Cx3 Study - Follow-up Provider Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx-xx-20xx

CDC’s Cervical Cancer Study (Cx3 Study)

Follow-up Provider Survey

[Name of clinic] is one of several Illinois clinics serving National Breast and Cervical Cancer Early Detection Program (NBCCEDP) patients that the Centers for Disease Control and Prevention (CDC) has selected for participation in the Cx3 Study. As a health care provider in the [name of clinic], we are inviting you to participate in a survey of clinicians being conducted for CDC by the Battelle Centers for Public Health Research and Evaluation.

In this survey, we will ask you a series of questions regarding your cervical cancer screening practices and opinions. The information provided by you and other clinicians will provide valuable information to CDC to assist them in their efforts to provide cervical cancer screening to NBCCEDP women.

• This survey has been sent to 70 clinicians in 18 practices who have agreed to participate in the Cx3 Study. We need the response of every clinician to make this important study valid. You will be asked to complete a similar survey once each year over the next three years

• All answers that you give will be kept private. This is so because this study has been given a Certificate of Confidentiality. This means anything you tell us will not have to be given out to anyone, even if a court orders us to do so, unless you say it’s okay. Responses will be reported only in summary form along with information from the other clinicians that participate in the survey. No personal identifiers will be included in either oral or written presentation of the study results.

• Battelle, the contractor, must maintain the link between names and participant ID numbers for tracking survey mailings, and to link your responses to all follow-up surveys. While Battelle will have the capability to link responses to individual participants, this capability will only be present until data collection is completed. At that point, the tracking file will be destroyed and there will be no way to link responses to you.

• On average, the survey will take about 30-35 minutes to complete, depending on the scope of your practice.

• Some questions about your provision of advice to patients about sexual risk, or about your practices that may differ from institutional clinical practice recommendations may cause you discomfort.

• Your participation in this survey is voluntary. You may choose to withdraw from the study or to skip any questions that you do not want to answer.

When you have completed the survey, please seal it in the envelope provided and return it to the clinic Study Coordinator.

Thank you for your participation in this important study.

Public reporting burden of this collection of information varies from 30 to 35 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Section A: Personal and Professional Characteristics

In this section we ask questions that will let us describe the survey participants. Please write in or check () the best answer.

1. What is your date of birth?

month year

2. During a typical month, approximately what percentage of your professional time do you spend in the following activities?

a. Providing primary care _______ %

b. Providing subspecialty care _______ %

c. Research _______ %

d. Teaching _______ %

e. Administration _______ %

f. Other (specify):________________________________ _______ %

Total 100%

3. On average, how many hours per week total do you spend in direct patient care in all your primary care settings?

______________ Average number of hours per week

4. On average, how many hours per week do you spend on outpatient care at this clinic?

______________ Average number of hours per week

5. Approximately how many patients do you see at this clinic in a typical week? ______________

6. Approximately what percentage of the patients you see at this clinic in a typical week are female? _________%

7. Of your female patients, approximately what percent are in each age group? (If you see no female patients, enter ‘0’)

Under age 18 _______ %

Age 18-29 _______ %

Age 30-64 _______ %

Over age 65 _______ %

Total 100%

8. Do you provide health maintenance or routine “well woman” exams to female patients over age 18 at this site?

 Yes (Continue with the survey)  No (Stop and return the survey)

9. In a typical week, approximately how many female patients age 18 and older do you see for health maintenance or routine “well-woman” exams? ______________

10. Do you personally perform Pap tests for your female patients at this site?

 Yes (Continue with the survey)  No (Stop and return the survey)

Section B: Cervical Cancer Screening

Cervical cancer screening is defined in this survey as the periodic use of a testing procedure intended to detect the disease in patients who display no signs or symptoms of possible cancer. Please answer the following questions for the patients that you see at [name of clinic].

1. During a typical month, for how many asymptomatic, average-risk female patients do you personally perform Pap tests for cervical cancer screening? It is not necessary to provide an exact number. Your best estimate is all we need. _________________

2. During a typical month, approximately what percentage of your patients that receive Pap testing are identified with any abnormal or borderline cervical cytology? _________ %

3. For female patients who have a Pap test showing ASC-US, and fall into one of the categories below, please indicate what you would typically do. (Check one box on each line)

	Manage in my own practice	Refer to another practitioner
a. Premenopausal, < 30 years old		
b. Premenopausal, > 30 years old		
c. Postmenopausal		

4. Do you or other providers perform cervical colposcopy at this clinic?

 Yes, I provide colposcopy at this clinic

 No, another clinician provides colposcopy at this clinic

 No, patients must be referred to another care facility

5. When screening for cervical cancer in average-risk women, for what proportion of patients do you use each of the following cytology methods?

Conventional Pap test (smear spread on glass slide and fixed) _______ %

Liquid-based Pap test, such as ThinPrep or SurePath (specimen suspended in liquid solution) _______ %

Other (specify):________________________________ _______ %

Total 100%

6. Does your decision to use a conventional versus a liquid-based Pap test depend on: (For each row, please only one)

	Yes	No
a. The patient’s age?		
b. The patient’s type of health insurance coverage?		
c. The ease of using the same sample for doing an HPV DNA test with liquid-based cytology?		
d. The ease of using the same sample for doing other molecular tests (for example can do GC/CT now with liquid-based cytology)?		
e. Accuracy (higher sensitivity, lower specificity with liquid-based cytology)?		
f. Unsatisfactory smears (lower unsatisfactory smears with liquid-based cytology)?		
g. Laboratory preference?		
h. Clinic policy?		
i. Cost of the test?		
j. ACOG or other guidelines?		
k. Pharmaceutical marketing?		

Section C: Risk Assessment/Management

1. Please indicate the extent to which you agree or disagree with the following statements regarding the importance of an annual health maintenance or “well woman” exam? (For each row, please only one)

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. In addition to seeing a patient for acute illnesses and chronic medical problems, an annual exam is necessary					
b. An annual exam improves detection of subclinical illness					
c. An annual exam improves patient-physician relationships					
d. An annual exam is expected by most patients					
e. An annual exam is covered by many insurance plans					
f. An annual exam is of little or no proven value					
g. An annual exam is recommended by national organizations					
h. An annual exam provides a valuable time to counsel on preventive health behaviors					

2 Do you routinely perform or refer asymptomatic non-pregnant female patients for the following examinations and laboratory tests during health maintenance or “well woman” exams? (For each row, please only one)

	Yes	No	Depends on circumstances or patient
Examinations
a. Height/Weight			
b. Blood Pressure			
c. Clinical breast exam			
d. Mammogram referral in women 40+ years old			
e. Pap smear			
f. EKG			
g. Fecal Occult Blood Test			
h. Treadmill Cardiogram			
i. Urinalysis			
Laboratory tests
j. CBC/Hgb/Hct			
k. Blood Glucose			
l. Lipid Panel			
m. HIV/AIDS			
n. Kidney Function			
o. Liver Function			
p. Thyroid Function			

3. Please indicate how often you take each approach to assess a patient’s risk of cervical cancer during a health maintenance or “well woman” exam? (For each row, please only one)

	Never	Sometimes	Half the time	Usually	Always
a. I rely on cues (e.g., appearance, social situation, lifestyle, etc) that the patient may be at increased risk and ask specific questions if it seems appropriate					
b. I rely primarily on the patient’s Pap test history to identify patients who may be at increased risk					
c. I pursue a discussion of risks for all patients in certain demographic groups that may be at increased risk (e.g., on the basis of age, marital status, race)					
d. Regardless of apparent risk, I ask specific questions to see if the patient engages in behaviors that put her at increased risk					
e. I ask questions about sexual and behavioral risk as a routine part of the patient history					
f. I depend on my professional intuition or judgment to identify patients who may be at increased risk					
g. I depend on my knowledge of each patient to identify patients who may be at increased risk					

4. Approximately how many female patients do you see with any STD (including HIV) in a typical month? ____________

Section D: HPV Testing Practices

1. For your female patients who are over age 30, we would like to know more about your experiences with using human papillomarivus (HPV) DNA testing for screening and management. (For each row, please only one)

	Never	Sometimes	Half the time	Usually	Always
a. How often do you use HPV DNA testing with the Pap test for routine cervical cancer screening (co-testing)?					
b. How often do you use HPV DNA testing as a follow-up test for an ASC-US Pap test (reflex testing)?					

2. For your female patients who are age 21-30, please answer the following questions regarding HPV DNA testing. (For each row, please only one)

	Never	Sometimes	Half the time	Usually	Always
a. How often do you use HPV DNA testing with the Pap test for routine cervical cancer screening (co-testing)?					
b. How often do you use HPV DNA testing as a follow-up test for an ASC-US Pap test (reflex testing)?					

3. During the last month, did any of your patients ask if they could or should be tested for HPV?

 Yes, approximately how many in the past month? ______________ number of patients

 No

4. Next, we would like to ask you a few questions about your attitudes and beliefs regarding HPV testing. Conducting HPV testing along with Pap testing for routine screening in women over age 30 is: (For each row, please only one)

		Extremely	Quite	Neither	Quite	Extremely
a.	Good						Bad
b.	Difficult						Easy
c.	Beneficial						Harmful

5. Please indicate the extent to which you agree or disagree with the following statements: (For each row, please only one)

Conducting HPV testing along with Pap testing for routine screening in women over age 30:	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. is not needed because my patients have timely access to colposcopy					
b. helps me determine the appropriate future screening intervals for the patient					
c. is not needed because most of my patients have 3+ prior normal Pap tests					
d. would necessitate a difficult discussion with the patient about HPV as an STD					
e. helps me determine a plan for follow-up if the Pap result is abnormal					
f. is costly to patients because it is not a covered service for most patients					
g. takes too much of my time					
h. does not provide any more useful information than the Pap test alone					
i. helps me explain cervical cancer risk to patients					
j. gives me a more complete understanding of a patient’s current state of health and risk for disease					
k. is the best way to screen for cervical cancer					
l. is only needed for high risk patients					
m. is a test my patients would not want					
n. would be an extra burden for my office staff					

6. Please indicate the extent to which you feel that the following individuals or entities encourage or discourage you to conduct HPV testing along with Pap testing for routine screening in women over age 30. (For each row, please only one)

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
a. your patients					
b. your colleagues					
c. your professional specialty organization					
d. national health organizations (e.g., ACS)					
e. professional journals					
f. the administration in your practice					

7. Please indicate the extent to which you agree or disagree with the following statements. (For each row, please only one)

Discussing with patients the results of a positive HPV DNA test and a normal Pap test would:	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. make many patients feel uncomfortable, upset or angry					
b. reduce the willingness of patients to seek care from me in the future					
c. increase the likelihood that patients will return for repeat Pap screening					
d. distract attention from cervical cancer prevention					
e. raise patients’ concerns about confidentiality of care issues (e.g., privacy of medical records, bills being sent home)					
f. raise patients’ concerns about partner fidelity					
g. make me feel uncomfortable					
h. take too much time					
i. assure patients they are getting the best standard of care					
j. be too complex for most patients to understand					
k. encourage patients to talk openly about sexual health with their partners					

8. Please indicate the extent to which you agree or disagree with the following statements. (For each row, please only one)

Discussing with patients the results of a positive HPV DNA test and an abnormal Pap test would:	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. make many patients feel uncomfortable, upset or angry					
b. reduce the willingness of patients to seek care from me in the future					
c. increase the likelihood that patients will return for repeat Pap screening					
d. distract attention from cervical cancer prevention					
e. raise patients’ concerns about confidentiality of care issues (e.g., privacy of medical records, bills being sent home)					
f. raise patients’ concerns about partner fidelity					
g. make me feel uncomfortable					
h. take too much time					
i. assure patients they are getting the best standard of care					
j. be too complex for most patients to understand					
k. encourage patients to talk openly about sexual health with their partners					

9. If you order an HPV DNA test along with a Pap test, how often would you: (For each row, please only one)

	Never	Sometimes	Half the time	Usually	Always
a. Tell the patient that you are ordering an HPV DNA test?					
b. Explain to the patient the purpose of an HPV DNA test in relation to the Pap test?					
c. Explain to the patient that the HPV DNA test detects a sexually transmitted infection?					
d. Discuss with the patient how HPV DNA test results may determine when she will need to be screened for cervical cancer again?					

Section E: Screening Interval Questions

1. Imagine that you are responsible for determining the plan of care for a woman who is 35 years old and has received the cervical cancer screening results listed below. For each scenario, please indicate the cervical cancer screening interval you would be most likely to recommend for her next test. (For each row, please only one)

	Next Cervical Cancer Screening Interval
	Sooner than 1 year	1 year	2 years	3 years	More than 3 years
a. Normal Pap this visit, no HPV test, no previous Pap record					
b. Normal Pap this visit, no HPV test, normal Pap 1 year ago					
c. Normal Pap this visit, no HPV test, normal Pap 1 and 2 years ago					
d. Normal Pap this visit, Negative HPV test this visit					
e. Normal Pap this visit, Positive HPV test this visit					

2. Imagine that you are responsible for determining the plan of care for a woman who is 35 years old and has received the cervical cancer screening results listed below. For each scenario, please indicate: (1) whether or not you would order a colposcopy; and (2) if you would not order a colposcopy, or if the colposcopy was negative, when you would recommend the patient have her next Pap test. (For each row, please only one)

	Would you perform or order a colposcopy?
	Yes		No
a. ASC-US Pap, No HPV test			
b. ASC-US Pap, Negative HPV test			
c. ASC-US Pap, Positive HPV test			
d. LSIL Pap			
	If you would not order a colposcopy, or if the colposcopy was negative, when would you recommend the patient have her next Pap test?
	Pap sooner than 1 year	Next Pap in 1 year		Next Pap in more than 1 year
a. ASC-US Pap, No HPV test				
b. ASC-US Pap, Negative HPV test				
c. ASC-US Pap, Positive HPV test				
d. LSIL Pap				

Please answer the following questions about your attitudes regarding extending cervical cancer screening intervals.

3. Deciding to extend the cervical cancer screening interval to 3 or more years because a woman over age 30 had received 3 normal Pap results the last 5 years would be: (For each row, please only one)

		Extremely	Quite	Neither	Quite	Extremely
a.	Good						Bad
b.	Difficult						Easy
c.	Beneficial						Harmful

4. Deciding to extend the cervical cancer screening interval to 3 or more years because a woman over age 30 had received a normal Pap result and negative HPV test would be: (For each row, please only one)

		Extremely	Quite	Neither	Quite	Extremely
a.	Good						Bad
b.	Difficult						Easy
c.	Beneficial						Harmful

5. For a 30 year old with 3 normal Pap results in the past 5 years, please indicate the extent to which you agree or disagree with the following statements about extending the screening interval to 3 or more years between tests. (For each row, please only one)

Extending the screening interval to 3 or more years between tests:	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. would result in the patient not visiting annually for other screening tests that are recommended					
b. would put me and my practice at risk for liability if the patient’s next result is abnormal					
c. would put the patient at increased risk for cervical cancer					
d. would help reduce health care costs					
e. would increase patient concerns about missing cervical cancer					
f. would take too much of my time to explain to the patient					
g. would reduce patient worries about acquiring cervical cancer					
h. would result in higher rates of cervical precancer (CIN 2/3)					
i. would cause patients to lose contact with the medical care system					
j. would decrease care provided to the patient					

6. Please indicate the extent to which you feel that the following individuals or entities encourage or discourage you to extend the screening interval to 3 or more years between tests for a 30 year old with 3 normal Pap results in the past 5 years. (For each row, please only one)

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
a. your patients					
b. your colleagues					
c. your professional specialty organization					
d. national health organizations (e.g., ACS)					
e. professional journals					
f. the administration in your practice					

7. For a 30 year old with a normal Pap result and a negative HPV test, please indicate the extent to which you agree or disagree with the following statements about extending the screening interval to 3 or more years between tests. (For each row, please only one)

Extending the screening interval to 3 or more years between tests:	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
a. would result in the patient not visiting annually for other screening tests that are recommended					
b. would put me and my practice at risk for liability if the patient’s next result is abnormal					
c. would put the patient at increased risk for cervical cancer					
d. would help reduce health care costs					
e. would increase patient concerns about missing cervical cancer					
f. would take too much of my time to explain to the patient					
g. would reduce patient worries about acquiring cervical cancer					
h. would result in higher rates of cervical precancer (CIN 2/3)					
i. would cause patients to lose contact with the medical care system					
j. would decrease care provided to the patient					

8. Please indicate the extent to which you feel that the following individuals or entities encourage or discourage you to extend the screening interval to 3 or more years between tests for a 30 year old with a normal Pap result and a negative HPV test. (For each row, please only one)

	Strongly Discourage	Discourage	Neither	Encourage	Strongly Encourage
a. your patients					
b. your colleagues					
c. your specialty professional organization					
d. national health organizations (e.g., ACS)					
e. professional journals					
f. the administration in your practice					

9. To what extent do you consider the following factors in deciding whether or not to extend the cervical cancer screening interval for a woman over age 30? (For each row, please only one)

	Not at all	Some	A great deal
a. Patient age			
b. Race/ethnicity			
c. Current number of sexual partners			
d. Lifetime number of sexual partners			
e. Cigarette smoking			
f. Current Pap test results			
g. History of abnormal test results			
h. Current HPV status			
i. Income			
j. History of regular Pap screening			
k. Educational level			
l. Likelihood of the patient not returning for future screening			
m. Immune system status (e.g. HIV/AIDS)			
n. Number of children			
o. Using birth control for a long time			
p. Language barrier			
q. STD History			
r. Diethylstilbestrol (DES) exposure			
s. Type of insurance coverage			

Section F: HPV Vaccine

1. Do you currently recommend the HPV vaccine?

 Yes (SKIP TO QUESTION 3)

 No

2. Do you plan on recommending the HPV vaccine?

 Yes

 No (SKIP TO QUESTION 4)

3



. What age group(s) do you recommend patients get the HPV vaccine? (Please  all that apply)

 Females 9-12 years of age

 Females 13-26 years of age

 Females 27 years of age and older SKIP TO QUESTION 5

 Males 9-12 years of age

 Males 13-26 years of age

 Males 27 years of age and older

4. Please indicate the reason(s) why you do NOT plan on recommending the HPV vaccine. (Please  all that apply)

 Not a large proportion of recommended age group in my practice

 Concern that it encourages sexual promiscuity

 Not wanting to convince parents/patients to accept vaccine

 Awkwardness of conversation that HPV is sexually transmitted

• Concern about safety of the vaccine

• Awaiting final study results to better assess benefits and harms

 Concern about vaccinated women failing to get screened

 Concern about thiomersal in vaccine

 Concern about decreased efficacy in population that has been exposed to HPV (e.g., sexually active)

 Concern that the office schedule is too crowded to accommodate additional visits

 Insurance reimbursement issues

 Up-front costs to purchase vaccine

 Concern regarding the storage and administration protocol of vaccine

 Other ___________________________________________________________________(Please specify)

5. As it relates to the HPV vaccine, how often do you: (For each row, please only one)

	Rarely or never	Sometimes	Usually	Always or almost always	Unknown/not applicable/ Do not ask
a. Use HPV test to determine who should get the HPV vaccine?					
b. Perform a Pap test to determine who should get the HPV vaccine?					
c. Recommend the HPV vaccine to females with a history of an abnormal Pap test result (ASC-US higher)?					
d. Recommend the HPV vaccine to females with a positive HPV test?					
e Use the number of sexual partners to determine who should get the HPV vaccine?					

6. Will your cervical cancer screening and management procedures change for females who have been fully vaccinated with the HPV vaccine?

 Yes

 No (SKIP TO QUESTION 10)

 Don’t know (SKIP TO QUESTION 10)

7. How will you determine when to start routine cervical cancer screening for fully HPV vaccinated females? (Check all that apply)

• By age

  • At same age as non-HPV vaccinated females – Specify age ______________

  • At a later age – Specify age ______________

  • Other (specify): ________________________________________________________________

• By onset of sexual activity – Specify number of year(s) after onset of sexual activity? ______________

• We will not be screening fully HPV vaccinated females

• Unknown

8. How often will you routinely screen for cervical cancer among females that have been fully vaccinated with the HPV vaccine? (Please only one)

 Annually

 Every 2-3 years

 Every 4-5 years

 Greater than every 5 years

• Will not be screening fully HPV vaccinated females

• Unknown

9. Will you use the HPV DNA test for managing abnormal cytology for females that have been fully vaccinated with the HPV vaccine?

 Yes

 No

 Don’t know

10. During the past month, did any of your patients ask if they or their daughters could or should be vaccinated against HPV?

 Yes, approximately how many in the past month? ______________ number of patients

 No

11. Please indicate to what extent you agree, disagree, or are unsure with each statement. (For each row, please only one)

Vaccinating female patients will result in:	Agree	Disagree	Unsure
a. Fewer numbers of abnormal Pap tests among vaccinated females			
b. Fewer referrals for colposcopy among vaccinated females			
c. Fewer CIN results.			

Section G: Education/Guidelines

1. Do you personally follow published guidelines for cervical cancer screening and management?

 Yes

 No (SKIP TO QUESTION 2)

 Don’t know/not sure (SKIP TO QUESTION 2)

1a. Which guidelines for cervical cancer screening and management do you follow? (Please  all that apply)

 U.S. Preventive Services Task Force

 American Cancer Society

 American College of Obstetricians and Gynecologists

 American Academy of Family Physicians

• American College of Physicians

• National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

• American Society for Colposcopy and Cervical Pathology (ASCCP)

 Other (specify): ________________________________________________________________

2. Has this clinic implemented guidelines for cervical cancer screening and management?

 Yes

 No (SKIP TO QUESTION 3)

 Don’t know/not sure (SKIP TO QUESTION 3)

2a. Which guidelines for cervical cancer screening and management has the clinic implemented? (Please  all that apply)

 U.S. Preventive Services Task Force

 American Cancer Society

 American College of Obstetricians and Gynecologists

 American Academy of Family Physicians

• American College of Physicians

• National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

• American Society for Colposcopy and Cervical Pathology (ASCCP)

 Other (specify): ________________________________________________________________

2b. Do you have access to these practice guidelines in an electronic format (such as a web site or computer information system)? (Check one box on each line)

	Yes	No
i. At the point of care (e.g., exam room)		
ii. At your desk or a work station, away from the point of care		

3. Did you participate in any CME on cervical cancer screening in the past year?

 Yes

 No (SKIP TO QUESTION 5)

4. How many CME credits for cervical cancer screening did you receive in the past year?

______________ CME credits

5. Are you aware of, and have you ever referred a patient to, any of the following services for cancer information? (For each row, please only one)

	Aware and referred	Aware of it, never referred	Not aware of it	Not sure
a. The 1-800-4-CANCER Cancer Information Service telephone line				
b. The www.cancer.gov National Cancer Institute web site				
c. The www.cdc.gov Centers for Disease Control and Prevention web site				
d. Other (specify): ____________________________________				

6. Do you currently provide patients with any educational materials (e.g., brochures, fact sheets) regarding cervical cancer screening?

• Yes, I provide information to all women

• Yes, but only to some women (specify): ________________________________________________

• No

7. Do you have a mechanism to remind you that a patient is due for cervical cancer screening? (Check all that apply)

a. Yes, special notation or flag in patient’s chart	
b. Yes, computer prompt or computer-generated flow sheet	
c. Yes, I routinely look it up in the medical record at the time of the visit	
d. Yes, other mechanism (specify): _______________________________________________________	
e. No	
f. Don’t know	

THANK YOU FOR YOUR PARTICIPATION IN THIS SURVEY. PLEASE MAIL THE SURVEY IN THE POSTAGE PAID ENVELOPE.

Comments:

Attachment D2. Follow-up provider survey 19