke systems of care surveillance, planning, and program development; setting and implementing stroke systems of care standards; and ensuring the provision of high quality stroke care. States rely on these delegates (empaneled through state law and/or formal endorsement) to perform these essential public health services rather than fulfill the duties themselves because the delegates are uniquely positioned to assess and oversee stroke systems of care within a jurisdiction and provide direct interaction with healthcare provider groups, treatment associations, EMS providers and stroke patients.^1,7,8Specific delegates included in this information collection vary depending on the state, but may include EMS-Related Task Force Members, Rural Health Task Force Members, and Healthcare Task Force Members.

The six states included in this information collection were chosen to ensure a diversity of state-level actions relevant to pre-hospital stroke systems of care. States varied in terms of their current status of state-level actions relevant to EMS protocols for stroke patient assessment and triage, EMS transport protocols for transporting the stroke patient to the most appropriate stroke facility using ground transport, and statewide/regional stroke system(s) of care with at least 3 levels of stroke centers.

To identify respondents within the selected states, ASTHO will contact the stroke task force and/or EMS Director within each selected State Department of Health to verify appropriate contacts based on stroke system of care role and knowledge of the decision process and implementation process within the state. ASTHO will develop and maintain the distribution list for the respondents and will be solely responsible for making contact with each of the respondents. No one outside of the ASTHO team members will have access to this information.

Respondents will include State Health Department staff leading efforts on stroke systems of care, State EMS Task Force Leaders, State EMS Medical Directors, State EMS data managers and stroke, EMS and trauma advisory council and task force members directed by the state health or safety departments which may include Rural Health Officers, EMS Program Managers, Community Health System Administrators, Emergency Preparedness Directors, and Public Health Epidemiologists.

Procedures for the Collection of Information

Data will be collected via telephone respondent interviews and respondents will be recruited through a notification (see Attachment C: Recruitment Email) to the respondent list. The notification email will explain:

The purpose of the data collection, and why their participation is important
Instructions for participating
Method to safeguard their responses
That participation is voluntary
The expected time to complete the interview
Contact information for the project team

Following the recruitment email, those who do not respond within 10 business days will receive a reminder email (see Attachment D: Email Reminder) asking those who have not scheduled an interview date/time to do so. If any of the invited respondents are unable or unwilling to participate, they will be allowed to designate a substitute from their same agency and location, serving in a similar role to respond in their stead. If a designee is provided, ASTHO will follow the original protocol and send a recruitment email (see Attachment C: Recruitment Email) directly to the designee and, if needed, an email reminder (see Attachment D: Email Reminder) asking those who have not scheduled an interview date/time to do so. Respondents declining to participate will receive no further communication.

Respondents who agree to participate will be sent a confirmation email (see Attachment E: Confirmation Email) with additional information about the content of the telephone interview and scheduling request.

Interviews will be conducted over the span of approximately 8 weeks. The telephone interviews will be conducted with each respondent individually by a two-member team: one interviewer and one note taker. Data collection teams will consist of ASTHO project team members. The interviewer will read the telephone interview guide instructions (see Attachment B: Telephone Interview Guide) to the respondent prior to beginning of the interview. Interviews will be recorded in order to capture the conversation accurately and subsequently transcribed. Verbal permission to be recorded will be obtained from the participant prior to the beginning of the interview. The note taker will initiate recording using a commercial conference calling service and take written notes as back up.

When the telephone interviews are completed, a follow up email (see Attachment F: Follow-up email) will be sent from an ASTHO team member to each respondent thanking them for their participation and letting them know whom to contact with further questions.

Once the information collection period has closed, interview audio files and supporting documents shared by respondents will be assigned an ID number by ASTHO. All information will be kept on secure, password protected servers accessible only to ASTHO project team members. Data collected during the assessment will be shared only in aggregate form.

Interview files will be transcribed, cleaned and analyzed by ASTHO using Dedoose software. A qualitative analysis approach will be used to conduct a thematic analysis of responses to open-ended questions. The process will include independently coding each interview based on the list of variables and constructs to be analyzed. At several predefined points in the coding process, codes will be refined, collapsed, and/or eliminated, as appropriate based on data collected.

Once coding is completed, information will be grouped into larger themes and examined in relationship to other themes, interviewees, and states. The constructs to be explored through qualitative analysis of interview transcripts will address process variables related to development, and implementation of state-level actions to enhance pre-hospital stroke systems of care as well as program improvement processes, outcomes, and sustainability.

Methods to Maximize Response Rates Deal with Nonresponse

Although participation in the data collection is voluntary, the project team will make every effort to maximize the rate of response. The data collection instrument was designed with particular focus on streamlining questions to allow for skipping questions based on responses to previous questions, thereby minimizing response burden.

The interview guide (see Attachment B: Telephone Interview Guide) was designed to collect the minimum information necessary for the purposes of this project (i.e., limited to 29 questions). A reminder email (see Attachment D: Email Reminder) will be sent to those who have not responded to initial invitation within 10 business days. Those who do not respond within 20 business days from the reminder email will be considered non-responders.

Test of Procedures or Methods to be Undertaken

The estimate for burden hours is based on a pilot test of the data collection instrument by three public health professionals. In the pilot test, the average time to complete the instrument including time for reviewing instructions, gathering needed information and completing the instrument, was approximately 70 minutes (range: 60 to 90 minutes). For the purposes of estimating burden hours, the upper limit of this range (i.e., 90 minutes) is used.

Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

Colleen Barbero, MPPA, PhD

Health Scientist

Division for Heart Disease and Stroke Prevention, NCCDPHP, CDC

Phone: 770-488-7311

Email: [email protected]

Erika Fulmer, MHA

Policy Analyst

Division for Heart Disease and Stroke Prevention, NCCDPHP, CDC

Phone: 770-488-5334

Email: [email protected]

Alicia D. Smith, MPH

Director, Chronic Disease Prevention