Form 0920- Patient Survey

Attachment B. Patient Survey

Form Approve

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 10 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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 NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (0920-xxxx).

Introduction

Abt Associates is working with the Centers for Disease Control and Prevention (CDC) to evaluate the effects of policies and guidelines on treating chronic pain including the using opioids for chronic pain, and diagnosis and treatment of patients with opioid use disorder (OUD, also known as an opioid addiction) when needed. For the purposes of this evaluation, “chronic pain management policies/guidelines” refers to policies/guidelines that may include prescribing of opioid medicines, nonpharmacologic (non-medicine) therapies like exercise, and/or non-opioid medicines like ibuprofen or acetaminophen for chronic pain, as well as diagnosing and treating OUD.

This 10-minute survey aims to gain a better understanding of your knowledge and experience with your clinic’s use of policies and guidelines about chronic pain management and opioid prescribing, including access to treatment for opioid use disorder, and how you are doing related to your pain and daily functioning. This study is funded by the CDC.

 Consent

• This survey will take approximately 10 minutes.

• Your participation is voluntary. You can skip any question(s) you do not wish to answer, or quit the survey at any time.

• It is OK if you do not wish to answer a specific question. Skipping any questions or quitting the survey will not impact the care you receive from your doctor or health system. There is a small risk of loss of confidentiality. We have many procedures in place to reduce this risk.

• We will keep your information and answers confidential. Your responses will remain anonymous. Neither the CDC nor Abt Associates will have access to your personal information, and your clinician will not be able to see your responses.

• This study has a “Certificate of Confidentiality” from the CDC to protect your privacy. Unless you consent and say it is okay, researchers cannot share or release information that may identify you¹, with a few exceptions² (please see footnotes).

• You will be given $5 as a token of our appreciation.

Thank you for participating in this survey. First, we will start with some basic questions about your background.

Patient characteristics (Source: OMB items; CAHPS)

1. In general, how would you rate your overall physical health?

• Excellent

• Very good

• Good

• Fair

• Poor
  
  
  

2. In general, how would you rate your overall mental health (e.g., emotional, psychological, and social well-being)?

• Excellent

• Very good

• Good

• Fair

• Poor

3. What is the highest grade or level of school that you have completed?

• 8^th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or 2-year degree

• 4-year college graduate

• More than 4-year college degree

4. What is your age?

• 18-29 years

• 30-44 years

• 45-54 years

• 55-64 years

• 65 or older

• Prefer not to answer

5. How do you describe your gender identity?

• Male

• Female

• Male-to-female transgender (MTF)

• Female-to-male transgender (FTM)

• Other gender identity (specify)_____________________

6. Which of the following best represents how you think of yourself?

• Gay (lesbian or gay)

• Straight, this is not gay (or lesbian or gay)

• Bisexual

• Something else

• I don’t know the answer

7. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

8. What is your race?

• American Indian or Alaskan Native

• Asian

• Black or African-American

• Native Hawaiian or other Pacific Islander

• White

9. What language do you mainly speak at home?

• English

• Spanish

• Chinese

• Russian

• Vietnamese

• Portuguese

• German

• Some other language (please print): ___________________________________

Chronic Pain Care History and Awareness of Health Systems’ Policies or Guidelines

10. If you are comfortable, would you mind sharing a little bit about your pain condition? Please describe the condition for which you take (or used to take) prescription opioids that you last saw your primary care clinician about. Examples of prescription opioids include oxycodone (OxyContin®] or hydrocodone (Vicodin®).

____________________________________________________________________________

• I have never taken prescription opioids SKIP TO Q13

11. How long have you been treated for this chronic pain condition with opioids?

• Less than 1 year

• 1-3 years

• 4-5 years

• 5-9 years

• 10+ years

12. Are you currently taking opioids for your chronic pain?

• Yes

• No

13. Did you know that [HEALTH SYSTEM] started a new chronic pain or opioid prescribing policy or guideline in [insert month(s) and year]?

• No, I do not know about this.

• Yes, I know that there has been a new policy/guideline.

14. What changes have you noticed since [insert month(s) and year] in how your clinician treats your chronic pain? Please check all that apply.

• My clinician started telling me that prescription opioids could be addictive and dangerous.

• My clinician discussed and encouraged non-opioid medications like Tylenol® (acetaminophen), Aleve® (naproxen), Advil® (ibuprofen), and/or steroid injections, as a few examples.

• My clinician discussed and encouraged non-medication treatments like exercise, cognitive behavioral therapy, physical therapy, occupational therapy, and/or acupuncture, as a few examples.

• My clinician started asking me more often than before how well my pain was controlled.

• My clinician started asking me more often than before how easily I was able to do the things I like to do.

• I was asked to provide urine samples more often than I had to before.

• My clinician wanted to talk to me about reducing my opioids to a lower dosage.

• My clinician wanted to talk to me about reducing my opioids and stopping them completely.

• I take medications like Xanax® (alprazolam), Valium® (diazepam), or Klonopin® (clonazepam), and my clinician wanted to stop them.

• My clinician offered me a prescription for naloxone, a medication that can reverse an opioid overdose, or told me where I could get naloxone.

• My clinician told me they were concerned that I might be developing opioid use disorder (opioid addiction) and either offered me treatment for it (such as buprenorphine (e.g., Suboxone), methadone, or naltrexone (e.g., Vivitrol)), or offered to refer me to another clinician who could treat it.

• Other: __________________________________

15. Did you experience any of the following with your chronic pain since the new policy/guideline was implemented in [insert month(s) and year]? Please check all that apply.

• I experienced more pain.

• I tried non-opioid medications to treat my pain, like acetaminophen (Tylenol®) or ibuprofen (Motrin® or Advil®), as examples, but they did not help my pain.

• I take non-opioid drugs to treat my pain, like acetaminophen (Tylenol®) or ibuprofen (Motrin® or Advil®), as examples, and I still take opioids too. My pain is under control taking both kinds of medicines.I agreed to stop taking opioids, and my pain is well managed with non-opioid medicines and/or nonpharmacologic (non-medicine) methods.

• My chronic pain did not improve, and I tried other prescription opioid medicines that I got from friends or family members to treat my pain, without my clinician’s knowledge.

• My chronic pain did not improve, and I tried illicit drugs, such as heroin or pills I bought on the street, to treat my pain.

• I changed clinicians, since my previous clinician would no longer treat my chronic pain condition with opioids and I wanted a clinician that would.

• My clinician stopped prescribing opioids for pain completely, but I did not change to a different clinician.

• My clinicians changed my opioid medicines without talking to me about it.

• I was taking prescription opioids for my pain, and I experienced symptoms of opioid withdrawal because of reductions or stopping of my opioid medicines.

• My chronic pain has overall improved.

• My overall quality of life improved.

• I am able to do more without my chronic pain slowing me down.

• I agreed to reduce the dosage of opioids that I take to a lower dosage, and I still take them.

• I agreed to reduce how often I take opioids, and I still take them.

• I was diagnosed with opioid use disorder (opioid addiction), and I am receiving treatment for it (such as buprenorphine (e.g., Suboxone), methadone, or naltrexone (e.g., Vivitrol))

• Yes, other: __________________________________

16.What is the level of satisfaction of your care related to your chronic pain?

• Very satisfied

• Satisfied

• Dissatisfied

• Very dissatisfied

17. Could you tell me more about your satisfaction or dissatisfaction with the care you received for your chronic pain?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________

Your Care from Clinicians

In answering these questions, please think about how your primary care clinician has addressed your chronic pain condition (Source: CAHPS³ adapted items)

18. Over the past 6 months, how often did your primary care clinician listen carefully to you about your chronic pain?

• Never

• Sometimes

• Usually

• Always

19. Over the past 6 months, how often did your primary care clinician explain chronic pain management in a way that was easy to understand?

• Never

• Sometimes

• Usually

• Always

20. Over the past 6 months, how often did your primary care clinician show respect for what you had to say about your chronic pain?

• Never

• Sometimes

• Usually

• Always

Views on Clinician Communication Skills⁴

On a scale from 1 to 5, with 1=poor and 5=excellent, please rate your prescribing clinician on their communication skills in your last encounter regarding your chronic pain condition:

Scale: 1 = poor; 2 = fair; 3 = good; 4 = very good; 5 = excellent.

	1	2	3	4	5
21. Greeted me in a way that made me feel comfortable	⚪	⚪	⚪	⚪	⚪
22. Treated me with respect	⚪	⚪	⚪	⚪	⚪
23. Showed interest in my ideas about my health	⚪	⚪	⚪	⚪	⚪
24.Understood my main health concerns	⚪	⚪	⚪	⚪	⚪
25. Paid attention to me (looked at me, listened)	⚪	⚪	⚪	⚪	⚪
26. Let me talk without interruptions	⚪	⚪	⚪	⚪	⚪
27. Gave me as much information as I wanted	⚪	⚪	⚪	⚪	⚪
28. Talked in terms I could understand	⚪	⚪	⚪	⚪	⚪
29. Checked to be sure I understood everything	⚪	⚪	⚪	⚪	⚪
30. Encouraged me to ask questions	⚪	⚪	⚪	⚪	⚪
31. Involved me in decisions as much as I wanted	⚪	⚪	⚪	⚪	⚪
32. Discussed next steps	⚪	⚪	⚪	⚪	⚪
33. Showed care and concern	⚪	⚪	⚪	⚪	⚪
34. Spent the right amount of time with me	⚪	⚪	⚪	⚪	⚪
35. Staff treated me with respect	⚪	⚪	⚪	⚪	⚪

36. Is there anything that I haven’t asked you regarding your chronic pain and taking opioids that would be important for me to know to help me understand your health system?

• No

• Yes:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________­­_______________

________________________________________________________________________

That completes the survey. Thank you for participating!

1 Unless you say it is okay, researchers cannot release information that may identify you for a legal action, a lawsuit, or as evidence. This protection applies to requests from federal, state, or local civil, criminal, administrative, legislative, or other proceedings. As an example, the Certificate would protect your information from a court subpoena.

2 The Certificate does not protect your information if a federal, state, or local law says it must be reported. For example, some laws require reporting of abuse, communicable (contagious, infectious) diseases, and threats of harm to yourself or others.  The Certificate cannot be used stop a federal or state government agency from checking records or evaluating programs. The Certificate does not stop reporting required by the U.S. Food and Drug Administration (FDA). The Certificate also does not stop your information from being used for other research if allowed by federal regulations.

Researchers may release your information when you say it is okay. For example, you may give them permission to release information to insurers, your doctors, or any other person not connected with the research.  The Certificate of Confidentiality does not stop you from releasing your own information. It also does not stop you from getting copies of your own information. 

3 https://www.ahrq.gov/cahps/index.html

4 Gregory Makoul, Edward Krupat , Chih-Hung Chang. “Measuring patient views of physician communication skills: Development and testing of the Communication Assessment Tool.” Patient Education and Counseling 67 (2007) 333–342.

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