0920-0572 HCP Screener In Depth Interview

OMB No. 0920-0572

Expiration Date 08/31/2021

Brand Concept and Message Testing for Diabetes Self-Management Education and Support (DSMES) Services:

Recruitment Screener for Health Care Providers

Introduction

Hello. My name is [name]. I work with _________.  [As needed, discuss how you got their contact information]. We are recruiting interested health care providers to take part in interviews. We are conducting this work on behalf of the U.S. Centers for Disease Control and Prevention, also known as CDC. If you qualify and complete the interview, you will receive $150 as a token of appreciation. The interview will be conducted by telephone. It will last no more than one hour. To see if you qualify, I would like to ask you a few questions. These questions will take less than 5 minutes to answer and we will keep your answers confidential. May I continue?

• Agreed to answer screening questions Continue

• Did not agree to answer screening questions Thank and Terminate

[Please use the following language for termination of screening:]

Thank you very much for your time and interest today. Unfortunately, you do not qualify for this interview.

Screening Questions

1. Gender

• Male Continue

• Female Continue

2. To participate in the interview, you will need to have access to a computer and the internet, do you have access?

• Yes CONTINUE

• No TERMINATE

• 
  

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

  
  

  Do not know/Unsure TERMINATE

3. Are you a…?

• Physician/MD/DO Continue

• Nurse Practitioner Continue

• Registered Nurse Terminate

• Advanced Practice Registered Nurse Continue

• Physician Assistant Continue

• Other Terminate

4. [For Physicians only] What is your medical specialty?

• General Practice/General Medicine/Internal Medicine/Family Medicine Continue

• Endocrinology Continue

• Other Terminate

5. [for NPs, APRNs and PAs only] Which of the following medical specialty areas do you work in?

• Endocrinology Continue

• Internal Medicine Continue

• General/Family Medicine Continue

• Other Terminate

6. Are you a Certified Diabetes Educator, a part of the Fellows Program of the American Association of Diabetes Educators, or have a Board Certified-Advanced Diabetes Management credential (BC-ADM)?

• Yes Terminate

• No Continue

7. What type of practice/health system(s) do you work in?

• Solo or two-physician practice (independent) Continue

• Physician-owned group practice (independent) Continue

• Health care system (employed physician practice)…………………………………. Continue

  • Health maintenance organization (HMO)

  • Medical school or parent university

  • Non-government hospital or clinic

  • City/county/state government hospital or clinic

  • US (federal) government hospital or clinic (e.g., Military or VA hospital)

  • Nonprofit community health center (e.g., Federally Qualified Health Center)

• Other (do not need to specify): Terminate

8. How many years have you been in practice?

• Under 1 year Terminate

• 2-10 years Continue

• 11+ years Continue

9. Are most of your patients 18 years old and older?

• Yes Continue

• No Terminate

10. Roughly what percentage of the adult patients you see have type 1 or type 2 diabetes [RECORD RESPONSE AND CLASSIFY] ­­­­­­­­

• Less than 20% Terminate

• 20% or more Continue

11. Do you serve adult patients with Type 1 diabetes?

• Yes Continue

• No Continue

12. Now I’d like to ask you some questions about your referral practices. Do you refer your patients with diabetes to a diabetes care and education specialist or team of professionals who provide education and support in an individual or group setting? These services are called diabetes self-management education and support services.

[Do NOT include people that only refer to an endocrinologist, UNLESS endocrinologist practice offers DSMES. We are NOT interested in referrals to endocrinologists solely for medical treatment/monitoring—must be about education as well]

• Yes, DSMES Continue

• No Continue

13. [IF YES TO Q12] Do you know if the diabetes self-management education and support services you refer your patients to are provided by a program that is accredited or recognized by ADA or ADCES (formerly AADE)? (American Diabetes Association, Association of Diabetes Care and Education Specialists, formerly known as American Association of Diabetes Educators)

• Yes, they are accredited/recognized Continue

• No, they are NOT accredited/recognized Continue

• Don’t know Continue

14. [IF YES TO Q12] What is/are the name(s) of the program(s)/organization(s) that you refer your patients to for diabetes education and support? In what city and state is this program? [Look up whether program is certified before scheduling; you can use street address, phone number, or name of the provider to see if they work in an accredited program]

[insert name(s)]_________________________________________________

15. [IF YES TO Q12] Is this diabetes education program or service within your practice, within your health care system/organization [only applies to people in health care system], part of an external organization, or offered online? [select all that apply]

• Within my practice Continue

• Within my health care organization Continue

• External organization Continue

• Online [note which type of organization offers the online program_________] Continue

16. Do you work in a rural, urban, or suburban area?

• Rural Continue

• Urban Continue

• Suburban Continue

17. Roughly what percentage of your patients are…

	1-24%	25-49%	50-74%	75-100%	Don’t know
Hispanic or Latino?
Asian, Native Hawaiian, or Pacific Islander?
American Indian or Alaska Native?
Black or African American?

18. Roughly what percentage of your patients are insured by …

	1-24%	25-49%	50-74%	75-100%	Don’t know
Private insurance?
Medicare?
Medicaid?
Are uninsured?

Invitation

Thank you for answering my questions. We would like to invite you to participate in a phone interview that will last no more than one hour and will be audio recorded. You will need a computer with internet access so you can view images on the screen. As a token of appreciation, you will receive $150 for participating.

Are you interested in participating?

• Yes ........................................................................................................[SCHEDULE INTERVIEW TIME]

• No ......................................................................................................................Thank and Terminate

We will send you a confirmation email and information about the interview. What is your contact information?

[RECORD APPROPRIATE CONTACT INFORMATION]

Name________________________________________________________________________

Address______________________________________________________________________

City/State/Zip_________________________________________________________________

Day Phone Number____________________________________________________________

Night Phone Number___________________________________________________________

Email address_________________________________________________________________

What is the best number to reach you? ____________________________________________

So that we can start and end on time, please plan to be dialed into the call at least 5 minutes before the scheduled start time. We are counting on your participation, so please be sure to contact us as soon as possible if something comes up and you cannot be part of the interview. [PROVIDE NAME AND PHONE NUMBER]

Thanks again for your time and we’ll talk with you at [date/time].

Screener for Health Care Providers for DSMES Brand and Concept Testing 7