0920-20PT Moderator Guide-FG_Nurse-NP-PA

ATTACHMENT 3b: MODERATOR’S GUIDE

OMB No. 0920-0572

Exp. Date 08/31/2021

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 90 minutes per response. 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 D-74, Atlanta, Georgia 30333; Attn: OMB-PRA 0920-0572.

MODERATOR’S GUIDE (NURSES, NPs, PAs)

May 6, 2020 FINAL

90-Minute Focus Group With

Nurses, Nurse Practitioners and Physician Assistants

About Tuberculosis*

Group Composition:

Audience	Los Angeles, CA	Houston, TX	New York, NY
Nurses, RN and LPN	1 (non-prescriber)	1 (non-prescriber)
Nurse Practitioner (NP) or Advanced Practice Nurse (APN)			1 (prescriber)
Physician Assistant	1 (prescriber)
Groups Per Location	2 (7participants)	1 (7participants)	1 (7participants)
Total Groups	4 (28 total participants)

DIRECTIONS TO MODERATOR:

• Sections of the guide are marked by gray boxes. Each section is given a time estimate and additional details on rationale or goal of each section.

• Instructions for the Moderator are noted with ALL-CAPS and marked in bold.

• Questions are numbered. Some questions include sub-questions. These are marked by letters.

• Probes are listed as “probes” under the questions. They are listed as additional points to bring up if participant gets off track or does not provide a detailed response.

• TOTAL FOCUS GROUP TIME IS APPROXIMATELY 90 MINUTES

DISCUSSION OVERVIEW:

90 minutes

1. Background & Introductions (10 minutes)

2. Current Practice & Patient Population (17 minutes)

3. General Knowledge & Awareness of TB/Latent TB Infection (18 minutes)

4. Guidelines & Testing of TB/Latent TB Infection (13 minutes)

5. Treatment of TB/Latent TB Infection (10 minutes)

6. Material Review (17 minutes)

7. Wrap-up (5 minutes)

1. BACKGROUND & INTRODUCTIONS (10 MINUTES)

Moderator Introduction (5 min.)

1. Welcome! Thank you for joining today’s discussion. My name is [INSERT]. I’m an independent researcher and moderator with GC Global Research.

2. The sole sponsor of today’s focus group discussion is The Centers for Disease Control and Prevention—CDC. Our conversation today will focus on a health topic.

3. I’m a professional researcher, but not a CDC employee or a subject matter expert on health topics. My role is to facilitate our conversation for the next 90 minutes. Let me tell you a bit about it:

   1. There are no wrong answers. You may have different opinions. That’s ok—all of your experiences and opinions are important and we want to hear from all of you.

   2. Since we are having these groups online, we will need to talk one at a time and let everyone have time to speak. Not everyone has to answer each question, however it’s important that everyone participates throughout this conversation.

   3. We will be showing you information on your screen to look at and respond to.

   4. If at any time, you can’t see the screen well or have difficulty hearing, let me know – we have a technician here who can help us with any technical issues.

   5. Please silence your cell phones and put away portable devices.

   6. If you need to step away from our discussion for any reason, you don’t have to ask for my permission—just step away and come back when you finish.

   7. We are going to look at some materials today, so please grab a paper and pen or pencil so you can jot down any notes.

4. Because privacy is important, I’m going to show you our Privacy Policy. READ:

   1. We will protect your privacy for today’s discussion, and nothing you say will be reported in association with your name.

1. We will use first names during the conversation. You may choose to use a nickname or other name if you prefer.

1. Your participation is voluntary—you do not have to answer anything you are uncomfortable with.

2. Like our technician who is with us today virtually, but who you do not see, a few colleagues are also with me virtually today to watch quietly and take notes.

3. We are audio- and video-recording for transcribing today’s discussion. Because we are speaking with many groups similar to this one, it is important for me to have an accurate record of today’s conversation.

4. We ask that you not share any information, participants’ comments, or participants’ identities with others outside of this group.

Participant Introductions (5 min.)

5. Ok, thanks again for joining the conversation today. We are having discussions with a variety of people. One thing you all have in common is that you are all [INSERT NURSES AND/OR NURSE PRACTITIONERS AND/OR PHYSICIAN ASSISTANTS]. Let’s go around the virtual the table and introduce ourselves to one another. Tell us:

1. Your first name

2. The type of practice setting you work in

2. CURRENT PRACTICE & PATIENT POPULATION (17 MINUTES)

The goal of this section is to warm-up and understand their patient population and how they communicate with them, specific to the at-risk populations included in this project.

Let’s start off by talking about your work and the populations that you see.

1. What does your patient population look like, demographically?

   1. PROBE: What are the ranges of ages you typically see?

   2. PROBE: Do you see patients of all income levels? What about education levels?

2. What are the largest racial and ethnic populations that you see and treat?

   1. What is your best guess as to the ratio of U.S.-born to non-U.S.-born patients that you see?

   2. Are there any specific health concerns that affect this population at higher rates than other populations? LISTEN FOR MENTIONS OF TB/LATENT TB INFECTION

3. About how much time do you spend talking to each patient?

4. What are some ways that you establish trust with a patient in the short amount of time you spend with them?

5. How does your role differ from a physician’s in terms of patient communication?

   1. PROBE: What are you doing that physicians are not?

   2. PROBE: What are physicians doing that you’re not?

6. Within your workplace, are you able to enter an order for TB testing in the electronic system?

7. Can your workplace provide a TB skin test to a patient, or draw blood for TB testing?

   1. IF NO OR DON’T KNOW: Do you know where to refer a patient to get a TB skin test or blood draw for TB?

8. How do you communicate with patients who do not speak English?

9. What are some of the ways that you manage or overcome cultural and/or language barriers that might arise when delivering healthcare to this population?

   1. PROBE: Do you have any tools or resources that help you navigate cultural barriers?

   2. PROBE: Do you rely on any specific educational materials? IF YES: What are they and how do you utilize them?

1. Where do you go to find educational materials?

2. What types/formats of materials do you look for (ex: posters, brochures, flip books, fact sheets, videos, infographics)?

3. GENERAL KNOWLEDGE & AWARENESS OF TB/LATENT TB INFECTION

(18 MINUTES)

The goal of this section is to understand respondents’ knowledge about TB and latent TB infection, including its seriousness, prevalence and risk factors.

Next, I’d like to discuss topics related to specific diseases and infections that you see and treat in your practice.

1. Thinking specifically about your [Chinese/Filipino/Indian/Vietnamese] patient populations, are there certain diseases that you regularly test for? PROBE FOR DIABETES. LISTEN FOR MENTIONS OF TB/LATENT TB INFECTION

   1. What about infectious diseases?

2. SHOW TERMS ON SCREEN: For the remainder of our discussion today, we are going to talk specifically about tuberculosis, or TB disease, and latent tuberculosis infection, or latent TB infection. What first comes to mind when you hear the word, tuberculous? What about latent tuberculous?

   1. PROBE: How familiar are you with TB? What about latent TB infection?

3. Let’s talk about each of these conditions individually. First, let’s discuss TB disease. We would like to get a sense of your familiarity with TB. Don't worry if you do not know a lot of the specifics on the subject.

   1. In your opinion, how serious of a problem is tuberculosis disease in the United States?

      1. PROBE: What about among your patient population?

4. Now let’s talk about latent tuberculosis infection or latent TB infection.

   1. How serious of a problem is latent TB infection in the United States?

      1. PROBE: What about among your patient population? What about in your state? What about in your city?

   2. In your opinion, how common is latent TB infection in the U.S.? What about among your patient population specifically?

   3. What are some of the risk factors for contracting latent TB infection?

      1. PROBE: What are the risk factors that lead to an increased likelihood of latent TB infection developing into TB disease?

   4. How do you diagnose latent TB infection in your practice setting?

      1. What role does the BCG vaccine play in the diagnosis?

      2. PROBE FOR PRESCRIBERS: How familiar are you with the tuberculin skin test, often called the TB skin test? What about the TB blood test?

         1. What are your thoughts around using the skin test, versus the TB blood test? What are pros and cons of each?

   5. IF THEY DO NOT DIAGNOSE OR TREAT IN THEIR PRACTICE SETTING: What would you need to start testing for TB in your practice? What about treating latent TB infection in your practice?

      1. PROBE: What about things like educating of staff on the topic, the alignment of leadership, funding, and EMR prompts, etc.

   6. How familiar are you with the treatment regimens for latent tuberculosis infection?

      1. What various treatment regimens are you familiar with?

      2. PROBE: If you need to look up information about treatment regimens for latent TB infection, what would be your first go-to resource?

         1. PROBE: What about websites? Which websites do you frequent? What about medical apps like UptoDate, Epocrates, or Medscape?

      3. PROBE: Are you familiar with short-course, rifamycin-based, 3 or 4-month latent TB infection treatment regimens, including:

         1. Three months of once-weekly isoniazid plus rifapentine (3HP)

         2. Four months of daily rifampin (4R)

         3. Three months of daily isoniazid plus rifampin (3HR)

Shorter, rifamycin-based treatment regimens generally have a lower risk of hepatoxicity than longer 6 to 9 months of isoniazid monotherapy (6H/9H, respectively

5. SHOW LEVEL-SETTING MATERIAL ON SCREEN: Here is some brief information about tuberculosis. I will read it aloud and then give you a few minutes to review it. Once you’re finished, we will discuss it.

   1. What information surprised you, or was new to you?

   2. What is your reaction to these recommendations?

      1. PROBE: How familiar are you with the recommendations?

4. GUIDELINES & TESTING OF TB/LATENT TB INFECTION (13 MINUTES)

The goal of this section is to explore the prevalence of TB/latent TB infection in their practice, their testing and treatment protocols, and their level of knowledge of the TB/latent TB infection guidelines.

1. Let’s now discuss how much TB and latent TB infection you see in your practice.

   1. Can you estimate the proportion of your patients that you test for TB, both TB disease and latent TB infection? Your best guess is fine.

   2. And of that proportion, how many cases of TB disease have you identified in the last year? What about the last five years? MODERATOR NOTE NUMBER OF CASES AND REFER TO IT IN SECTION V.

   3. And how many of the cases of latent TB infection have you seen in the last year? What about the last five years? Your best guess is fine.

2. What protocols does your practice have in place for TB testing?

   1. If you can, please walk me through the protocols and procedures.

      1. LISTEN FOR KNOWLEDGE OF TESTING OPTIONS, INCLUDING THE BLOOD TEST, AND MENTIONS OF BCG VACCINE AS A CONSIDERATION. PROBE TO DETERMINE IF EHR PROMPTS FOR TESTING AND THE TRIGGERS.

3. Let’s discuss reasons for testing patients for TB. Typically, for what reasons would you consider having your patients tested for TB?

   1. PROBE: What protocols does your practice have in place for testing for TB?

   1. From your perspective, what is the value of testing for TB?

   2. If you can, please walk me through the protocols and procedures.

LISTEN FOR KNOWLEDGE OF TESTING OPTIONS, INCLUDING THE TB BLOOD TEST, AND BCG

1. IF NO PROTOCOL/EXPERIENCE: If you did have a patient you suspected might be at risk for TB or latent TB infection, what steps would you take then?

1. I have a list of factors that will show you on the screen. Pick the factors that would generally prompt you to test for TB if the factor is present.

   1. Patient was born in a country where TB disease is common

   2. Patient has spent time with someone who has TB disease

   3. Patient has a history of incarceration or has worked in a correctional facility

   4. Patient has lived or worked in a long-term care facility, nursing home, or homeless shelter

   5. Patient is HIV positive

   6. Patient has a history of injection drug use

   7. Patient has another illness that weakens their immune system, or is taking medications that suppress the immune system such as corticosteriods.

   8. Patient has been diagnosed previously with latent TB infection

1. What are some other considerations you take into account when deciding to test a patient?

   1. PROBE: What about considerations like benefits/potential complications of the test, insurance, billing, reimbursement, CDC guidelines, EMR, and priorities/policies of your practice?

2. Which TB test do you typically use, the TB blood test or the skin test? For what reasons?

   1. PROBE: What are some reasons you may not test patients with the TB blood test? What if the patient has had the BCG vaccine?

3. Where do you go for trusted sources of information related to TB? LISTEN FOR CDC AND PROBE FOR OTHER CREDIBLE SOURCES

4. I want you to imagine that it’s your responsibility to increase latent TB infection testing in your practice setting. Your goal is to test 100% of your high-risk patients.

   1. What would you need to do to accomplish this goal?

   2. What would you worry about getting in the way of accomplishing that goal?

      1. PROBE: What about clinic-related barriers, like time, training, supplies, costs, insurance, or EMR? What about patient-related barriers, like communication, culture, or stigma?

c) What are some solutions you think might resolve these issues?

5. TREATMENT OF TB/LATENT TB INFECTION (10 MINUTES)

The goal of this is to understand how it is determined to treat patients with TB and/or latent TB infection and the challenges they (and their patients) may face.

1. What considerations are made when thinking about a treatment recommendation?

2. What about for patients who are diagnosed with latent tuberculosis infection specifically?

   1. What types of discussions happen with patients? Who has these discussions with patients?

      1. PROBE: What are the typical patient reactions? What are their concerns?

      2. PROBE: What are some of the things you say or do to help them understand the diagnosis?

   2. Once a treatment is recommended, how do you usually motivate a patient to stay on their treatment to the very end?

      1. What role do the nursing / PA staff play in the adherence or completion?

      2. How do you typically follow up on treatment protocols?

3. Now, imagine again that you are doing more testing for TB, which means you have more patients with positive diagnoses?

1. What would you need to do in order to make it viable for your practice setting to treat these patients?

1. PROBE: What about clinic-related barriers, like time, training, supplies, support staff and capacity to monitor treatment adherence and completion, costs, insurance, or EMR? What about patient-related barriers, like communication, culture, or stigma?

2. PROBE: What about the role of nurses, PAs and other staff for managing side effects, or monitoring treatment, etc.?

2. What are some solutions you think might resolve these issues?

6. MATERIAL REVIEW (17 MINUTES)

The goal of this section is to test messages to motivate (a) testing for TB/latent TB infection and (b) to get treated for latent TB infection.

Now let’s look at some information about TB. The last item on our agenda tonight is to review information and get your feedback. This information was created specifically for healthcare providers like yourself and it is not final. It is important to remember that we want your open and honest feedback. I did not create these messages and won’t feel offended by your opinions. Again, we only want your full and honest opinion.

I am going to show and read aloud to you four sets of statements, one by one. There are several statements in each set. I’d like you to rate each statement using a 1-5 scale, where 1 means not at all compelling and 5 means very compelling,

[SHOW MESSAGE CATEGORIES/SETS ON SCREEN IN ORDER ONE BY ONE. AFTER RESPONDENTS FINISH RATING EACH SET, ASK:]

1. What is your overall reaction to these statements? What is this information telling you?

[SHOW RESPONDENTS THE RESULTS AND DISCUSS MOST AND LEAST COMPELLING STATEMENTS] Now I’m going to show you how you rated the statements and let’s discuss each one briefly. [FOR EACH ONE AS TIME ALLOWS]

2. What did you like about that statement? What about it is compelling?

3. Is there anything that isn’t compelling? For what reasons?

4. Is there anything that is unclear or confusing? Tell me about that.

[AFTER RESPONDENTS REVIEW ALL MESSAGE SETS, ASK:] Of everything you have seen and we have discussed, what information is most important for health care providers like yourself?

7. WRAP UP (5 MINUTES)

Let’s go around the virtual table so I can hear from each of you one at a time before we wrap up today. What advice would you give to CDC for how CDC can support healthcare providers who serve patients at-risk for TB. Specifically,

1. What information would motivate you to test at-risk patients for TB?

2. What information would motivate you to recommend treatment to patients diagnosed with latent TB infection?

MODERATOR TO ASK ANY ADDITIONAL QUESTIONS FROM CHAT AS TIME ALLOWS.

THANK AND DISMISS ONCE ALL QUESTIONS ARE ANSWERED AND EVERYONE HAS BEEN ABLE TO PROVIDE THEIR FINAL COMMENTARY.

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