2020 Q3 Emergency NHIS SSA 06172020

Emergency Request

Changes to 2020 National Health Interview Survey in light of Novel Coronavirus (2019-nCoV)

Request for OMB approval

OMB No. 0920-0214, Expiration Date 12/31/2020

Contact Information:

Stephen Blumberg

Division of Health Interview Statistics

National Center for Health Statistics/CDC

3311 Toledo Road

Hyattsville, MD 20782

301.458.4107 (voice)

301.458.4035 (fax)

swb5@cdc.gov

June 17, 2020

Table of Contents

1. Circumstance Making the Collection of Information Necessary

2. Purpose and Use of Information Collection

3. Use of Improved Information Technology and Burden Reduction

4. Efforts to Identify Duplication and Use of Similar Information

5. Impact on Small Businesses or Other Small Entities

6. Consequences of Collecting the Information Less Frequently

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

8. Comments in Response to the Federal Register Notice and

Efforts to Consult Outside the Agency

9. Explanation of Any Payment or Gift to Respondents

10. Protection of the Privacy and Confidentiality of Information Provided

by Respondents

11. Institutional Review Board (IRB) and Justification for Sensitive Questions

12. Estimates of Annualized Burden Hours and Costs

13. Estimates of Other Total Annual Cost Burden to Respondents

or Record Keepers

14. Annualized Cost to the Federal Government

15. Explanation for Program Changes or Adjustments

16. Plans for Tabulation and Publication and Project Time Schedule

17. Reason(s) Display of OMB Expiration Date in Inappropriate

18. Exceptions to Certification for Paperwork Reduction Act Submissions

Attachments

A. COVID-19 Questions

B. Proposed Uses of the Data and Duplication with Other Surveys

C. Power Calculations

D. ICR 0920-0214 SSA

NCHS National Health Interview Survey

This is a request for an emergency approval for the addition of COVID-19 related content and modification of field procedures for the National Health Interview Survey (NHIS) (OMB No. 0920-0214, Exp. Date 12/31/2020), conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) specifically in response to the ongoing Coronavirus pandemic and COVID-19 crisis.

NCHS is requesting this emergency clearance because these modifications to the field procedures are necessary to enable the NHIS to adapt to rapidly changing field conditions and continue to collect high quality data on the 2020 subject areas previously approved. These changes include 1) an immeditate transition to telephone data collection until field conditions improve for in-person interviewing, and 2) the addition of a sample of 2019 NHIS respondents starting in August 2020. In addition to providing a representative sample of adults with robust contact information for telephone interviews, the follow-back with the 2019 NHIS respondents will enhance the reliability of comparisons between 2019 and 2020, which will be of particular interest given the pandemic.

NCHS is also requesting this emergency clearance to add COVID-19 related content that will help researchers and policymakers better understand the coronavirus pandemic. The addition of new content now, rather than several months from now, will improve the precision of our estimates; precision is a function of total sample size, so precision will be improved if the new content is added as soon as possible (July 2020). The COVID-19 questions will also be included in the NHIS revision package that will be posted for public comment later this year so that the questions can continue into 2021; this will further improve the precision because we will be able to combine data from 2020 with data from 2021.

This request is to modify the NHIS OMB clearance package to (1) add COVID-19 related content to the NHIS and (2) modify data collection procedures to adapt to changing field conditions due to COVID-19.

Addition of COVID-19 related content

This request adds 31 COVID-19 related items to and remove 4 lung cancer items from the National Health Interview Survey (NHIS) beginning July 1 and ending December 31. Six of the 31 items are sponsored by the National Institute for Occupational Safety and Health (NIOSH) and 4 are sponsored jointly by the National Cancer Institute (NCI) and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).

The following is a summary of the questions to be added to the NHIS Quarter 3 questionnaire and intended to continue on the NHIS questionnaire through the end of 2021:

• Add 4 questions on COVID-19 testing and symptoms including doctor-diagnosed COVID-19, testing-confirmed COVID-19, and severity of symptoms of COVID-19

• Add 2 items on immunosuppression including medical treatments or medical conditions that weaken the immune system

• Add 4 items on access to care including delayed care, unmet need and telehealth use due to the pandemic

• Add 4 items on access to cancer care including: being in treatment for cancer; changes, delays or cancellations of cancer treatment because of the pandemic; needing ongoing monitoring or other care; and interruption of such care because of the pandemic (sponsored by NCI and NCCDPHP)

• Add 4 items on access to caregiving including unmet need for skilled home care because of the pandemic, receipt of home care from family members or friends, and having unmet need for this informal care because of the pandemic

• Add 2 items on social support including how often one gets social support and how that amount compares to social support received 12 months ago

• Add 6 items on workplace social distancing including how often work requires interactions closer than 6 feet to others and the extent to which this changed due to social distancing measures (sponsored by NIOSH)

In addition, there are 5 core items that have been fielded on the NHIS before and were scheduled to rotate onto the NHIS in 2021. NCHS intends to add them early, in July 2020, in order to maximize precision of resulting estimates.

• Add 3 items on underlying health conditions including weak or failing kidneys, hepatitis, cirrhosis or any kind of long-term liver conditions

• Restore 2 items on the impact of chronic pain including how often pain limits daily activities, and the impact on family and significant others (previously fielded as part of the 2019 rotating core)

Deletion of questions planned to be dropped from the NHIS Quarter 3 Questionnaire

• Remove 4 questions on CT scans to screen for lung cancer. Consistent with CDC guidelines to defer non-urgent care during the COVID-19 pandemic, the American College of Chest Physician released a statement recommending both the initiation of CT scans and annual CT scans to check for lung cancer be deferred. Therefore, the questions about receipt of CT scans to check for lung cancers are no longer appropriate measures of best practices in lung cancer screening.

The burden hours associated with these modifications to the questionnaire is expected to be 1,275 as described in section 12. The additional sample adult and sample child questions for the 2020 Q3 NHIS are shown in Attachment A.

Modification of data collection procedures

Data collection for the NHIS shifted from personal visit to telephone data collection due to COVID-19 in the middle of March. Data collection has continued by telephone since then. This shift in data collection modes has enabled the NHIS to continue interviewing new sample, but has resulted in a reduction of the response rate from approximately 60% to about 40%.

We are requesting clearance to conduct a telephone follow-back with 2019 NHIS sample adults using the 2020 NHIS quarter 3 questionnaire described in this emergency clearance package. This sample adult follow-back will make it possible to compare the health of these sample adults in the year prior to the pandemic with their health after the start of the pandemic. The follow-back can be used to understand any changes in health insurance coverage, health care use and utilization, and health related behaviors over time.The follow-back would also provide a vehicle for NCHS to collect data in the event that in-person data collection remains suspended for a prolonged period of time due to the pandemic.

The burden hours associated with administering the 2020 questionnaire (including the COVID-19 items) to the 2019 NHIS sample adult is estimated to be 14,247.

1. Circumstance Making the Collection of Information Necessary

The NHIS is conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC), to comply with the NCHS mandate under 42 USC 242k to collect, on an annual basis, statistically valid data on the amount, distribution, and effects of illness and disability in the population and on the utilization of health care services for such conditions. The NHIS has been conducted every year since 1957. The NHIS sample adult and sample child questionnaires include annual core content that is scheduled to be fielded every year, rotating content that is fielded periodically, emerging content to address new topics of growing interest to NCHS, CDC, and DHHS, and sponsored content that is fielded when external funding is available. Please refer to the currently approved Information Collection Request (ICR) for the National Health Interview Survey (OMB Control No. /ICR Reference No. ICR 0920-0214) for more information on the design of the NHIS.

The United States is currently suffering from an outbreak of a novel Coronavirus (SARS-CoV-2). On January 31, 2020 the Secretary of Health and Human Services determined that this outbreak was a public health emergency. As of June 14, 2020 the Centers for Disease Control and Prevention reports 2,063,812 cases and 115,271 deaths from Coronavirus Disease 2019 (COVID-19). The Centers for Disease Control and Prevention, of which the National Center for Health Statistics is a component, is one of the federal agencies responsible for the federal response to this epidemic.

Congruent with its mission to monitor the health of the United States population and its access to and use of health care, the NHIS proposes to add questions that will increase our understanding of the populations during the coronavirus pandemic, including on their access to and receipt of needed health care. The NHIS provides an opportunity to examine health status during the coronavirus pandemic because of the wealth of information that is already collected about the health of NHIS respondents. For example, the NHIS can be used to examine whether people with a variety of chronic health conditions had different experiences during the pandemic. The NHIS will rather offer a retrospective examination of health changes and challenges experienced by U.S. households during the pandemic.

The Census Bureau suspended in-person data collection on March 19 due to the pandemic, and there is likely to be continued disruption to in-person data collection throughout 2020. Since March 19, NHIS interviews have been conducted by telephone where it is possible to match addresses to a phone number. There are concerns that telephone interviews with the existing address-based sample may not adequately cover the population. to address this concern, we are also requesting clearance to conduct a telephone follow-back with NHIS sample adults interviewed in 2019. The follow-back makes it possible to compare the health of these sample adults in the year prior to the pandemic with their health after the start of the pandemic. The follow-back also provides an alternative vehicle for NCHS to collect high-quality data in the second half of 2020, when in-person data collection still may not be possible in some areas of the country. This follow-back will recruit a sample known to yield high-quality representative estimates; as such it may provide insight regarding potential differences in non-response bias between 2019 and 2020 due both to methods and circumstances.

2. Purpose and Use of Information Collection

Addition of COVID-19 related content

Adding content to address COVID-19 beginning in quarter 3 of this year will improve the precision of the estimates from the data. All of the content being added will continue through the end of 2021. The addition of these questions fulfill the mandate of the NHIS to collect statistically valid data on the amount, distribution, and effects of illness and disability in the population and on the utilization of health care services for such conditions. The additional survey questions will address three general research areas about the (1) the effects of the disease on health outcomes, (2) access and utilization of health care during the pandemic, and (3) the use of safety measures to prevent the spread of COVID-19.

Table 1 summarizes the uses of the data and duplication with other surveys. See Attachment A for the full list of proposed items, Attachment B for more details on their expected use, and C for the precision of the estimates produced from the data.

Table 1. Summary of items included in the emergency package.

Items	Uses of the data	Duplication with other surveys
Positive COVID-19 cases	Understand health outcomes for people with COVID-19 Future research on association between health factors and mortality	Other national surveys and surveillance systems may include questions on these constructs, but these questions are still needed on NHIS to serve as covariates in analyses of health, health care, and well-being outcomes.
Underlying health conditions and Immunosuppression	Used along with other chronic conditions already captured on the core NHIS to identify persons with chronic conditions that increase their risk for complications from COVID-19 Assess the prevalence of comorbidities among COVID-19 survivors who had doctor-diagnosed COVID-19 or testing-confirmed COVID-19 Provide a clearer understanding of health outcomes during the pandemic.	These questions are part of the rotating core content for the NHIS, already scheduled to appear in the 2021 NHIS.
Access to care	Examine the prevalence of persons with unmet needs and whether historic demographic inequities in access to care are widening. Examine the prevalence of telehealth use, the prevalence of telehealth use as a substitute for in-person appointments during the coronavirus pandemic, and whether certain subgroups are more likely to use telehealth.	Two questions on delayed care and foregone care are included on the COVID-19 Household Pulse Survey, conducted by the Census Bureau. Question on foregone care is also included on the Current Population Survey starting in May. Inclusion of these items permits continued monitoring of the prevalence of delayed and foregone care later in 2020 and examination of these prevalence estimates in the context of other health care access ask about on the NHIS. The Research and Development Survey (RANDS), conducted by NCHS’s Collaborative Center for Questionnaire Design and Evaluation Research, will include access to care items and provide information on respondent’s understanding of this construct. The first telehealth question also is proposed for RANDS, but with a 2-month reference period.
Access to cancer care	Examine the extent to which cancer patients and survivors had their active cancer treatment and other cancer-related care disrupted during the coronavirus epidemic.	No duplication with other surveys
Access to skilled and informal caregiving	Estimate the prevalence of problems obtaining needed caregiving.	Questions from the Behavioral Risk Factor Surveillance System (BRFSS) Caregiving Module were used as a resource in constructing these items. The proposed NHIS questions focus on identifying persons receiving care and are more appropriate for a survey that includes extensive core content on disability and functioning.
Social support	Estimate the prevalence of adults who rarely/never receive needed social support, and the prevalence of adults who are receiving less social support than they were receiving 12 months earlier.	From 2005-2017, one of our questions was part of a BRFSS optional module titled “Emotional Support and Life Satisfaction.”
Impact of chronic pain	Anxiety can also be a root cause of pain and amplify pain perception and suffering. Anxiety related to the coronavirus pandemic has the potential to exacerbate chronic pain and its impact.	These questions were part of the rotating core content in 2019 and are scheduled to appear again in 2021.
Social distancing at current or most recent job.	Along with information about industry and occupation already collected in the NHIS, the proposed questions will be used to understand the ability of different industry sectors to implement social distancing guidelines. This information may be used to target interventions in future outbreaks that can benefit from social distancing measures.	Starting in May, the Current Population Survey (CPS) will include one item on working from home in the past 4 weeks because of the coronavirus pandemic. The U.S. Department of Labor’s Occupational Information Network (O*NET) can also be used to identify occupations with the highest risk of virus transmission. However, O*NET cannot reflect the reality of social distancing practices or possibilities as they have played out in the context of the COVID-19 pandemic and O*NET’s representativeness is unknown.

The Research and Development Survey (RANDS), conducted by NCHS’s Collaborative Center for Questionnaire Design and Evaluation Research, will include the foregone care question and provide information on respondent’s understanding of this construct. The findings from RANDS wil assist the NHIS in interpreting the questions and understanding data quality. If suggested by the results of RANDS, we may consider rewording the questions later in the year to address any data quality issues.

2019 Sample Adult telephone follow-back

The primary goal of the sample adult follow-back is to provide more reliable estimates of change over the past year. The production NHIS provides a cross-sectional picture of the health of the U.S. population before and after the start of the pandemic. The sample adult follow-back will provide more reliable estimates of change by comparing the health of sample adults in the year prior to the pandemic with their health after the start of the pandemic. For example, the follow-back could be used to understand any changes in health insurance coverage, health care use and utilization, and health related behaviors.

The data from the follow-back survey could also be used to provide a larger sample size for 2020 (if the production data can be combined with the followback data) or a second set of 2020 estimates to be used in conjuction with the 2020 NHIS production estimates to better understand bias introduced by telephone data collection. It is unclear how many sample addresses we will be able to successfully match to phone numbers for the 2020 production NHIS, however, we know that we have valid phone numbers for about 97% of the 2019 NHIS sample. The sample adult follow-back will recruit a sample known to yield high-quality representative estimates; as such it may provide insight regarding potential non-response and coverage bias in the 2020 production sample interviewed by telephone.

The follow-back also provides a vehicle for NCHS to continue to collect high quality data on the 2020 subject areas previously approved. This may be particularly important if in-person data collection remains suspended for a prolonged period of time due to the pandemic and there are data quality concerns for the 2020 production NHIS.

3. Use of Improved Information Technology and Burden Reduction

The questions related to the COVID-19 pandemic will be collected in the same manner as the NHIS. Like in past years, the survey will be conducted by Computer Assisted Personal Interview (CAPI), using Blaise software, which reduces the time required for collecting, transferring, processing, and releasing data. CAPI usually reduces the average duration of interviews compared to a paper questionnaire with identical content. Please refer to the currently approved Information Collection Request (ICR) for the National Health Interview Survey (OMB Control No. /ICR Reference No. ICR 0920-0214) for more information on the design of the NHIS.

4. Efforts to Identify Duplication and Use of Similar Information

NCHS staff in the NHIS program have discussed the addition of questions related to the COVID-19 pandemic with staff from the Bureau of the Census, the Bureau of Labor Statistics (BLS), the National Cancer Institute (NCI), the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), the National Institute for Occupational Safety and Health (NIOSH), and the National Center for Immunization and Respiratory Diseases (NCIRD). No concerns about duplication were identified.

For the newly proposed questions, Attachment B provides information about any duplication of effort between the NHIS and other surveys. While other surveys are also adding questions related to the COVID-19 pandemic, none can leverage the detailed demographic and health information already obtained through the NHIS.

5. Impact on Small Businesses or Other Small Entities

The data are collected from households; their collection does not involve any small businesses or other small entities.

6. Consequences of Collecting the Information Less Frequently

The NCHS intends to add the supplemental questions related to the COVID-19 pandemic to the regular collections of the NHIS for the upcoming 180 days. The data will supplement the health information already collected in the NHIS. The COVID-19 questions will continue into 2021 and will be part of the NHIS revision package that will be submitted later this year.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

Collection of the NHIS questions related to the COVID-19 pandemic and resulting data is conducted in a manner consistent with the guidelines in 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

A. This is an emergency request, and a Federal Register Notice will be published after OMB approval.

2. During the development of the NHIS questions related to the COVID-19 pandemic, NCHS has consulted several experts from several agencies:

Lisa McGuire, Lead

Alzheimer’s Disease and Healthy Aging Program,
Division of Population Health

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Toni Alterman, Senior Epidemiologist

Division of Field Studies and Engineering

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Tim Bushnell, Economist

Economic Research and Support Office

National Institute for Occupational Safety and Health

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Rafael Harpaz (retired)

Division of Viral Diseases

National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Jennifer Croswell, Medical Officer

Healthcare Assessment Research Branch

Healthcare Delivery Research Program

Division of Cancer Control and Population Sciences

National Cancer Institute

National Institutes of Health

9000 Rockville Pike

Bethesda, Maryland 20892

Mary White, Chief

Epidemiology and Applied Research Branch

Division of Cancer Prevention and Control

National Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Lindsay Howden

Survey Director, National Health Interview Survey

Bureau of Census

Department of Commerce

Washington, D.C. 20233

9. Explanation of Any Payment or Gift to Respondents

There are no payments or gifts provided to respondents.

10. Protection of the Privacy and Confidentiality of Information Provided by Respondents

Data collected through the questions related to the COVID-19 pandemic will be protected in the same manner as other data collected in the NHIS.

Respondents are read the following Assurance of Confidentiality

We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

See Attachment D ICR 0920-0214 SSA for more extensive information on how NHIS data are protected.

11. Institutional Review Board (IRB) Review and Justification for Sensitive Questions

The NHIS was determined to be a public health surveillance activity under the 2018 requirements of the Common Rule (45 CFR 46.102(l)(2)). Institutional Review Board approval is not required.

The questions related to the COVID-19 pandemic proposed for inclusion in the NHIS are not of a sensitive nature and do not concern matters that are commonly considered private.

12. Estimates of Annualized Burden Hours and Costs

1. Time Estimates

Adding the 31 COVID-19 pandemic items and deleting the 4 lung cancer items is expected to add a net total of 1,275 annualized burden hours to the NHIS, 1,125 to the Sample Adult interview and 150 to the Sample Child interview.

Administering the 2020 questionnaire (including the COVID-19 items) to the 2019 NHIS sample is expected to add 14,247 annualized burden hours.

The total annualized burden hours for the modifications to the NHIS Q3 questionnaire and the administration of the questionnaire to the 2019 Sample Adult respondents is expected to be 15,522 annualized burden hours.

Estimated Annualized Burden Hours

Type of Respondent	Form Name	Number of Respondents	Number of Responses per respondent	Average Burden per Response (in hours)	Total Burden Hours
Sample Adult	COVID-19 Items	13,500	1	5/60	1,125
Adult Family Member	COVID-19 Items Sample Child	4,500	1	2/60	150
Sample Adult	2019 Follow-back	16,129	1	53/60	14,247
Total					15,522

B. Cost to Respondents

At an average wage rate of $21.00 per hour, the estimated annualized cost for the 1,275 burden hours for the additional COVID-19 items is $26,775. This estimated cost does not represent an out of pocket expense but represents a monetary value attributed to the time spent doing the interview.

At an average wage rate of $21.00 per hour, the estimated annualized cost for the 14,247 burden hours for administering the 2020 questionnaire (including the COVID-19 items) to the 2019 NHIS sample is $299,187 .

Estimated Annualized Burden Costs

Type of Respondent	Form Name	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Sample Adult	COVID-19 Items	1,125	$21.00	$23,625
Adult Family Member	COVID-19 Items Sample Child	150	$21.00	$3,150
Sample Adult	2019 Follow-back	14,247	$21.00	$299,187
Total	$325,962

13. Estimates of Other Total Annual Cost Burden to Respondents or Record keepers

There are no additional costs to the respondents other than their time to participate.

14. Annualized Cost to the Federal Government

As shown in the table below, the annual cost of the NHIS is estimated to be about $42 million, the same as for the 2019 survey. This includes costs to NCHS directly and to its fieldwork contractor, the Bureau of the Census. For NCHS, the estimated cost for annual data collection is about $9 million. This cost includes work on survey design, evaluation, analysis, comparability studies, coding, processing, questionnaire design laboratory testing, field pretests, weighting, and estimation, printing of survey materials, and staff observation costs (travel and per diem). It is estimated that the annual Census Bureau costs for survey planning, design, and data collection for will be about $33 million, which is transferred to the Census Bureau through an Interagency Agreement.

Annual Survey Costs 42 million

U.S. Bureau of the Census 33 million

(Interagency Agreement)

Sampling 4.5 million

Survey Management 1.5 million

Field Operations 23.5 million

Data Editing 1.5 million

Programming and IT 2.0 million

National Center for Health Statistics 9 million

Approximately $9 million of these costs are provided to NCHS through Interagency Agreements with survey sponsors.

15. Explanation for Program Changes or Adjustments

The burden hours associated with adding the 31 COVID-19 pandemic items and deleting the 4 lung cancer items is anticipated to increase the overall burden of the Sample Adult Questionnaire from 48 to 53 minutes. The Child Questionnaire is expected to increase from 28 to 30 minutes. The overall burden times for other data collection instruments will not be impacted by the proposed modifications.

The burden hours associated with modifying the current 2020 Quarter 3 instrument and administering the 2020 Questionnaire (including the COVID-19 items) to the 2019 sample is expected to increase the overall burden from 33,921 to 49,443 hours.

16. Plans for Tabulation and Publication and Project Time Schedule

NCHS plans to summarize the findings from the questions related to the COVID-19 pandemic and make them available to the public as soon as is practicable. The raw data will also be released as public-use microdata files June, 2021.

17. Reason(s) Not to Display OMB Expiration Date

The expiration date will be displayed.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

The certifications are included in this submission.

16