Form 0920-0234 ACPI

Attachment C2:

NAMCS Draft Ambulatory Care Provider Interview (ACPI)

Form Approved:

OMB No. 0920-0234

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, MS D-74, Atlanta, GA 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 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). 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. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Exp. Date xx/xx/20XX

1. We have your primary specialty as: {FILL SAMPLED SPECIALTY}. Is this correct?

1. Yes

2. No (Go to question 1a)

1a. What is your specialty?

PA Specialties	PHYSICIAN Specialties
Addiction Medicine (Skip to question 2) . . Other (Go to question 1b) . . Vascular Surgery (Skip to question 2)	Adult Cardiothoracic Anesthesiology (Skip to question 2) . . Other Specialty (Go to question 1b) . . Vascular Surgery (Skip to question 2)

1b. Please specify Other Specialty ________________________

2. This survey asks about outpatient care, that is, care for patients receiving health services without admission to a hospital or other facility. Do you directly provide any outpatient care?

1. Yes (Skip to question 4)

2. No

Help text [paper & Web]  

Outpatient care is typically provided to individuals we consider ambulatory patients. Ambulatory patients are patients who are not being seen as inpatients in a hospital, nursing home or other institution. Patients who leave the institution and go to a doctor's office for care are considered to be ambulatory patients. 

3. Why are you not currently providing any direct outpatient care?

1. Engaged in research, teaching, and/or administration

2. Once provided direct outpatient care but now retired

3. Once provided direct outpatient care but temporarily not practicing (duration 3+ months)

4. Now not licensed/Never licensed

5. Something else (please specify): _____________________________

(Skip to question 48)

4. Do you see ambulatory patients in any of the following settings? SELECT ALL THAT APPLY.

Setting Name

1. Private solo or group practice

If you see patients in any of these settings, go to question 5

2. Freestanding clinic or Urgent Care Center

(e.g., Concentra Urgent Care, Patient First, NextCare Urgent Care, FastMed Urgent Care)

3. Health Center (e.g., Federally Qualified Health Center [FQHC], federally funded clinics or “look-alike” clinics)

4. Mental health center

5. Government clinic that is not federally funded (e.g., state, county, city, maternal and child health, etc.)

6. Family planning clinic (including Planned Parenthood)

7. Integrated Delivery System, Health maintenance organization, health system or other prepaid practice (e.g., Kaiser Permanente)

8. Faculty practice plan (i.e., an organized group of physicians and other health care professionals that treats patients referred to an academic medical center)

9. Retail health clinic (e.g., CVS MinuteClinic, Walgreen’s Healthcare Clinics, Kroger’s Little Clinic)

10. Hospital outpatient department

11. Hospital emergency department

If you select
only 11, 12, 13, 14, 15 or 16 Skip to question 48

12. Ambulatory surgery center/surgicenter

13. Industrial outpatient facility

14. Federal government clinics (e.g., Veterans Affairs, military only clinics)

15. Institutional facility

16. None of the above

5. At which outpatient setting (1-10) in the previous question do you see the most patients in a typical week? WRITE THE NUMBER LOCATED NEXT TO THE SELECTION MADE.

_____________________________

For the rest of the survey, we will refer to this as “your reporting location.”

6. What is the street address, city, state, and ZIP Code of your reporting location? What is the e-mail address of the physician to whom this survey was mailed?

Street: _______________________	City: ________________
State: _______________________________	ZIP Code: _______________
E-mail Address: _______________________

7. During a typical week, approximately how many patient visits do you personally receive at [“your reporting location” OR fill with address from Q6]? Your best single-number estimate is fine. By patient visit, we mean a billable encounter. Include only your visits; unless visits are to another provider supervised by you.

__________________________________________________________________________

Help text [paper & Web]

A typical or normal week is defined by a week that does not include a holiday, vacation, conference, time off, or any other type of non-normal absence.

8. In this survey, “other providers” mean any individuals administering any type of direct medical, mental, or behavioral health care. At [“your reporting location” OR fill with address from Q6], do you work in a solo medical facility, or do you work with other providers in a partnership, group practice, or in some other way (nonsolo)?

1. Solo (Skip to question 10)

2. Nonsolo

9. At [“your reporting location” OR fill with address from Q6], how many other providers are employed? Do not include interns, residents, fellows, or yourself in the count. Other providers mean any individuals administering any type of direct medical, mental, or behavioral health care.

__________________________________________________

9. Is [“your reporting location” OR fill with address from Q6] a multi- or single-specialty practice?

1. Multi

2. Single

9. At [“your reporting location” OR fill with address from Q6], are you a full- or part-owner, employee, independent contractor, or a volunteer?

1. Full-owner (If PA, skip to question 14; otherwise, physicians skip to question 13)

2. Part-owner

3. Employee

4. Contractor

5. Volunteer

9. At [“your reporting location” OR fill with address from Q6], who owns the practice?

1. Physician/Physician group

2. Advanced practice provider/Advanced practice provider group (i.e., advanced practice provider refers to nurse practitioners, PAs (physician assistants/physician associates), or certified nurse midwives)

3. Combination of physicians and advanced practice providers

4. Insurance company, health plan, or HMO

5. Health center

6. Academic medical center or teaching hospital

7. Other hospital

8. Other health care corporation

9. Other (please specify): _______________________________________

(If PA, skip to question 14; otherwise, physicians go to question 13.)

Workforce, Revenue, & Compensation Questions

The following questions pertain to [“your reporting location” OR fill with address from Q6].

9. The following questions concern advanced practice providers practicing at [“your reporting location” OR fill with address from Q6]. If the specified type of provider is not practicing at the reporting location, please select “not applicable.”

   	Always	Sometimes	Never	Don’t know	Not applicable
   Do PAs bill for services using their own NPI number?
   Do Nurse Practitioners bill for services using their own NPI number?
   Do Certified Nurse Midwives bill for services using their own NPI number?
   Do Clinical Nurse Specialists bill for services using their own NPI number?
   Do Certified Registered Nurse Anesthetists bill for services using their own NPI number?

10. Which of the following types of payment does [“your reporting location” OR fill with address from Q6] accept? SELECT ALL THAT APPLY.

1. Private insurance

2. Medicare

3. Medicaid

4. CHIP

5. Workers’ compensation

6. Self-pay

7. No charge

8. Other (e.g., car insurance, someone other than patient pays)

9. At [“your reporting location” OR fill with address from Q6], are you, personally, currently accepting new patients?

1. Yes

2. No

3. Don’t know

COVID-19 Questions

The following questions pertain to [“your reporting location” OR fill with address from Q6].

9. Does [“your reporting location” OR fill with address from Q6] offer COVID-19 vaccinations?

1. Yes

2. No (Skip to question 18)

9. Which vaccine(s) does [“your reporting location” OR fill with address from Q6] offer? SELECT ALL THAT APPLY.

1. Moderna

2. Johnson & Johnson/Janssen

3. Pfizer

4. Other (please specify): ________________

5. Don’t know

Electronic Health Records and Telemedicine

The following questions pertain to [“your reporting location” OR fill with address from Q6].

9. Does [“your reporting location” OR fill with address from Q6] use an EHR system? Do not include billing record systems.

1. Yes

2. No (Skip to question 20)

3. Don’t know (Skip to question 20)

Does [“your reporting location” OR fill with address from Q6] use an EHR to…?	Yes	No	Don’t know
Record social determinants of health (e.g., employment, education, race/ethnicity, language and literacy skills)?
Record behavioral determinants of health (e.g., tobacco use, physical activity, alcohol use, drug use, diet)?
Order prescriptions?
Send prescriptions electronically to the pharmacy?

9. At [“your reporting location” OR fill with address from Q6], what type(s) of telemedicine do you personally use for patient visits? SELECT ALL THAT APPLY.

1. Videoconference software with audio (e.g., Zoom, Webex, FaceTime)

2. Audio without video conference software

3. Telemedicine platform NOT integrated with EHR (e.g., Doxy.me)

4. Telemedicine platform integrated with EHR (e.g., update clinical documentation during telemedicine visit)

5. Other tool(s) (please specify): _____________________

6. I don’t use telemedicine for patient visits (Skip to question 23)

9. At [“your reporting location” OR fill with address from Q6] in a typical week, how many of your own visits use telemedicine?

1. None

2. Some

3. Most

4. All

9. Compared to in-person patient visits, please rate your personal overall satisfaction with using telemedicine for patient visits at [“your reporting location” OR fill with address from Q6].

1. Very satisfied

2. Somewhat satisfied

3. Neither satisfied nor dissatisfied

4. Somewhat dissatisfied

5. Very dissatisfied

9. At [“your reporting location” OR fill with address from Q6], what, if any, issues affect your own use of telemedicine? SELECT ALL THAT APPLY.

1. Limited Internet access and/or speed issues

2. Telemedicine platform not easy to use

3. Telemedicine isn’t appropriate for my specialty/type of patients

4. Limitations in patients’ access to technology (e.g., smartphone, computer, tablet, Internet)

5. Patients’ difficulty using technology/telemedicine platform

6. Improved reimbursement and relaxation of rules related to use of telemedicine visits

Health Equity and Language Barriers

The following questions pertain to [“your reporting location” OR fill with address from Q6].

9. At [“your reporting location” OR fill with address from Q6], do you personally see patients during the evening or on weekends?

1. Yes

2. No

3. Don’t know

9. Does [“your reporting location” OR fill with address from Q6] set time aside for same day appointments?

1. Yes

2. No

3. Don’t know

9. On average, about how long does it take to get an appointment with you for a routine medical exam at [“your reporting location” OR fill with address from Q6]? By “routine medical exam,” we mean any medical care considered “routine” for your specialty.

1. Within 1 week

2. 1-2 weeks

3. 3-4 weeks

4. 1-2 months

5. 3 or more months

6. Do not provide routine medical exams

7. Don't know

9. Are you comfortable providing care to a patient in another language? Please include American Sign Language (ASL).

1. Yes

2. No

9. At [“your reporting location” OR fill with address from Q6], how many of your own patients have limited English proficiency?

1. None (Skip to question 31)

1. Some

2. Most

3. All

4. Don’t know

When you use interpreters at [“your reporting location” OR fill with address from Q6], how often do you personally use each type?	Often	Sometimes	Rarely	Never	Don’t know
Staff/contractor trained as a medical interpreter
Bilingual Staff (not formally trained as an interpreter)
Patient’s relative or friend
Language translation service (iPad/phone-based)

30. What types of materials at [“your reporting location” OR fill with address from Q6], in at least one other language other than English, are available to your own patients? SELECT ALL THAT APPLY.

1. Wellness/Illness related education

2. Patient rights/Informed consent documents

3. Advanced directives

4. Payment

5. Care plan

6. Other (please specify): ___________________

7. No translated materials are available to my patients

8. Don’t know

30. What information does [“your reporting location” OR fill with address from Q6] record on patients’ culture and language characteristics? SELECT ALL THAT APPLY.

1. Nationality/Nativity

2. Primary language

3. Sexual orientation

4. Gender identity

5. Race/Ethnicity

6. Religion

7. Income

8. Education

9. Other (please specify):________________________________

10. We do not collect information related to patient characteristics.

(If PA, skip to question 41; otherwise, physicians go to question 32.)

Physician Only: Pain Treatment and Treatment with Opioids

The following questions pertain to [“your reporting location” OR fill with address from Q6].

30. At [“your reporting location” OR fill with address from Q6], do you personally currently treat any patients for pain?

1. Yes, I currently treat patients for chronic pain only.

2. Yes, I currently treat patients for both chronic and acute pain.

3. Yes, I currently treat patients for acute pain only.

4. No (Skip to question 39)

5. Don’t know (Skip to question 39)

When managing your own pain patients at [“your reporting location” OR fill with address from Q6], how often do you…	Never	Rarely	Sometimes	Often	Always	Don’t know	Not applicable
Establish treatment goals with your recently diagnosed pain patients (e.g., less pain, improved function, increased social activities, better sleep quality, etc.)?
Recommend non-pharmacological approaches to your recently diagnosed pain patients before or instead of opioid therapy?

30. What types of non-opioid medications do you currently recommend to pain patients at [“your reporting location” OR fill with address from Q6]? SELECT ALL THAT APPLY.

1. Acetaminophen

2. Anticonvulsants

3. Antidepressants

4. Benzodiazepines

5. Non-steroidal anti-inflammatory (NSAIDS)

6. Other non-opioid drugs

7. None of the above

8. Don’t know

30. How many of your own pain patients at [“your reporting location” OR fill with address from Q6] are currently being treated with opioids prescribed by you?

1. None (Skip to question 39)

2. A few

3. Some

4. Almost all

5. All

6. Don’t know

Prior to starting opioids for pain management at [“your reporting location” OR fill with address from Q6], how often do you personally do the following?	Never	Rarely	Sometimes	Often	Always	Don’t know
Screen patients for depression and other mental health disorders.
Discuss risks and benefits of using opioids for pain treatment.

30. After you start opioid therapy on a pain patient at [“your reporting location” OR fill with address from Q6], when do you personally re-evaluate him/her?

1. Within 1 week

2. Within 4 weeks

3. Within 3 months

4. Within 1 year

5. I don’t re-evaluate patients after starting opioid therapy

6. Don’t know

When prescribing opioid therapy to your pain patients at [“your reporting location” OR fill with address from Q6], how often do you personally …	Never	Rarely	Sometimes	Often	Always	Don’t know	Not Applicable
Perform substance abuse risk assessment before prescribing opioids (e.g., CAGE, COWS, TAPS)?
Establish an opioid treatment plan with your patients?
Review the patient’s history of abuse?
Perform a urine toxicology screening before starting opioid therapy?
Review your state’s prescription drug monitoring program database (PDMP)?
Prescribe naloxone to patients receiving opioids?
Perform a random urine toxicology screening quarterly for long-term opioid therapy?

30. At [“your reporting location” OR fill with address from Q6], how many of your own patients are you currently treating for opioid use disorder?

1. None

2. A few

3. Some

4. Almost all

5. All

6. Don’t know

30. Does [“your reporting location” OR fill with address from Q6] have an opioid treatment program where patients could be referred for opioid use disorder?

1. Yes

2. No

3. Don’t know

(If physician, skip to 48; otherwise, PAs go to 41.)

PA Only: Autonomy Questions

The following questions pertain to [“your reporting location” OR fill with address from Q6].

30. How long have you practiced in your current specialty?

1. 0-1 years

2. 2-4 years

3. 5-9 years

4. 10-20 years

5. 21 or more years

30. How many years have you worked clinically as a PA?

1. 0-1 years

2. 2-4 years

3. 5-9 years

4. 10-20 years

5. 21 or more years

30. At [“your reporting location” OR fill with address from Q6], are there supervision/collaboration guidelines describing the types of decisions you can make or activities you can perform without direct physician involvement in your own patients’ care?

1. Yes

2. No

3. Don’t know

30. At [“your reporting location” OR fill with address from Q6], do you have your own panel of patients?

1. Yes, entirely

2. Yes, but I also see patients from the practice

3. No

4. Don’t know

30. At [“your reporting location” OR fill with address from Q6], how are claims submitted most of the time?

1. My NPI

2. A physician’s NPI

3. Sometimes my own NPI and sometimes a physician’s NPI

4. I don’t bill for my medical services

5. Don’t know

30. At [“your reporting location” OR fill with address from Q6], which of the following tasks do you personally perform on a regular and ongoing basis? SELECT ALL THAT APPLY.

1. Admissions (i.e., conduct admission history and physical, write admission orders)

2. Develop treatment plans

3. Perform minor surgical procedures

4. Perform non-surgical procedures

5. Order referrals and consults

6. Order and interpret diagnostic testing and therapeutic modalities

7. Perform new patient encounters

8. Perform post-op patient encounters

9. Perform post-op global visits

10. Perform pre-op history and physicals (H&Ps)

11. See consults

12. Prescribe non-schedule medications

13. Prescribe schedule (II-V) medications

14. Order durable medical equipment (DME)

15. See urgent visits

16. Other (please specify): _______________________

30. At [“your reporting location” OR fill with address from Q6], are there any major activities that you are personally qualified to perform but must refer out to another provider to perform? Specify___________________________________________________________

    Provider Demographics

31. Are you of Hispanic, Latino/a, or Spanish origin? SELECT ALL THAT APPLY.

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

30. What is your race? SELECT ALL THAT APPLY.

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

30. Are you... SELECT ALL THAT APPLY.

1. Male

2. Female

3. Another sex or gender

30. Who completed this survey? SELECT ALL THAT APPLY.

1. The provider to whom the survey was addressed

2. Office staff

3. Other