Supporting Statement

Request for Approval of a Non-Substantive Change:

National Hospital Ambulatory Medical Care Survey

OMB No. 0920-0278

(Expires 12/31/2014)

Contact Information:

Farida B. Ahmad, MPH

Lead Health Scientist, Ambulatory Care Team

Ambulatory and Hospital Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road, Room 3329

Hyattsville, MD 20782

301-458-4801

301-458-4693 (fax)

hhi0@cdc.gov

October 30, 2013

National Hospital Ambulatory Medical Care Survey (NHAMCS)

A1. Circumstances making the collection of information necessary

This request is for a nonsubstantive change to an approved data collection (OMB No. 0920-0278) (expires 12/31/2014), the National Hospital Ambulatory Medical Care Survey (NHAMCS). On December 2, 2011, NHAMCS was approved to collect data for the three years – 2012, 2013, and 2014 – from emergency departments (EDs), outpatient departments (OPDs), and ambulatory surgery locations (ASLs). The approved supporting statement included permission to modify selected sections of the 2012-2014 surveys through a nonsubstantive change clearance request. Some questions change on a periodic basis to collect new and/or updated information as needed. A minor reduction in burden (OPD lookback module discontinuation) is also proposed and is described below. Changes to the content for 2014 are presented in the included attachments, highlighted below, and described in more detail in section A2.

Concurrent to this submission, the National Ambulatory Medical Care Survey (NAMCS, OMB No. 0920-0234, expiration 12/31/2014) is requesting nonsubstantive changes that contain mainly similar modifications. A majority of the requested data changes in this request apply to both surveys, and represents an attempt to maintain data collection consistency across ambulatory care settings.

The Cervical Cancer Screening Supplement (CCSS)

The Cervical Cancer Screening Supplement (CCSS), fielded since 2006, was sponsored by CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to evaluate adherence to recent national guidelines from 2006 to 2010. Permission to discontinue the supplement was originally approved on December 2, 2010 as a part of a non-substantive change package; however, this discontinuation is being noted again for clarification purposes.

Hospital Induction Interview

The 2014 induction interview will have modified questions in the electronic health records (EHR) section. As in 2013, the 2014 induction questions will be collected on a computer- assisted interviewing instrument. The changes are outlined in Attachment A. The new 2014 full induction interview is shown in Attachment E.

Patient Record Forms (PRF)

Minor changes are proposed for the 2014 NHAMCS Patient Record forms. There are three individual forms, one for patients seen in the OPD (Attachment B), one for those seen in the ED (Attachment C), and one for patients in ASLs (Attachment D). These attachments provide an itemized summary of proposed changes to the 2014 NHAMCS PRFs. All proposed question changes are highlighted in the attachments. As in 2013, the 2014 PRF questions will be collected on a computer-assisted PRF instrument. The new 2014 PDFs are shown in Attachment F (OPD), G (ED) and H (ASL).

A general summary of the PRF changes are highlighted below:

For the outpatient department (OPD) patient record form (Attachment B), the following changes will be made:

• Add/modify answer choices for selected items examining payment, tobacco use, major reason for visit, injury, and visit disposition

• Add a follow-up if the visit was for an injury that assesses timing of injury

• Re-order answer choices and slightly modify text related to intentionality of injury

• Add new/modify number of look-up and linked verbatim items in the following sections: reason for visit, cause of injury, diagnosis, and medications

• Add and modify various check-boxes related to a patient’s chronic conditions and medical services

The OPD lookback module has been discontinued for 2014. See A2 for additional details.

For the emergency department (ED) patient record form (Attachment C), the following changes will be made:

• Add new detail to the Medicaid answer choice for expected source of payment question

• Add new/modify number of look-up and linked verbatim items in the following sections: reason for visit, cause of injury, diagnosis, and medications

• Add/modify questions in injury intentionality and timing

• Add and modify various answer choices related to a patient’s chronic conditions

• Add a section on vital signs at discharge

For the ambulatory surgery (ASL) patient record form (Attachment D), the following changes will be made:

• Add new detail to the Medicaid answer choice for expected source of payment question

• Add/modify various answer choices related to a patient’s chronic conditions

• Allow up to 30 drug entries related to the current visit (currently allow up to 10)

• Modify answer choice wording for patient symptoms and patient follow up

A2. Purpose and use of information collection

Revisions to the Hospital Induction Interview

The electronic health records questions have been slightly modified in 2014 (see Attachment A). Small modifications are also proposed to this section to either increase or decrease the specificity of the information being requested in a given question. For instance, modifications 1, 2, 9, and 10 (in Attachment A4) add questions on EHR privacy issues and sharing of clinical data; modification 4 allows the responder to differentiate between Stage 1 and Stage 2 EHR incentive programs; and modification 8 adds a few brief “follow up” questions. Modifications 5, 6 and 7 are of similar scope.

Revisions to the Patient Record Forms (PRF)

The following section highlights proposed changes to all of the PRFs and can be reviewed in Attachments B, C, and D. It should be noted that the proposed changes described below follow sequentially how the changes will be ordered on the 2014 PRF, and thus are organized similarly in the attachment. Although not discussed in detail below, numerous section headings were modified to be more descriptive of the medical information contained within each group. Changes in the text of various headings can be reviewed in the attachment.

A review of the computer-assisted PRFs revealed that (a) changing the section headings and ordering of some questions, (b) expanding and adding new answer choice categories, and (c) increasing the number of verbatim (and subsequent look-up tables) would improve the flow of data collection, and enhance the richness of data collected at each visit.

The following changes will be made for the OPD, ED, and ASL PRFs. First, the Medicaid answer choice will be expanded to include “other state-based programs”. After examining the payment item, it was determined that we were potentially misclassifying payments by state-based programs as “other” because of the limited scope of the current check-boxes. Second, we are proposing to expand specific verbatim items so the Census FR can record up to 5 patient’s reasons for visit and diagnoses. Historically, NHAMCS has only included space to write-in 3 diagnoses and the patient’s reason for visit. Lastly, we are proposing to increase collection of medications per visit to 30 medications. Patients with chronic conditions often have many medications listed in the patient record, and expansion of this field will allow us to capture all of the listed medications.

1. Outpatient Department Patient Record form (Attachment B)

In addition to the general PRF changes highlighted above, various other small modifications were made to the OPD PRF: (a) two tobacco check-boxes will be added for patients who indicate they are not currently smoking and include “never” and “former,” (b) expanding the checkbox “Pre/Post surgery” under Major reason for visit into two distinct answer choices: “Pre-surgery” and “Post-surgery,” (c) adding additional text to the injury checkbox question to identify if the visit was due to an adverse effect of medical/surgical care, or adverse effect of medicinal drug, (d) adding a follow-up question when the visit was for an injury to determine if the cause occurred within 72 hours, and (e) changing the wording of the intentionality question identifying an injury and poisoning to include “overdose.”

There have been several modified and new checkboxes added to the collection of underlying chronic conditions, housed within the “Diagnosis” section of the computer-assisted PRF. These specific conditions were added after consultation with clinicians on staff, subject matter experts within NCHS, and a review of recommendations found in the Agency for Healthcare Research & Quality (AHRQ) “The Guide to Clinical Preventive Services, 2012.¹” NHAMCS has always had the ability to collect the chronic conditions listed below in write-in fields; however, adding these check-boxes will reduce burden substantially, and should increase reporting accuracy. There were eleven specific modified/new chronic condition check-boxes; a few are shown below and the others are shown in Attachment B.

• Alcohol misuse, abuse, or dependence

• Alzheimer's disease/Dementia

• HIV Infection/AIDS

• Obstructive sleep apnea (OSA)

NCHS is also proposing to make several changes to the medical services section of the computer-assisted PRF. As with the new patient chronic conditions, the NAMCS has always had the ability to collect the newly proposed services listed below from write-in fields, and adding these check-boxes should make data collection easier and more accurate. Some modified/new medical services are listed below; others are highlighted in Attachment B.

• Domestic violence screening

• General physical exam (DELETE)

• Comprehensive metabolic panel

• Creatinine /Renal function panel

• Hepatitis testing/Hepatitis panel

• Vitamin D test

• Genetic counseling

The lookback module was added in 2012 and collected additional information from the 12 month period prior to the sampled visit on risk factors and clinical management of patients with conditions that put people at high risk for heart disease and stroke. The module recorded medications prescribed, changes in medications, family history, and contraindications to certain medications. The intent of the lookback module was to improve the nation’s ability to monitor and evaluate the quality of clinical care to prevent heart disease and stroke as health reform proceeds. The lookback module was funded from prevention funds from the Patient Protection and Affordable Care Act (ACA) of 2010. Funding from ACA was removed and a decision was made to remove the module in 2014, with the possibility of a re-emergence in 2015.

2. Emergency Department Patient Record form (Attachment C)

A limited number of changes on the ED PRF are being made in tandem with changes on the OPD PRF. These include: changes to the payment sources question, modifications and additions to the injury questions, modification of the chronic conditions section, and expansion of fields for reason for visit, diagnosis, and medications.

The triage question of whether the patient was on oxygen at arrival was removed due to advice from a physician that the item was not useful. Response rates in previous years have been too low for analysis. Furthermore, the variable creates confusion with another vital sign item – pulse oximetry.

Vital signs have been added to the end of the ED PRF to assess any changes in the patient’s condition in the duration of the ED visit. Although vital signs are collected earlier in the PRF already, it is currently impossible to ascertain whether the patient’s condition was stabilized or had changed during the visit.

3. Ambulatory Surgery Patient Record form (Attachment D)

A number of changes on the Ambulatory Surgery PRF are being made in tandem with changes on the OPD and ED PRFs. These include: changes to the payment sources question, modification of the chronic conditions section, and expansion of fields for diagnosis and medications. Other minor changes were made in order to clarify the item for the person abstracting the data.

A12. Estimates of Annualized Burden Hours and Cost

a. Burden Hours

The burden table has been updated to reflect the reduction in burden for the OPD PRF and the discontinuation of the Cervical Cancer Screening Supplement. The OPD PRF previously had an average burden of 14 minutes due to the extensive nature of the Lookback Module. With the removal of the module, the burden for the PRF has been reduced to 10 minutes. No additional burden was added for the minor content changes to the survey forms. Meanwhile, the Cervical Cancer Screening Supplement (CCSS) that was fielded since 2006 to evaluate adherence to recent national guidelines from 2006 to 2010 has been discontinued.

Table 12-A. Annualized Burden to Respondents

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Response Burden (in hours)
Hospital Chief Executive Officer	Hospital Induction	482	1	1.5	723
Ancillary Service Executive	Ambulatory Unit Induction	1,779	1	15/60	445
Physician/ Registered Nurse/ Medical Record Clerk	ED Patient Record form	113	100	7/60	1,318
Physician/ Registered Nurse/ Medical Record Clerk	OPD Patient Record form	78	200	10/60	2,600
Physician/ Registered Nurse/ Medical Record Clerk	AS Patient Record Form	54	100	7/60	630
Medical Record Clerk	Pulling and re-filing Patient Records (ED, OPD, and AS)	730	133	1/60	1,618
Ancillary Service Executive - Reabstraction	Reabstraction Telephone Call	72	1	5/60	6
Medical Record Clerk - Reabstraction	Pulling and re-filing Patient Records (ED, OPD, and AS)	72	10	1/60	12
				Total	7,352

15. Explanation for Program Changes or Adjustments

The current approved burden is 8,456 hours. The proposed changes to the 2014 survey, including removing the OPD Lookback Module and the Cervical Cancer Screening Supplement , will reduce the burden to the respondent by 1,040 hours, resulting in a final burden of 7,352 hours.

Attachments

Attachment A. 2014 NHAMCS Hospital Induction Questionnaire - Electronic Health Record Question Changes

Attachment B. 2014 NHAMCS OPD PRF Changes

Attachment C. 2014 NHAMCS ED PRF Changes

Attachment D. 2014 NHAMCS ASL PRF Changes

Attachment E. 2014 NHAMCS Hospital Induction Interview

Attachment F. 2014 NHAMCS OPD PRF Screenshots

Attachment G. 2014 NHAMCS ED PRF Screenshots

Attachment H. 2014 NHAMCS ASL PRF Screenshots

1 Recommendations of the U.S. Preventive Services Task Force: Abstract (Guide to Clinical Preventive Services). September 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/abstract.html

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