Formative Research To Develop Zika Tools For Healthcare Providers

Form Approved

OMB No. 0920-1154

Exp. Date: 01/31/2020

Att F

DISCUSSION GUIDE

ACOG: Provider Attitudes and Behaviors Regarding Zika Virus
Online Focus Groups Among Ob-Gyns, Pediatricians, Certified Nurse-Midwives, and Nurse Practitioners

Draft 12 (12 December)

OBJECTIVES:

• Understand the extent to which Zika virus guidelines are being implemented

• Identify the information needs providers have concerning Zika, and learn how these needs can inform responses to future health crises

• Measure the effectiveness of existing Zika communications

1. WELCOME AND INTRODUCTION [5 minutes]

Thank you for agreeing to participate in this study. This online focus group is part of an opinion evaluation project to understand what health care providers like yourself see as health threats on the horizon and the best practices for mitigating risks with your patients. There are no right or wrong answers – we are just interested in how you feel and your candid feedback. We very much appreciate your willingness to discuss your views with us.

A few words about what will happen during this session. You are currently connected online to me (the Moderator) and numerous other participants. Over the next 90 minutes or so, you will respond to the questions you see appear on the right-side of your browser window. Please answer these questions openly and honestly. Your answers to these questions are anonymous and will not be seen by other participants.

Occasionally, you may find yourself waiting briefly as others finish their answers. Please be patient for the next question should you finish answering before others - the next question will always appear shortly.

At any time during the session, the Moderator may begin an instant messaging chat discussion. You should respond to the Moderator's questions as the discussion proceeds. Note that for these chats, you WILL also be able to see other participants' comments and respond to them. Please be collegial.

Some of you may also get a private pop-up chat window at any point during the session. In this chat, I will ask a few follow-up questions about some of your prior comments. Only you and the Moderator will be a part of this chat - not the rest of the group. When I close the private chat window, please return to the questions on your screen and catch up with the rest of the group.

Please be assured that we conduct this study on a confidential basis. We strictly adhere to our industry’s code of conduct regarding the privacy of all interviewees. No opinions are attributed to any individual.

2. GENERAL HEALTH CARE LANDSCAPE [15 minutes; 20 mins total]

Q: Thinking specifically about recent infectious disease threats –like seasonal outbreaks or pandemics - how confident do you feel talking with your patients about these topics?

PROBE: What if there was a new epidemic? How confident would you be to handle discussions with your patients?

Q: What information and/or resources are most valuable to help you prepare to discuss new health threats with patients?

PROBE: What content is most helpful to support you in caring for your patients during a health crisis? What content is most helpful to share with your patients?

Q: How likely are you to look to the following for clinical guidance on newly emerging health threats: [GRID: 0 unlikely - 5 likely]

American College of Obstetricians and Gynecologists (ACOG)

American Academy of Pediatrics (AAP)

Centers for Disease Control and Prevention (CDC)

American Association of Nurse Practitioners (AANP)

National Association of Pediatric Nurse Practitioners (NAPNAP)

Nurse Practitioners in Women’s Health (NPWH)

American College of Nurse-Midwives

State or local health department

Academic journals

UpToDate

Electronic Health Record

Other association or federal agency (Please specify)

Other (Please specify if employer, health care system, institution, etc.)

PROBE: How do you typically receive this guidance (e.g. receive email, check website)?

PROBE: For what reasons do you rely on each organization for guidance – or not? If you could only receive electronic updates from one source, which organization would that be and why?

Q: How interested are you in the following ways of getting information about emerging health threats: [SELECT ANY THAT APPLY]

	Yes, interested as a source of info	No, not interested	Have not heard of
Explanatory videos	1	2	3
Webinars	1	2	3
Published clinical guidance	1	2	3
Shorter, bulleted information summaries	1	2	3
Algorithms/decision trees/ checklists from guidance	1	2	3
Medical articles	1	2	3
Case studies	1	2	3
Smartphone app	1	2	3
Script for discussions with patients	1	2	3
Tools to help shared decision-making with patients	1	2	3
Clinical decision support tools, which use patient-specific information matched to recommended medical guidelines, and can be embedded in electronic health records (EHRs)	1	2	3
Repository of searchable clinical decision support tools	1	2	3
Grand rounds/educational sessions at meetings	1	2	3

PROBE: Which one or two are you most interested in – and for what reasons?

Q: [Poll question, with open-end option] What format and/or delivery methods are best for you: print, electronic, meetings or another way?

PROBE: How actively do you like to be alerted of updates? (prompt for: email alerts, app push notifications, webpage banners)

Q: [Poll question, with open-end option] What format method do you prefer for materials that you would directly share with your patients: Electronic versus print? In-office posters? Handouts? Videos? Apps? Are materials available in patients’ native language?

Q: [Poll question, with open-end option] Would you use tools that could be incorporated into your practice’s electronic health record (EHR) system, such as: a clinical decision support tool, patient education materials that could be pushed to the patient portal, or printed for a patient to take home?

PROBE: What types of tools, incorporated into the clinical workflow, would be helpful for you or your patients?

3. ZIKA VIRUS LANDSCAPE [20 minutes; 40 mins total]

For the remainder of the discussion we are going to focus on Zika virus. I’d just like to remind everyone that this discussion is completely confidential and anonymous, and none of the other participants can see your responses.

Q: [Poll question, with open-end option] To what extent do you see Zika as a current public health issue?

To a great extent

To some extent

To a minor extent

Not a current public health issue at all

PROBE: For what reasons is – or is it not – an issue you are paying attention to? Was it a public health issue previously? If so, when?

Q: [Poll question, with open-end option] How often do patients come to you with questions or concerns regarding Zika virus?

Very often

Somewhat often

Not that often

Never

PROBE: What are patients initially seeking information about? (prompt, as needed: screening, protection tips, advice on travel or pregnancy planning, symptoms to keep an eye out for, concerns about health effects, or something else?)

PROBE: Where else do your patients say they are getting information?

[For ob-gyns] PROBE: How often do you advise your patients who are pregnant or planning pregnancy to follow Zika prevention strategies, such as restrictions on travel, insect repellant use, or condom use or abstain from sex if their partners may have been exposed to Zika? To what extent do you think your patients are following your recommendations?

[For pediatricians] PROBE: To what extent do you think your patients’ caregivers are following your recommendations? Specifically, recommendations for testing and seeking appropriate follow-up care?

[For women’s health nurse practitioners/midwives] PROBE: How often do you advise your patients who are pregnant or planning pregnancy to follow Zika prevention strategies, such as restrictions on travel, insect repellant use, or condom use or abstain from sex if their partners may have been exposed to Zika? To what extent do you think your patients are following your recommendations?

[For all other nurse practitioners] PROBE: To what extent do you think your patients’ caregivers are following your recommendations? Specifically, recommendations for testing and seeking appropriate follow-up care?

Q: I’d like to get a quick sense of how confident you are when it comes to knowledge about Zika virus. Please indicate below whether you agree or disagree with each statement:

	Very confident	Somewhat confident	Neutral	Somewhat unconfident	Not at all confident
Understanding how Zika virus is spread	1	2	3	4	5
Understanding the latest recommendations in terms of Zika virus prevention	1	2	3	4	5
Identifying who is at highest risk for infection and screening patients for risk/exposure	1	2	3	4	5
Applying the newest testing guidelines	1	2	3	4	5
Following up, as appropriate, for a positive test result	1	2	3	4	5
Communicating with patients	1	2	3	4	5

Q: Overall, what information and/or resources do you most rely on to support your confidence related to Zika?

PROBE: How did you learn about these resources?
PROBE: How interested are you in information on: [GRID: 0 not interested- 5 very interested]

Recommendations on how to counsel patients about Zika

Recommendations on Zika prevention

Zika testing and diagnosis

Clinical management of Zika and treatment options

Patient education resources for Zika

Zika educational sessions, e.g. webinars, grand rounds, workshops, sessions at conferences, etc.

Something else (Please specify)

Q: When it comes to screening and applying the newest testing guidance…

When (or if) have you looked up Zika guidelines? Where did you go for guidelines?

PROMPT: ACOG Practice Advisory, CDC guidance for OBs, CDC Interim Guidance for Infants, tools within EHR, state or local health department, other)

Q: What aspects of screening and testing for Zika do you feel more confident about? What, if any, do you feel less confident about?

Q: When it comes to communicating with patients about Zika…

What aspects of communicating with patients about Zika do you feel more confident about? What, if any, do you feel less confident about? (E.g., communicating risks and effects of Zika, communicating prevention tips, explaining how transmission occurs, making shared decisions with patients about testing, communicating the possibility of false positive or false negative tests)

PROBE: Where did you look for support for communicating with patients? What was most helpful?

Q: Given that we all have room to grow, what are the areas you’d like to learn more about Zika, if any?

PROBE: In your view, why are there knowledge gaps? For example: Is it because Zika virus is not prevalent in your area, because you feel there is insufficient information available to you, concerns/questions about the accuracy of testing results, or some other reason?

Q: Below is a list of health organizations that providers may turn to for Zika virus recommendations. For each one, I’d like you to do two things: first I’d like you to indicate how trustworthy you find each source, and second, I’d like you to rank the organizations in terms of which you would likely turn to for Zika virus guidance.

	Very trustworthy	Somewhat trustworthy	Neutral	Somewhat untrustworthy	Very untrustworthy	Do not know org.	Rank
Centers for Disease Control and Prevention (CDC)	1	2	3	4	5	6
World Health Organization (WHO)	1	2	3	4	5	6
American College of Obstetricians and Gynecologists (ACOG)	1	2	3	4	5	6
State health departments	1	2	3	4	5	6
Local health departments	1	2	3	4	5	6
American Academy of Pediatrics (AAP)	1	2	3	4	5	6
National Institutes of Health (NIH)	1	2	3	4	5	6
American Medical Association (AMA)	1	2	3	4	5	6
National Association of Pediatric Nurse Practitioners (NAPNAP)	1	2	3	4	5	6
Nurse Practitioners in Women’s Health (NPWH)	1	2	3	4	5	6
American College of Nurse-Midwives (ACNM)	1	2	3	4	5	6
American Association of Nurse Practitioners (AANP)	1	2	3	4	5	6
Other	1	2	3	4	5	6

Q: Please describe why the organizations you named as most trusted are the most trusted.

PROBE: For any organization not trusted, what makes them not trusted?

Q: Thinking of the top two sources of information, why are those most reliable?

PROBE: What makes your “go-to” sources: convenient, clear and/or useful?

4. ZIKA GUIDELINES [20 minutes; 60 mins total]

Now, shifting to talk in more detail about Zika guidelines…

Q: How are you implementing Zika guidelines in your practice?

[For ob-gyns] PROBE: Are you implementing screening, counseling, travel recommendations? Are you collecting samples for testing? Are you following up with Zika-positive patients?

[For pediatricians] PROBE: Are you implementing screening and counseling recommendations? Are you collecting samples for testing? Do you know the characteristics of infants with congenital Zika virus infection? Are you referring to pediatric specialists, as appropriate?

[For women’s health nurse practitioners/midwives] PROBE: Are you implementing screening, counseling, travel recommendations? Are you collecting samples for testing? Are you following up with Zika-positive patients?

[For all other nurse practitioners] Are you implementing screening and counseling recommendations? Are you collecting samples for testing? Do you know the characteristics of infants with congenital Zika virus infection? Are you referring to pediatric specialists, as appropriate?

Q: What are the barriers to fully implementing Zika guidelines? (prompt as needed: screening, testing, care/follow-up)

Q: Below is a list of potential barriers to fully implementing Zika guidelines. Please indicate how much of a barrier each is for you in your practice:

	Major barrier	Minor barrier	Not a barrier
Lack of reliable resources	1	2	3
Frequency of new guidance	1	2	3
Lack of time to stay informed of changing guidance	1	2	3
Lack of notification when guidance changes	1	2	3
Difficulty understanding guidance	1	2	3
Screening and testing recommendations not incorporated into EHR	1	2	3
Lack of clinical decision support tools at the right place in the clinical workflow	1	2	3
[Ob-Gyns/nurse practitioners/midwives only] Uncertainty of patient’s timing of exposure	1	2	3
Lack of time to discuss Zika with patient	1	2	3
Slow laboratory processing time	1	2	3
Lack of educational materials in patient’s native language	1	2	3
[Ob-Gyns/nurse practitioners/midwives only] Lack of confidence that patients will follow preventative guidance	1	2	3
Patients not following recommendations for follow-up care	1	2	3
Poor communication between obstetric, hospital, or pediatric providers	1	2	3

Q: Thinking about the top barriers, what, if anything, is needed to fully implement guidelines in your practice?

PROBE: How can guidelines be clarified or translated into clear, actionable steps? How can guidelines be more relevant to your patient population?

PROBE: What other support is needed?

PROBE: What, if any, patient education materials are needed?

Q: Generally speaking, how accessible have Zika guidelines been to you?

PROBE: Do you feel the information you need is where you can find it?

PROBE: When you needed Zika recommendations, did you seek them out or were they delivered to you? Do you receive notifications with guidance is updated?

PROBE: What is the best way to deliver guidelines to you, including when they are updated? Where do you prefer to get this sort of information? For example: Do you prefer print, webinar, email, conferences, or something else? How could clinical decision support tools best help you adhere to Zika guidelines?

PROBE: Are you getting resources when you need them?

PROBE: Why, if at all, is there a delay in getting resources you need? (prompt, as needed: Is there a delay due to a lag in relaying guidance, a lack of research with findings to relay or some other reasons?)

PROBE: If you have had questions about guidance, have you had access to a subject matter expert to discuss your questions?

Q: Have you ever encountered inconsistent or conflicting guidance?

PROBE: What were the conflicting documents? What recommendations differed? Was that a challenge for you? How did you handle it?

Q: What, if anything, can be done to improve adherence to Zika guidelines?

PROBE: How can quality of care be improved for patients – including those concerned about or directly affected by Zika?

5. WORKING AMONGST PROVIDERS [20 minutes; 80 mins total]

Now I’d like you to think about how patients navigate the health care system when Zika virus concerns arise.

Q: [Poll question, with open-end option] From what you’ve seen or heard, to what extent are patients making appointments with follow-up providers, as appropriate, if there was suspected Zika exposure during pregnancy?

Patients always make follow-up appointments

Patients usually make follow-up appointments

Patients sometimes make follow-up appointments

Patients rarely make follow-up appointments

Patients never make follow-up appointments

Q: To what extent have procedures been established within your hospital or practice for dealing with follow-up for affected patients?

PROBE: What procedures have been working best?

PROBE: What challenges still exist that prevent appropriate follow-up?

Q: How is relevant information from the prenatal care period communicated to the pediatric care provider?

[For ob-gyns] Are records from prenatal Zika screening or testing available at L&D? What if the patient received prenatal care at a Federally Qualified Health Center?

[For pediatricians] Are records of Zika screening or testing prenatally or at L&D available for pediatric visits?

[For women’s health nurse practitioners/midwives] Are records from prenatal Zika screening or testing available at L&D? What if the patient received prenatal care at a Federally Qualified Health Center?

[For all other nurse practitioners] Are records of Zika screening or testing prenatally or at L&D available as needed for follow-up visits?

Q: [For ob-gyns] To the best of your knowledge, are patients receiving information and guidance from their pediatricians that is consistent with what you communicate with patients?

[For pediatricians] To the best of your knowledge, are patients receiving information and guidance from their ob-gyns that is consistent with what you communicate with patients?

[For women’s health nurse practitioners/midwives] To the best of your knowledge, are patients receiving information and guidance from their pediatricians that is consistent with what you communicate with patients?

[For all other nurse practitioners] To the best of your knowledge, are patients receiving information and guidance from their ob-gyns that is consistent with what you communicate with patients?

PROBE: In what ways is information different?

PROBE: What challenges are created from inconsistent information between pediatricians and ob-gyns?

Q: Overall, how well do you think obstetric and pediatric providers are working together to respond to Zika?

PROBE: What has gone well?

PROBE: What presented challenges? How have those challenges been addressed? What challenges still linger? (prompt, as needed: health privacy concerns, lack of time for follow-up, lack of established communication between providers, lack of transparency of infant/mother providers)

PROBE: How would you recommend doing things differently?

5. LEARNING LESSONS FROM ZIKA [5 minutes; 85 mins total]

I’d like to switch focus and discuss how the reaction to Zika virus can serve as a guide for dealing with future health crises.

Q: What, in your experience, was the most important lesson learned from Zika, particularly related to interpreting guidelines and caring for patients?

PROBE: Did you learn anything from Zika that you think would help you better address future epidemics?

Q: Thinking about the information and resources you used regarding Zika, when preparing for a future health crisis…

What information is most important to provider to healthcare providers like you?

What resources or materials are most useful to share with patients and caregivers?

What methods of delivery are most useful?

What formats are most useful?

Q: What about the response to Zika virus would you NOT like to see happen again?

PROBE: For what reasons was this not a benefit? In what ways did it create a challenge in your practice?

5. Wrap Up [5 minutes; 90 mins total]

And, just before we wrap up…

Q: What, if anything else, would you like to better prepare you related to Zika?

Q: What do you perceive as emerging health threats that may affect you or your patients in the next five years?

Q: Is there anything else that we did not discuss that you would like to add?

That's the end of our session. Thanks very much for your participation. You may close your browser now.

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