Clinician Survey

Attachment C. Clinician Survey

Form Approve

OMB No: xxxx-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 10 minutes, 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (xxxx-xxxx).

Thank you for your willingness to complete this survey. You have received this survey because you were identified as a licensed clinician. This survey is intended for physicians, nurse practitioners, and physician assistants, who provide direct patient care as part of their role.

In 2022 the Centers for Disease Control and Prevention (CDC) released the Clinical Practice Guideline for Prescribing Opioids for Pain (herein “2022 CDC Clinical Practice Guideline”) which provided up to date evidence regarding pain management approaches and emphasizes the need for prescribers to be focused on patient-centered care, shared decision making between patients and clinicians, equitable care for those in pain, and flexibility for clinicians in patient care. CDC, Abt Global and General Dynamics Information Technology (GDIT) are conducting a research study to better understand the adoption, implementation, and outcomes of the 2022 CDC Clinical Practice Guideline on evidence-based care for pain management. The questions ask about your role in patient care, activities related to caring for patients with pain (acute, subacute, or chronic pain), your awareness and adoption of the 2022 CDC Clinical Practice Guideline recommendations, and how your clinical practice or practice environment has changed since 2022. Please note that the findings from this survey will not be used to revise the 2022 CDC Clinical Practice Guideline. This project is funded by the CDC.

Before launching the survey, here are a few things to keep in mind:

• Participating in this survey is voluntary.

• Your input is critical for helping us understand the care provided to patients with pain and clinical processes around pain management, including opioid therapy.

• If you participate, you do not have to answer every question. You can also stop answering questions at any time. However, we encourage you to respond to this survey as completely and accurately as possible to ensure we collect a variety of perspectives.

• You will receive a $25 virtual gift card for completing this survey.

• Your answers to this survey will be kept private and secure, and will be combined with responses from other survey respondents and presented in aggregate form in our reports. CDC and GDIT will only receive de-identified survey responses. Abt Global, GDIT, and the CDC are committed to protecting data privacy.

• Your answers will not be connected to any information that could individually identify you, such as your name, in any internal reports or public-facing publications.

• This survey and the answers you provide reside in a secure, protected computing environment, and measures are in place to prevent a breach of the information collected.

Would you like to continue with the survey?

• Yes

• No à GO TO END

ELIGIBILITY

First, please answer the following eligibility questions.

1. Do you currently provide patient care within the Veterans Health Administration?

• Yes à GO TO END

• No à CONTINUE TO B.

2. Do you currently practice in an ambulatory, outpatient care setting, and/or in an emergency department at least once a week?

• Yes à CONTINUE TO C.

• No. à GO TO END.

3. In your clinical practice, do you primarily treat adult patients (aged ≥18 years)?

• Yes à CONTINUE TO D.

• No. à GO TO END.

4. Do you treat patients with acute, subacute, or chronic pain other than pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and/or end of life care?

• Yes à CONTINUE TO E.

• No. à GO TO END.

5. Is your main clinical practice in any of the following practice areas – family medicine, internal medicine, emergency medicine, surgery, occupational medicine, physical medicine and rehabilitation, neurology, obstetrics and gynecology?

• Yes, my main clinical practice is in one of the practice areas listed above à CONTINUE TO 1.

• None of the above à GO TO END.

CURRENT CLINICAL PRACTICES

Next, we’d like to get a sense of your current clinical practice. The following questions ask about your current patient panel and your experiences interacting with patients and managing their pain.

Patient Panel

1. Approximately what percent of your care time in the last month was spent managing the following types of pain?¹ [NOTE: these will not necessarily add to 100%]

___% of care time spent addressing patients’ acute pain (pain for <1 month)

___% of care time spent addressing patients’ subacute pain (pain for 1 – 3 months)

___% of care time spent addressing patients’ chronic pain (pain for > 3 months)

Current Clinical Practices

2. When caring for your patients with pain, how often do you use the following strategies:

	Never	Rarely	Sometimes	Always	N/A to my practice
Use nonpharmacologic therapies as appropriate for specific pain conditions and individual patients.
Use opioid therapies as appropriate for specific pain conditions and individual patients.
Use of nonopioid pharmacologic therapies as appropriate for specific pain conditions and individual patients.
Discuss with patients the benefits and known risks of opioid therapy when considering starting or continuing opioids.
Prescribe immediate-release (IR) instead of extended-release or long-acting (ER/LA) opioids when starting patients on opioid therapy.
Prescribe the lowest effective dosage when starting patients on opioids who are opioid-naïve and have acute, subacute or chronic pain.
Prescribe only a quantity of opioids that covers the expected duration of acute pain.
Review patients’ controlled substance prescriptions in your prescription drug monitoring program (PDMP) when initially prescribing opioid therapy for acute, subacute or chronic pain.
Review patients’ controlled substance prescriptions in your PDMP, periodically while they’re on long-term opioid therapy (LTOT).
Prescribe opioids and benzodiazepines concurrently.
Discontinue a patients’ opioid(s) without tapering.
Accept new patients already established on LTOT.
Require new patients who are on high dosage opioids to taper to a lower dose or off opioids completely before beginning care.
Offer or arrange for evidence-based treatment for patients with opioid use disorder (OUD).

Shared Decision-Making

3. Think about a recent encounter you had with one of your patients with acute, subacute, or chronic pain where a decision needed to be made regarding their pain management (e.g., starting, stopping, continuing, or changing their existing treatment(s)). Using the below scale, please indicate how much you agree or disagree with each statement regarding how you approached interacting with this patient.²

	Completely Disagree	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree	Completely Agree
I made it clear to my patient that decisions needed to be made.
I wanted to know from my patient how exactly they wanted to be involved in making decisions.
I told my patient that there are different options for treating their pain.
I precisely explained the risks and benefits of the various treatment options.
I helped my patient understand all the information.
I asked my patient which treatment options they preferred.
My patient and I thoroughly weighed the different treatment options.
My patient and I selected a treatment option together.
My patient and I reached an agreement on how to proceed.

Confidence

4. Think about your care and treatment of patients with acute, subacute or chronic pain. Using the scale provided below, please indicate how confident you are in your ability to do each of the following?³

	Not at all confident	Slightly confident	Fairly confident	Very confident	This does not apply to my practice
Providing individualized, patient-centered care to patients on opioid therapy for pain when appropriate.
Discussing risks and benefits of opioids with patients.
Discussing non-opioid pharmacologic options for pain with patients.
Discussing non-pharmacologic options for pain with patients.
Executing a tapering plan collaboratively with the patient if or when appropriate.
Engaging in conversations with patients on their current opioid use and/or use of other substances, after receiving results of their urine drug test or reviewing their PDMP record.
Assessing patients currently taking opioids for opioid use disorder (OUD).
Transitioning a patient taking opioids with a positive OUD screen onto medications for OUD (MOUD).

Changes to Prescribing Practices

5. Using the scale below, please indicate how much you agree with the following statements regarding how your own clinical practice has changed in the past two years?

	Strongly Disagree	Slightly Disagree	Slightly Agree	Strongly Agree	My practice has not changed
I feel more confident in my ability to collaboratively engage patients in pain management decisions.
I feel more confident discussing non-opioid medication options for pain management.
I feel more confident discussing non-pharmacologic treatment options for pain management.
I feel more confident managing patients on opioid therapy when indicated for their type of pain.
I feel more confident in my ability to help patients safely taper off opioids when it is needed.
I have had more autonomy to implement recommended practices when caring for my patients’ pain.
I feel more open to accepting new patients already on long-term opioid therapy (LTOT).

AWARENESS OF GUIDELINE

6. In November 2022, the CDC released the 2022 CDC Clinical Practice Guideline. Are you aware of the 2022 CDC Clinical Practice Guideline?⁴

• Yes

• No à GO TO PRACTICE AND CLINICIAN CHARACTERISTICS

• Don’t know

7. Have you completed any training or educational offerings on the 2022 CDC Clinical Practice Guideline?

• Yes

• No à SKIP TO 9.

• Don’t know

8. If you have completed a training or educational offering about the 2022 CDC Clinical Practice Guideline, which organization or agency sponsored the training? [Please check all that apply.]

• CDC

• My health system or clinic

• A professional association or membership organization

• A medical information website (e.g., Medscape)

• Don’t know/Not sure

• Other, please specify: __________________________________

9. How familiar are you with the specific recommendations in the 2022 CDC Clinical Practice Guideline?

• Very familiar

• Moderately familiar

• Slightly familiar

• Not at all familiar

ATTITUDE TOWARD GUIDELINE (Determinants of Use Instrument)

The next questions ask about your understanding of the 2022 CDC Clinical Practice Guideline and your ability to implement included recommendations.

10. Please indicate your level of agreement with the following statements about the 2022 CDC Clinical Practice Guideline.⁵

	Strongly Disagree	Slightly Disagree	Slightly Agree	Strongly Agree	Not Sure
Following the Guideline will improve care delivery.					NS
Following the Guideline will improve patient outcomes.					NS
Following the Guideline brings advantages to me, my practice or organization, or my patients (e.g., supports communication and decision-making, etc.).					NS
Following the Guideline brings disadvantages to me, my practice or organization, or my patients (i.e. time, costs, etc.).					NS
I possess general knowledge about pain and opioids that is needed to use this Guideline.					NS
I am confident that I possess the skills (i.e., technical, procedural, cognitive, problem-solving, etc.) needed to use this Guideline.					NS
It is among my self-acknowledged professional responsibilities to follow the procedures, actions or activities recommended in this Guideline.					NS
Colleagues in my own organization use the Guideline.					NS
I have the autonomy to make changes needed to follow this Guideline.					NS
My organization provides support (leadership, resources, assistance, etc.) needed to use this Guideline.					NS
The recommendations in this Guideline are consistent with my patients’ values and preferences.					NS
The procedures, actions or activities recommended in this Guideline are easy to incorporate in my practice.					NS
The wording of the recommendations is clear and unambiguous.					NS
The Guideline provides flexibility in the recommended care of patients with pain, including those taking opioids, to enable person-centered decision-making, taking into account an individual’s expected health outcomes and well-being.					NS

ADOPTION AND IMPLEMENTATION OF GUIDELINE

The following questions ask about your experiences within your clinic, health system, or general practice environment related to implementation or adoption of recommendations from the CDC Clinical Practice Guideline and managing your patients’ pain.

Implementation in Clinic/Health System

11. Has your health system/clinic made any changes to its policies or practice tools (including creating new) to adopt and/or implement recommendations within the 2022 CDC Clinical Practice Guideline?

• Yes

• No à GO TO FACILITATORS AND BARRIERS

• Not sure

• Other, Please specify: ________________________________

12. Which of the following has your clinic done to adopt and/or implement the recommendations of the 2022 CDC Clinical Practice Guideline? [Please check all that apply.]

• Developed or updated policies or procedures related to care of patients with pain, including those taking opioids.

  • {If selected} Please specify, _____________________________________________________

• Removed any policies or procedures related to care of patients with pain, including those taking opioids.

  • {If selected} Please specify, _____________________________________________________

• Developed or updated electronic health record (EHR) tools (e.g., notes templates, alerts, clinical decision support tools).

• Collected quality improvement (QI) measures to monitor recommended care in the Guideline.

• Conducted training or education about the Guideline.

• Other, please specify: __________________________________

• I am not aware of anything my clinic has done related to the Guideline.

Facilitators and Barriers

13. Have any of the following factors made it challenging for you to provide an individualized approach to care for your patients’ pain that is consistent with the guideline? Please select all that apply. ⁶ 

• Insufficient time to spend with patients to adequately address their pain. 

• Limited or no telehealth availability in your practice for visits specific to pain management.

• Patients’ fear of or hesitance to change existing pain management regimens or begin new treatment(s) for their pain. 

• Limited local availability of nonpharmacologic therapies for treatment of pain. 

• No or limited coverage of nonpharmacologic therapies by patients’ insurers, including prior authorizations or visit limits.

• Concerns that patients who are on LTOT will develop OUD.

• Navigating care for patients new to your practice who are already on LTOT. 

• Limited confidence in having conversations with patients on opioids about results of their urine toxicology test or their PDMP record.

• Lack of training or experience assessing patients who may be at risk of developing OUD.

• Other factors that can affect a patient’s health, such as limited income, food insecurity, being unhoused.

• Other (please specify): ___________________________ 

• I have not encountered challenges

14. How have these challenges or barriers changed in the past 2 years (since the CDC released the 2022 CDC Clinical Practice Guideline)?

	Has become easier	Has stayed the same	Has become harder
[Autofill each item selected from previous question]

15. What is the single most important factor that has made it challenging to adopt recommendations of the 2022 CDC Clinical Practice Guideline?⁷

______________________________________________________________________________

16. What is the single most important factor that has enabled you to adopt recommendations of the 2022 CDC Clinical Practice Guideline?⁸

______________________________________________________________________________

PRACTICE AND CLINICIAN CHARACTERISTICS

The following questions ask in more detail about the characteristics of your practice, patient panel, as well as yourself.

17. Which of the following best describes your practice’s ownership? [Please check all that apply.]

• Clinician-owned solo or group practice

• Hospital/health system owned

• Health maintenance organization, (e.g., Kaiser Permanente)

• Federally Qualified Health Center or Look-Alike

• Non-federal government clinic (e.g., state, county, city, public health clinic, etc.)

• Academic health center/faculty practice

• Federal (Military, Veterans Administration, Department of Defense)

• Rural Health Clinic

• Indian Health Service

• Other, please specify___________________________

18. Zip code and state of your primary practice:

Zip Code: _________

State: ___________

19. What is the size of your patient panel?⁹

• 1 - 999

• 1,000 – 1,499

• 1,500 – 1,999

• 2,000 – 2,499

• 2,500 – 3,000

• 3,000+

• Don’t know

20. What is the approximate age distribution of your patients? If you treat few or no patients in a group, report 0 percent. The percentages should total to 100%.

17 years old or younger _____%

18 to 64 years old _____%

65 years old or older _____%

Don’t know _____%

21. For the following question, please give your best estimate. If you treat few or no patients in a group, report 0 percent. The percentages should total to 100%. What percent of your current patient population identify as the following:

American Indian or Alaska Native? ____ %

Asian? ___%

Black or African American? ___ %

Hispanic or Latino? ____ %

Middle Eastern or North African? __ %

Native Hawaiian or Pacific Islander? ____%

White? ___%

Mixed race and/or ethnicity? __ %

Unknown/Not Sure __ %

22. To the best of your ability, please estimate what percent of your patient population identifies as the following: 

If you treat few or no patients in a group, report 0 percent. Because gender can be a complex identity, the percentages may not total to 100%.

Female____ %

Male____ %

Transgender, non-binary, or another gender _____%

Unknown/Not sure ___ %

23. What proportion of your patient panel are covered by the following payer sources? If you treat few or no patients in a group, report 0 percent.

Patients covered by Medicare _____%

Patients covered by Medicaid _____%

Patients dually eligible for both Medicare and Medicaid _____%

Patients with other forms of public insurance _____%

Patients with private insurance _____%

Uninsured patients _____%

Don’t know

24. What type of clinician best describes you? [Please select one answer.]

• Physician (MD/DO)

• Nurse Practitioner (NP)

• Physician’s Assistant (PA)

• Other, please specify _________________________

25. What is the primary specialty of the care setting in which you practice the most time during the week?

• Family Medicine

• Internal Medicine

• Emergency Medicine

• Surgery (or General Surgery)

• Occupational Medicine

• Physical medicine and rehabilitation

• Neurology

• Obstetrics and Gynecology

• Other, please specify ______________________

26. Number of years practicing medicine? ________

27. Which categories best describe your race and/or ethnicity? Select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Middle Eastern or North African

• Native Hawaiian or Pacific Islander

• White

• Not sure/Prefer not to say

28. Are you: [Mark all that apply.]

• Female

• Male

• Transgender, non-binary, or another gender

• Not sure/Prefer not to say

29. If you would be willing to participate in a follow-up interview based on your responses, please enter your contact information below. Respondents participating in the follow-up interview will be provided with a $100 virtual gift card.

30. Would you be willing to participate in a follow-up interview?

• Yes, Please provide your information below:

• Name

• Phone number

• Email

• No. à GO TO END.

1 Adapted from the Evaluating and Implementing the Six Building Blocks Team Approach to Improve Opioid Management in Primary Care - Clinical Staff Survey

2 Tool is adapted from the 9-item Shared Decision-Making Questionnaire (SDM-Q-Doc, physician version).

3 Adapted from AHRQ Opioids among Older Adults – Clinician Survey

4 Adapted from Gagliardi, A. R., Armstrong, M. J., Bernhardsson, S., Fleuren, M., Pardo-Hernandez, H., Vernooij, R. W., ... & Amer, Y. S. (2019). The Clinician Guideline Determinants Questionnaire was developed and validated to support tailored implementation planning. Journal of Clinical Epidemiology, 113, 129-136.

5 Adapted from Gagliardi, A. R., Armstrong, M. J., Bernhardsson, S., Fleuren, M., Pardo-Hernandez, H., Vernooij, R. W., ... & Amer, Y. S. (2019). The Clinician Guideline Determinants Questionnaire was developed and validated to support tailored implementation planning. Journal of Clinical Epidemiology, 113, 129-136.

6 Adapted from Evaluating and Implementing the Six Building Blocks Team Approach to Improve Opioid Management in Primary Care - Clinical Staff Survey

7 Adapted from Gagliardi, A. R., Armstrong, M. J., Bernhardsson, S., Fleuren, M., Pardo-Hernandez, H., Vernooij, R. W., ... & Amer, Y. S. (2019). The Clinician Guideline Determinants Questionnaire was developed and validated to support tailored implementation planning. Journal of Clinical Epidemiology, 113, 129-136.

8 Adapted from Gagliardi, A. R., Armstrong, M. J., Bernhardsson, S., Fleuren, M., Pardo-Hernandez, H., Vernooij, R. W., ... & Amer, Y. S. (2019). The Clinician Guideline Determinants Questionnaire was developed and validated to support tailored implementation planning. Journal of Clinical Epidemiology, 113, 129-136.

9 Murray et al. Panel Size: Answers to Physician’s FAQs. American Academy of Family Physicians, 2007.