[Federal Register Volume 69, Number 159 (Wednesday, August 18, 2004)]
[Notices]
[Pages 51312-51314]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-18851]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Agency for Healthcare Research and Quality


Request for Ambulatory Care CAHPS[reg] (ACAHPS) Test 
Sites

AGENCY: Agency for Healthcare Research and Quality (AHRQ), DHHS.

ACTION: Notice of request.

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SUMMARY: The Agency for Healthcare Research and Quality (AHRQ) is 
soliciting volunteer sites for the testing of a draft Ambulatory 
CAHPS[reg] (ACAHPS) instrument. This instrument will be part 
of a suite of standardized patient surveys that are reliable, valid, 
and provide a flexible, modular approach to measurement. This goal is 
in direct response to requests from stakeholders to revise the 
CAHPS[reg] tool in order to measure different levels of 
ambulatory health care to provide practical information for quality 
improvement for multiple and more varied audiences. The result will be 
data derived from patients' perspectives that are more actionable for 
quality improvement than the current CAHPS[reg] instrument.
    AHRQ has initiated the redesign of the CAHPS instrument to include 
different levels of ambulatory health care delivery, i.e., services 
provided by individual primary care clinicians (such as physicians, 
physician assistants, or nurse practitioners), sites of care (that is a 
particular geographic location or facility from which care is 
delivered) or group practices (where two or more practitioners legally 
organize as a medical group to deliver care under certain conditions), 
and health plans (the payor of health care services in either fee-for-
service or managed care arrangements). These levels are not necessarily 
relevant to all survey users. The modular approach to the ACAHPS 
instrument allows users to assess the quality of ambulatory care in 
their particular market while maintaining comparability to the CAHPS 
survey users in other markets.
    AHRQ will respond to stakeholder input to provide users with a 
flexible and modular approach to assess the quality of ambulatory care 
for all of the functions at each of the delivery levels listed above, 
using instruments specific to plans, groups or sites, or physicians. 
Presently, we are interested in soliciting volunteers to be test sites 
for the ACAHPS instrument. The instrument will be tested beginning in 
2004 and continuing into 2005.

Testing the ACAHPS Instrument

Survey Method Issues

    The following are some examples to methodological studies that AHRQ 
plans to address during the pilot test of the ACAHPS instrument, and 
which you may be willing to participate in:
    1. Testing of mode effects (mail versus telephone) within levels of 
ambulatory care. Because ACAHPS will be fielded by both mail and 
telephone it is a primary concern to test and revise the instrument in 
these two modes in order to ensure comparability across these modes.
    2. Testing in other modes. We are also interested in testing ACAHPS 
administration in other modes to assess mode effect and response rates.
    3. Testing the use of screener items versus non- screener items. 
CAHPS[reg] surveys traditionally use some screener items to 
establish whether the respondent falls within a particular category to 
determine whether a question is appropriate or whether the response in 
meaningful. Through additional testing of the draft instrument, it can 
be determined whether screeners are necessary and appropriate.
    4. Assessing the impact on measurement of similar concepts when 
using a reference period of care versus visit-specific care. Some 
surveys at the physician level and group level use a visit-specific 
reference for survey items. Others use a reference period (e.g., the 
last six months).
    5. Testing the adequacy of different response scales. We wish to 
test the benefits of scales of differing lengths (e.g., four vs. six 
points).
    6. Assessing supplemental item placement. We wish to test the 
effects of embedding additional questions within the ACAHPS instrument.
    7. Testing the equivalence of the English and Spanish versions of 
the draft instrument.
    8. Assessing the correlation of survey measures with clinical 
measures of quality.
    9. Testing the effect on response rate of different survey 
materials, taking into account incremental changes in cost. There is 
some evidence in the survey research literature that response rate can

[[Page 51313]]

be influenced by the type of survey materials used. As a general rule, 
impersonal materials from a source of lower status will result in lower 
response rates than personalized materials from a source of higher 
status. Cost could be an issue, as personalized materials may cost more 
than impersonal materials.
    10. Psychometric analyses to evaluate the instrument. Examples of 
characteristics to be evaluated are:
     Quality of item responses (missing item rates, skip 
pattern errors);
     Factors associated with item response rates;
     Factors associated with survey response rates;
     Construct validity of composites and ratings;
     Internal consistency;
     Language equivalence;
     Components of variance; and
     Case mix adjustment.
    11. Assessing sampling and survey operations procedures.

Criteria for Additional Test Site Selection

    While AHRQ would ideally like to provide wide access to the survey 
for testing, resource limitations require the establishment of some 
selection criteria. Test sites must be able to provide the resources 
for data collection using the ACAHPS survey and agree to submit the 
data to a central repository for analysis. Ambulatory care plans, 
groups, and physicians may volunteer to participate in the testing 
program individually, or in a group, in cooperation with an association 
or other coalition. Potential testing sites will be chosen based on 
their ability to meet the analytic needs of the ACAHPS development 
effort. Thus, selection from among potential candidate sites will be 
made using the practical criteria enumerated below. Criteria for 
selection of the voluntary test sites are designed to achieve diversity 
in the characteristics of the sites, obtain the most reliable and valid 
data possible, and to maximize the use of limited resources allotted 
for this work.
    For selection, a test site must:
    1. Be able to pay the full cost of data collection and database 
creation using specifications provided by AHRQ;
    2. Be able to field the survey within the timeframe specified by 
AHRQ to be determined at the time of selection (Most of the testing 
will be done in 2004 and 2005. Applicants should indicate their ability 
to carry out the work during those periods.);
    3. Employ a survey vendor with an established record of patient 
survey experience;
    4. Be able to provide an adequate sample size to meet the needs of 
analyses;
    5. Be able to adapt survey implementation as requested by AHRQ to 
meet the needs of the experimental design; and
    6. Be able to provide a person to coordinate the test site work 
with AHRQ.
    Selection of test sites will be determined at the sole discretion 
of AHRQ.
    Information Requirements: To volunteer to participate as a 
voluntary test site, please provide the following information:
    1. Volunteer site(s) name(s) and location(s).
    2. Contact person information including name and title, address, 
telephone number, fax number and e-mail address.
    3. Coordinator for site data collection information (if different 
from contact person) including name and title, address, telephone 
number, fax number and e-mail address.
    4. Indication of which studies you will or will not be willing to 
participate in (See list of possible studies in Survey Method Issues 
under Testing the ACHPS Instrument.).
    5. Number of plans/groups/sites/physicians proposed for inclusion 
in the testing.
    6. Evidence that plan/group/site/physician is willing to 
participate (i.e., acknowledgement or confirmation from senior 
administrator).
    7. Average number of patient visits per month.
    8. Number of patients.
    9. Name of current surveys being used by the site and modes of 
administration of each survey used.
    10. Name of current survey vendors working with site(s).
    11. Statement or affidavit indicating authorization to commit the 
organization(s) to pay the specific estimated cost of sample selection, 
data collection, database preparation and coordination with AHRQ.
    12. Current schedule for data collection of patient survey data, if 
you have one.
    13. Process and schedule for selecting a vendor for the proposed 
testing or name of vendor already selected.

DATES: Please submit requested information on or before October 18, 
2004.

ADDRESSES: Submissions should include a brief cover letter and the 
requested information about the potential site(s). They may be in the 
form of an e-mail with attachments, or a letter, preferably with an 
electronic file in a standard word processing format, (e.g., Microsoft 
Word or Word Perfect) on a 3\1/2\ inch diskette. E-mail submissions are 
preferred and will be acknowledged upon receipt.

FOR FURTHER INFORMATION CONTACT: E-mail responses to this request 
should be submitted to, or for further information contact: Charles 
Darby, Agency for Healthcare Research and Quality, 540 Gaither Road, 
Rockville, MD 20904, Phone: (301) 427-1324, Fax: (301) 427-1341, E-
mail: [email protected].
    In order to facilitate handling of submissions, please include all 
requested information about the candidate facilities. Please do not use 
acronyms. Electronic submissions are strongly encouraged.

SUPPLEMENTARY INFORMATION: There are several functional areas of 
ambulatory care that existing instruments (or items) speak to at 
specific delivery levels, but presently, not every level of ambulatory 
care delivery is addressed. Functional areas include: access; 
communication; courtesy and respect; shared decision making; 
coordination/integration of care; health promotion and education; 
customer service and decision support. Some functions are specific to 
one delivery level, while others are the shared responsibility of 
multiple levels of care. These functions are assessed because they are 
necessary in maintaining high quality care, they have been determined 
to be important to consumers in selecting health care, and they are 
aspects of care for which consumers are the best or only judge.

Background

    Since 1995, the only ambulatory CAHPS[reg] survey has 
been focused on the health plan level, though there are different 
versions across types of plans from fee-for-service through HMOs, as 
well as optional modules. Significant stakeholder interest has emerged 
in using a standard CAHPS[reg] survey beyond the health plan 
level specifically for group practices and clinician-level surveys.
    The idea behind ACAHPS is to provide flexible, modular approach to 
assessing the quality of ambulatory care at different levels of the 
health care system while still retaining the valuable aspects of the 
current CAHPS[reg] Health Plan Survey such as industry-wide 
standardization of measures for comparability.
    Although many combinations of ACAHPS modules are possible, the 
CAHPS Consortium plans to simplify the task of constructing a survey by 
developing several sets of pre-packaged

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survey instruments and data collection protocols. These surveys will be 
designed to address the most common uses based on the market research 
completed in 2003 as well as the on-going input from stakeholders. We 
will also provide guidelines for reporting the results of these surveys 
to external and internal audiences.
    In addition, we will design some simple decision trees to help 
users assess their needs and recommend a prepackaged survey or help 
users to build their own using the ACAHPS modules. Technical assistance 
will continue to be offered from the CAHPS-SUN Helpline, 1-800-492-9261 
and the Web site located at www.cahps-sun.org.

    Dated: August 7, 2004.
Carolyn M. Clancy,
Director.
[FR Doc. 04-18851 Filed 8-17-04; 8:45 am]
BILLING CODE 4160-90-M