2019 CDC Provider Questions

Form Approved

OMB No. 0920-0234

Exp. Date xx/xx/20xx

Attachment C4: 2019 NAMCS-1 List of All Proposed Questions for CHC Providers

This table lists all proposed 2019 survey questions in the order that they would appear in the survey. Several blocks of questions have been deleted and are indicated in red.

Notice-CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-0234).
Assurance of confidentiality-We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Variable

Name

CHC Providers

SPECVER

N/A

PRV_SPEC_SP

N/A

PROFACT

Which of the following categories best describes (your/Provider name's) professional activity -
patient care, research, teaching, administration, or something else?

1. Patient Care

2. Research

3. Teaching

4. Administration

5. Something else – Specify PROFACT_SP

AMBCARE

(Do/Does) (you/provider's name) directly care for any ambulatory patients in (Your/ his/her) work?

1. Yes

2. No - does not give direct care

3. No longer in practice (i.e., retired, not licensed)

4. Temporarily not practicing (refers to duration of 3 months or more)

Skip Instructions:

1: If CHCPROV (flag for CHC providers) = 1, goto ADDCHECK
2: Goto VERIF9A
3: Goto THANK_OOS

4: Goto THANK_OOS

VERIF9A

We include as ambulatory patients, individuals receiving health services without admission to a hospital or other facility.  Does (your/Provider name's) work include any such individuals?

1. Yes, cares for ambulatory patients

2. No, does not give direct care

Specify reason VERIF9a_SP

Skip Instructions:

1: If CHCPROV (flag for CHC providers) =1, goto ADDCHECK
2: Goto VERIF9A_SP

FED

N/A

Skip Instructions:

N/A

PRIVPAT

N/A

Skip Instructions:

N/A

HOSPRIVPAT

N/A

Skip Instructions:

N/A

REMINDER

N/A

ADDCHECK

We have (your/Provider name's) address as
( Address)

Is that the correct address for the CHC?

1. Yes

2. No, update address

NEW_PINFO

What is the correct address and phone number of your current CHC location?

THANK_OOS

Thank you, (Respondent's name/Provider’s name), but since you are not currently practicing, our questions would not be appropriate for you.
I appreciate your time and interest.

Skip Instructions:

IF AMBCARE = 3 goto WHYNO_PRACT
IF AMBCARE = 4 goto WHY_UNAVAIL

WHYNO_PRACT

  Why isn't the doctor practicing?

1. Retired

2. Not licensed

3. Other

WHY_OOS

Describe the provider's practice or medical activities which define him/her as ineligible or out-of-scope.

Enter all that apply, separate with commas

1. Federally employed

2. Radiology, anesthesiology or pathology specialist

3. Administrator

4. Work in institutional setting

5. Work in hospital emergency department, hospital outpatient department, or community health center at a site not at this location.

6. Work in industrial setting

7. Ambulatory surgicenter

8. Laser vision surgery

9. Other – Specify WHY_OO_SP

WHY_UNAVAIL

Why is provider temporarily not practicing?

Verbatim response

INDUCT_APPT

I would like to arrange an appointment with you within the next week or so to discuss the study.
It will take about 30 minutes.  What would be a good time for you, before Friday, (last Friday before the assigned reference week)?

I appreciate that you choose not to participate in the study, but I would like to ask a few short questions about the CHC at this location so we can make sure responding providers do not differ from nonresponding providers.

“Providers” filled for CHC Providers

NUMLOCR

Overall, at how many different office locations do you see ambulatory patients? Do not include settings such as EDs, outpatient departments, surgicenters, Federal Clinics, and community health centers.

NUMLOCR_CHC

Overall, at how many different CHC locations do you see ambulatory patients?

NOPATSENR

In a typical year, about how many weeks do you NOT see ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALFR

LTHALFR_SP

You typically see patients fewer than half the weeks in each year. Is that correct?

1. Yes

2. No – Please explain LTHALFR_SP

ALLYEARR

ALLYEARR_SP

You typically see patients all 52 weeks of each year. Is that correct?

1. Yes

2. No – Please explain ALLYEARR_SP

NUMVISR

During your last normal week of practice how many patient visits did you have at all CHC locations?

WKHOURSR

During your last normal week of practice, how many hours of direct patient care did you provide?

NOTE – Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services. Do not include hours from EDs, outpatient departments, surgicenters, or Federal clinics.

NUMBPAR

At the current CHC location:

How many physicians are associated with you?

SINGSPCR

At the current CHC location:

Is this a single- or multi-specialty CHC at this location?

OWNERSHR

At the current CHC location:

Are you a full- or part-owner, employee, or an independent contractor?

OWNSR

At the current CHC location:

Who owns the CHC at this location?

INDUCT_INTRO

Before we begin, I'd like to give you some background about this study.

Medical researchers and educators are especially interested in topics like medical education, health workforce needs, and the changing nature of health care delivery.  The National Ambulatory Medical Care Survey (or NAMCS) was developed to meet the need for such information.  

The CDC’s National Center for Health Statistics works closely with members of the medical profession to design the NAMCS each year.  The NAMCS supplies essential information about how ambulatory medical care is provided in the United States, and how it is utilized by patients.  

Your part in the study is very important and should not take much of your time.  It consists of your participation during a specified 7-day period.  During that time, you would supply a minimal amount of information about the patients you see.

First, I have some questions to ask about the CHC at this location.  Your answers will only be used to provide data on the characteristics of office-based practices in the U.S.  Any and all information you provide for this study will be kept confidential. Participation is voluntary, and you or your staff may refuse to answer any question or stop participating at any time without penalty or loss of benefits.

NUMLOC

At how many different office locations, (do/does) (you/physician's name) see ambulatory patients?  Do not include settings such as emergency departments, outpatient departments, surgicenters, federal clinics, and community health centers.

NOPATSEN

In a typical year, about how many weeks (do/does) (you/physician's name) NOT see any ambulatory patients (e.g., conferences, vacations, etc.)?

LTHALF

LTHALF_SP

(You/provider’s name) typically (see/sees) patients fewer than half the weeks in each year.
Is that correct?

1. Yes

2. No Please explain LTHALF_SP

ALLYEAR

ALLYEAR_SP

(You/provider’s name) typically (see/sees) patients all 52 weeks of the year.
Is that correct?

1. Yes

2. No Please explain ALLYEAR_SP

SEEPAT

WHYNOPAT

This study will be concerned with the AMBULATORY patients (you/provider’s name) will see at this CHC location during the week of Monday, (Reporting period begin date) through Sunday, (Reporting period end date).

(Are/Is) (you/provider’s name) likely to see any ambulatory patients at the current CHC location during that week?

  For allergists, family practitioners, etc. - if routine care such as allergy shots, blood pressure checks, and so forth will be provided by staff in physician's absence, enter "Yes."

1. Yes

2. No Why is that?
    Enter verbatim response

(12b) WHYNOPAT

CHECK_BACK

Since it’s very important that we include any ambulatory patients that you might see at this CHC location during that week, I’ll check back with you just before (starting date) to make sure your plans have not changed.

  Even though the physician/provider is not available during the reporting week, continue with the induction

OFFSTRET

N/A

OFFICE_CITY

N/A

OFFICE_ST

N/A

OFFICE_ZIP

N/A

LOCTYPE

N/A

CUR_OFFICE

N/A

CUR_CHC_ADD

What does the current address below represent?

[Fill with original or updated CHC address]

1. Sampled CHC location-goto OTHLOC

2. Sampled CHC that moved-goto OTHLOC

3. Not sampled CHC location-goto CALL_RO_PHYS

CALL_RO_PHYS

Call your RO and inform them of the situation. Await resolution from the RO before continuing with this case.

OFFICETYP

Choice #5 will be automatically populated:

(5) Community Health Center (e.g., Federally Qualified Health Center (FQHC), federally funded clinics or ‘look alike’ clinics)

FREESTAND_PROBE

N/A

FAMPLAN_PROBE

N/A

OTHLOC

Are there other CHC locations where (you/physician's name) normally would see patients, even though (you/physician's name) will not see any during (Your/ his/her) 7-day reporting period? 

1. Yes Go to OTHLOC_NUM

2. No Skip to ESTDAYS

OTHLOC_NUM

In how many other CHC locations do you NORMALLY see patients?

______ Number of locations

OTHLOCVS

Of these CHC locations where (you/physician's name) will not be seeing patients during (Your/ his/her) 7-day reporting period, how many total office visits did (you/physician's name) have during (Your/ his/her) last week of practice at these CHC locations?

ESTDAYS

During the week of Monday, [Fill Date] through Sunday, [Fill Date] how many days do you expect to see any ambulatory patients at this CHC location?

ESTVIS

During (Your/ his/her) last normal week of practice, approximately how many office visit encounters did (you/provider’s name) have at this CHC location?

Only include the visits to the sampled CHC provider.

          If physician is in group practice, only include the visits to sampled physician.

SAME

During the week of Monday, (fill) through Sunday (fill), do you expect to have about the same number of visits as you saw during your last normal week at the current CHC location taking into account time off, holidays, and conferences?

1. Yes

2. No

ESTVISP

Approximately how many ambulatory visits do you expect to have at this CHC location?

ESTTOTVS

Tally of estimated number of visits

SOLO

Now, I'm going to ask about the CHC at [Pre-fill location].

Do you work solo at this CHC, or are you associated with other physicians in a partnership, in a group at this CHC, or in some other way at this location?

1. Solo

2. Nonsolo

OTHPHY

How many physicians are associated with (you/provider’s name) at (Office location)? Do not include interns, residents, or fellows.

MULTI

Is this a single- or multi-specialty CHC at [Pre-fill location]?

1. Multi

2. Single

MIDLEV

How many mid-level providers (i.e., nurse practitioners, physician assistants, and certified nurse midwives) are associated with (you/physician's name) at (Office location)?

OWNERSH

(Are/Is) (you/provider’s name) a full- or part-owner, employee, or an independent contractor at (Office location)?

1. Full-owner

2. Part-owner

3. Employee

4. Contractor

OWNS

Who owns the CHC at (Office location)?

1. Physician or Physician group

2. Insurance company, health plan, or HMO

3. Community Health Center

4. Medical/Academic health center

5. Other hospital

6. Other health care corporation

7. Other

ONSITE_EKG

ONSITE_PHLEB

ONSITE_LAB

ONSITE_SPIRO

ONSITE_ULTRA

ONSITE_XRAY

Does the CHC have the ability to perform any of the following on site at (Office location)?

1. EKG/ECG

2. Phlebotomy

3. Lab testing (not including urine dipstick, urine pregnancy, fingerstick blood glucose, or rapid swab testing for infectious diseases)

4. Spirometry

5. Ultrasound

6. X-ray

1. Yes

2. No

3. Don’t know

PATEVEN

(Do/Does) (you/provider’s name) see patients in the CHC during the evening or on weekends at (Office location)?

1. Yes

2. No

3. Don’t know

NPI

What is (your/Provider name's) National Provider Identifier (NPI) at (Office location)?

FEDTXID

What is your Federal Tax ID, also known as an Employer Identification Number (EIN)13, at (Office location)?

WKHOURS

During (your/Provider name's) last normal week of practice, how many hours of direct patient care did (you/provider’s name) provide?

Direct patient care includes: Seeing patients, reviewing tests, preparing for and performing surgery/procedures, providing other related patient care services.

NHVISWK

HOMVISWK

HOSVISWK

TELCONWK

ECONWK

During (Your/ his/her) last normal week of practice, about how many encounters of the following type did (you/provider’s name) make with patients:

1. Nursing home visits

2. Other home visits

3. Hospital visits

4. Telephone consults

5. Internet/e-mail consults

STD-PrEP Questions

STD_INTRO

The following question set asks about policies, services, and experiences related to the prevention and treatment of sexually transmitted infections (STIs) and HIV prevention.

1. Enter 1 to Continue-SKIP to STIADOLPOL

STIADOLPOL

◊The next 5 questions refer to the currently sampled CHC which is (fill address of sampled CHC).

Does the current sampled CHC have a written policy that asks parents, relatives or guardians of an adolescent patient to leave the room during any part of the visit?

1. Yes-go to STIADOLPOL_ASK

2. No-go to STIEVAL

3. Don’t know—go to STIEVAL

STIADOLPOL_ASK

When does the CHC policy require that I/Dr. X (fill last name or greet name) ask relatives or guardians of adolescent patients to leave the room during part of the visit?

1. Always

2. Depending on the circumstance

3. Don’t know

STIEVAL

Do you/Does Dr. X (fill last name or use greet name) evaluate patients for sexually transmitted infections or treat patients with sexually transmitted infections at the current CHC location?

1. Yes-SKIP to STINJABX

2. No-SKIP to STIRSKEVAL

STINJABX

Which of the following injectable antibiotics are provided onsite at the current CHC location for same-day treatment for patients diagnosed with gonorrhea or syphilis? (Mark all that apply)

1. Benzathine penicillin G (bicillin) 2.4 million units IM

2. Ceftriaxone 250 mg IM

3. Other injectable cephalosporin

4. None of the above

STIPOSTST

For patients with vaginal discharge or urethritis, which of the following point-of-service tests does the current CHC location provide onsite? (Mark all that apply)

1. Dipstick urinalysis

2. KOH (whiff) test

3. pH test

4. Rapid Bacterial vaginosis test

5. Rapid Trichomonas test

6. Stained microscopy using either gram stain, methylene blue stain, or gentian violet stain

7. Standard (unstained) microscopy of urine sediment

8. Wet mount microscopy (wet prep)

9. None of the above

STIRSKEVAL

◊The next question asks about STI and HIV-related risk assessment and services that you/Dr. X (fill last name or greet name) provide(s).

Do you/Does Dr. X (fill last name or use greet name) document any of the following about your/their patients on at least an annual basis? [Mark all that apply]

1. Any substance abuse or injection drug use

2. Condom use

3. HIV status of their sex partners

4. Number of sex partners they have

5. Patients’ sexual orientation or the sex of their sex partners

6. Types of sex that they have (vaginal, anal, oral)

7. None of the above

PRP_INTRO

The next questions must be answered by Dr. X (fill last name or greet name) who is the sampled CHC provider. They ask specifically about Dr. X’s (fill last name or greet name) experience with HIV-prevention using PrEP (pre-exposure prophylaxis).

1. Enter 1 to Continue-SKIP to PRPHRD

PRPHRD

◊ (The following question must be answered by the sampled CHC provider.)

Have you heard of PrEP (pre-exposure prophylaxis) to prevent HIV infection?

1. SKIP to PRPEFF

2. No-SKIP to CLASTRAIN [end section]

◊ (The following question must be answered by the sampled CHC provider.)

Please indicate whether you agree or disagree with the following statements about PrEP. They include various attitudes and beliefs that some providers might have about PrEP.

	1. Disagree	2. Agree	3. Don’t know
PrEP is effective for HIV prevention. [PRPEFF]
PrEP use will result in an increase in risky sexual behavior and sexually transmitted infections. [PRPRSB]
PrEP will lead to drug resistance if a patient gets infected while taking PrEP. [PRPDR]
Most patients will have difficulty affording PrEP regardless of their insurance status. [PRPAFF]
Most patients will have difficulty adhering to daily dosing of PrEP. [PRPADH]

	1. Yes		2. No
One or more of my patients have asked for PrEP. [PRPASK]
One or more of my patients have declined PrEP [PRPDEC]

PRPRX

◊ (The following question must be answered by the sampled CHC provider.)

Have you prescribed PrEP?

1. Yes CLASTRAIN [end section]

2. No-Go to PRPWHY

PRPWHY

◊ (The following question must be answered by the sampled CHC provider.)

Why have you not prescribed PrEP? (Mark all that apply):

1. I do not have any patients at high risk of acquiring HIV infection.

2. Prescribing PrEP is outside my scope of practice.

3. I do not have enough information about PrEP to prescribe it.

4. I am uncomfortable prescribing antiretroviral medications.

5. I refer my patients to another provider or clinic for PrEP.

6. My patients have not asked for PrEP.

7. I have offered PrEP to one or more of my patients but they have declined.

8. PrEP is not effective for HIV prevention.

9. PrEP use will cause an increase in risky sexual behavior and sexually-transmitted infections in my patients.

10. PrEP will lead to drug resistance if my patients get infected while taking PrEP.

11. My patients will have difficulty affording PrEP, regardless of their insurance status.

12. My patients will have difficulty adhering to daily dosing of PrEP.

13. Other (Prompt text field for response)

National CLAS Standards Questions

CLASTRAIN

(The following two questions must be answered by the sampled provider.) Within the past 12 months, have you participated in any cultural competence training?

1. Yes

2. No

CLASKNOW

(The following question must be answered by the sampled provider.) How familiar are you with the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards)?

1. Never heard of it

2. Heard of it but do not know much about it

3. Know something about it

4. Very familiar with it

ALCOHOL_INTRO

The next set of questions are only administered to primary care providers and seeks to determine the extent to which alcohol screening and brief intervention (SBI) is being conducted within their practices.

ALCSCREEN

Screening for alcohol misuse (excessive consumption and alcohol-related problems) is often conducted in clinical settings. How do you screen for alcohol misuse?

1. I don’t screen

2. T-ACE

3. TWEAK

4. CAGE

5. CRAFFT

6. AUDIT

7. Ask number of drinks per occasion (For example, “On a typical day, how many drinks do you have?”)

8. Ask frequency of drinking (For example, how many days a week do have an alcoholic drink?”)

9. Ask binge question (For example, for women: “How many times in the past year have you had 4 or more drinks in a day?” For men: “How many times in the past year have you had 5 or more drinks in a day?”)

10. I don’t use a formal screening instrument

11. Other (specify) ALCSCREENOTH

ASCREENOFT

How often do you screen for alcohol misuse?

1. At every health maintenance visit (annually)

2. At every health care visit

3. When I suspect a patient has a substance/alcohol-related problem

4. Almost never or never

ASCREENADM

How are screening question(s) administered?

3. Interview

4. Patient completes a form

5. Electronic

6. Other (specify) ASCREENADMOTH

ASCREENWHO

If patient is interviewed, who administers the screening?

1. Physician, nurse practitioner, physician assistant

2. Nurse, excluding nurse practitioner

3. Medical assistant

4. Administrative staff

5. Other (specify) ASCREENWHOTH

ABRFINTERV

Brief interventions for risky alcohol use are short discussions with patients who drink too much or in ways that are harmful. These interventions typically include some of the following elements:

• Feedback on screening results

• Gathering further information on drinking patterns, alcohol-related harm, or symptoms of alcohol dependence

• Discussing the risks and consequences of drinking too much

• Providing advice about cutting back or stopping

Among patients who screen positive for risky alcohol use, how often are brief interventions conducted?

1. Never

2. Sometimes

3. Often

4. Always

ARESOURCE

What resources would be helpful in implementing alcohol/substance screening and intervention in primary care settings? (Select all that apply)

1. Implementation guide for alcohol screening and intervention

2. Training on how to conduct alcohol screening

3. Training on how to conduct intervention

4. Office-based mentoring

5. Access to patient education materials

6. Scripts on what to say to patients

7. Information about reimbursement for services

8. Information about where or how to refer for additional services

9. Other (specify) ARESOURCEOTH

SDAPPT

Roughly, what percent of (your/Physician name's) daily visits are same day appointments?

PRVBYEAR

What is your year of birth?

PRVSEX

What is your sex?

PRVDEGR

What is your highest medical degree

1. MD

2. DO

3. Nurse practitioner

4. Physician assistant

5. Certified nurse midwife

6. Other

PRVPSPEC

What is your primary specialty?

PRVSSPEC

What is your secondary specialty?

PRVPBC

What is your primary board certification?

PRVSBC

What is your secondary board certification?

PRVYRGRD

What year did you graduate from medical school?

PRVFMS

Did you graduate from a foreign medical school?

PRVETHN

Are you Hispanic, Latino/a, or Spanish origin? Enter all that apply, separate with commas

1. No, not of Hispanic, Latino/a, or Spanish origin

2. Yes, Mexican, Mexican American, Chicano/a

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, Another Hispanic, Latino/a or Spanish origin

RACE

What is (your/Physician name's) race? Enter all that apply, separate with commas

1. White

2. Black or African-American

3. American Indian or Alaska Native

4. Asian Indian

5. Chinese

6. Filipino

7. Japanese

8. Korean

9. Vietnamese

10. Other Asian

11. Native Hawaiian

12. Guamanian or Chamorro

13. Samoan

14. Other Pacific Islander

PHY_UNAVAIL

Thank you for your time and cooperation ^RESPNAME_FILL.  The information you provided will improve the accuracy of the NAMCS in describing office-based patient care in the United States.

I will call you on Monday, (Reporting period begin date) to see if your plans have changed.
If you have any questions (Hand respondent your business card) please feel free to call me.

Page 9 of 9