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Physician Survey of Practices on Diet, Physical Activity, & Weight Control: Questionnaire on Administrative Structure

About This Questionnaire

This questionnaire is presented for informational purposes only, and is not intended to be filled out by visitors to this Web site.

You are viewing an accessible version of the contents of this questionnaire. The original questionnaire is available in PDF format.

OMB No. 0925-0583
Expiration Date: 12/31/2010

Conducted by:

Introduction

The Physician Survey of Practices on Diet, Physical Activity, and Weight Control is sponsored by the National Cancer Institute in collaboration with the Office of Behavioral and Social Science Research, the National Institute of Child Health and Human Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and the Centers for Disease Control and Prevention. Obesity, poor diet, and lack of physical activity are recognized as major public health problems in the United States. The Administrator Questionnaire asks about factors that could facilitate or hinder physicians’ practices intended to address these problems. The survey is being sent to a random sample of Family Medicine Physicians, General Internists, Obstetrician/Gynecologists, and Pediatricians, and their associated administrators. The information you provide in this survey will remain confidential to the fullest extent of the law. Your answers will be combined with those of other respondents in reports to NCI and anyone else. Participation is voluntary, and there are no penalties to you for not responding. However, not responding could seriously affect the accuracy of final results, and your point of view may not be adequately represented in the survey findings. Please return the completed survey in the enclosed postage-paid envelope. If another envelope is used, please send to:

Westat
Attn: B. Burroughs, RB 3274
1650 Research Blvd.
Rockville, Maryland 20850-3195

Public reporting burden for this collection of information is estimated to average 20 minutes per response, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0583). Do not return the completed form to this address.

Physician Survey of Practices on Diet, Physical Activity, & Weight Control

Please provide answers to the survey questions based on the patient characteristics, clinical guidelines, and financial arrangements related to the clinical site at which the doctor listed on the cover practices medicine. You may need to obtain information from multiple members of the clinic team.

Survey Instructions

  • Use an X in the box to indicate your answers.
  • If your answer is not adequately represented by available choices, use the box provided in “Other (Please specify):”
  • If you are not sure of an answer, give your best estimate.

Section A. Practice Characteristics

  1. A1. Is this doctor’s office part of a . . .

    Check one box.

    a. Solo practice  → Go to A5 1
    b. Group practice 2
    c. Medical School 3
    d. Hospital 4
    e. Clinic or Community Health Center 5
    f. Other (Please specify): 6
  2. A2. Is this doctor’s office a . . .

    Check one box.

    a. Single specialty practice 1
    b. Multi-specialty practice, where physicians from more than one specialty provide services 2
    c. Other (Please specify): 3
  3. A3. Who owns this doctor’s office?

    Check one box.

    a. One or more physicians or a physician-owned corporation 1
    b. A health system or integrated delivery system 2
    c. A health plan or insurance company 3
    d. Federal, state, or local government 4
    e. A medical school, hospital, or related organization 5
    f. Other (Please specify): 6
    g. Don’t Know 8
  4. A4. About how many part-time and full-time physicians, nurse practitioners, and physician assistants work in this office?

    Please give your best estimate.

    1. Number of part-time and full-time physicians, nurse practitioners, and physician assistants.
    2. Number of physician, nurse practitioner, and physician’s assistant full-time equivalents (FTEs)
  5. A5. Which of the following types of health care professionals work in this office?

    Check all that apply.

    a. Nurse Practitioners or Clinical Nurse Specialist 0 1
    b. Physician Assistants 0 1
    c. Nurses (e.g., RN, LPN, LVN) 0 1
    d. Dieticians/Nutritionists 0 1
    e. Health Educator 0 1
    f. Occupational/Physical Therapists 0 1
    g. Social Workers 0 1
    h. Psychologists 0 1
    i. Medical Assistants 0 1
    j. Other (Please specify): 0 1
  6. A6. Where is this office located?

    Check one box.

    a. Large City (Population over 500,000) 1
    b. Medium City (Population 100,000–500,000) 2
    c. Small City (Population under 100,000) 3
    d. Rural Community 4
    e. Other (Please specify): 5
  7. A7. At this office, approximately how many patient visits with physicians, nurse practitioners, or physician assistants occur during a typical week?

    Please give your best estimate.

    Number of patient visits per week

  8. A8. In this office, approximately what percentage of the patients is . . .

    Please give your best estimate.

      0–5% 6–25% 26–50% 51–75% 76–100% Don't Know
    a. Uninsured 1 2 3 4 5 8
    b. Privately Insured 1 2 3 4 5 8
    c. Medicare Insured 1 2 3 4 5 8
    d. Medicaid Insured 1 2 3 4 5 8

Section B. Clinical Policies & Procedures

  1. B1. In this office, who usually performs the following for patients?

    Check all that apply in each row and each column.

      Measuring weight and height Assessing diet and physical activity Counseling about diet, physical activity, and weight control
    a. Physician 0 1 0 1 0 1
    b. Nurse practitioner or physician assistant 0 1 0 1 0 1
    c. Other staff (Please specify): 0 1 0 1 0 1
    d. No one does this 0 1 0 1 0 1
    e. Don’t know 8 8 8
  2. B2. In this office, is there a standard protocol that requires that each patient have the following assessed?

    Check all that apply in each row and each column.

      Diet Physical Activity Weight
    Yes No Yes No Yes No
    a. At each visit 1 0 1 0 1 0
    b. At new patient visit 1 0 1 0 1 0
    c. Annually 1 0 1 0 1 0
    d. Other timeframe (Please specify): 1 0 1 0 1 0
    e. A standard protocol is implemented ONLY for high-risk patients 1 0 1 0 1 0
  3. B3. Does this office provide preventive medicine/well-patient visits?
    a. Yes, this site provides preventive/well-patient visits 1
    b. No, this office does NOT provide preventive/well-patient visits → Skip to B4 0
  4. B3a. If yes, do these visits include counseling for diet, physical activity, and weight management?
    a. Yes 1
    b. No 0
  5. B4. What type of medical record system does this office use?

    Check one box.

    a. Paper charts 1
    b. Partial electronic medical records (e.g., lab results available electronically,
    but patient history on paper)
    2
    c. In transition from paper to full electronic medical records 3
    d. Full electronic medical records 4
  6. B5. Which of the following mechanisms does this office have to follow up with patients who have received counseling within the practice on diet, physical activity, or weight management?

    Check all that apply.

    a. Verbal reminder from the physician or other staff during an office visit 0 1
    b. Reminder by U.S. mail, telephone, or e-mail 0 1
    c. Personalized web page or other mechanism (Please specify): 0 1
    d. None of these 0 1
    e. Don’t Know 8
  7. B6. Which of the following mechanisms does this office have to follow up with patients who are referred out from your practice for counseling on diet, physical activity, or weight management?

    Check all that apply.

    a. Verbal reminder from the physician or other staff during an office visit 0 1
    b. Reminder by U.S. mail, telephone, or e-mail 0 1
    c. Personalized web page or other mechanism (Please specify): 0 1
    d. None of these 0 1
    e. Don’t Know 8

Section C. Information Resources

  1. C1. Please indicate which of the following information resources on diet, physical activity, or weight control are available in the waiting or exam rooms.

    Check all that apply.

    a. Brochures, pamphlets 0 1
    b. Video 0 1
    c. Flyers for related programs or services (e.g., weight loss or exercise program) 0 1
    d. Books/Journal articles 0 1
    e. Magazines 0 1
    f. No materials are available for diet, physical activity, or weight control 0 1
  2. C2. Does the office have a newsletter that goes out to patients?
    a. Yes → Go to C2a 1
    b. No → Go to C3 0
  3. C2a. In the past 12 months, did any of the newsletters provide information about:

    Check all that apply.

    a. Diet/Nutrition 0 1
    b. Physical Activity 0 1
    c. Weight Control 0 1
  4. C3. Does the office have a website?
    a. Yes → Go to C3a 1
    b. No → Go to D1 0
  5. C3a. If yes, in the past 12 months, did the website provide information about:

    Check all that apply.

    a. Diet/Nutrition 0 1
    b. Physical Activity 0 1
    c. Weight Control 0 1

Section D. Billing & Reimbursement

  1. D1. Do you review or work with billing data on a regular basis?
    a. Yes → Go to D2 1
    b. No → Go to Section E, page 12 0
  2. D2. About what percentage of the office’s revenue is derived from the following sources?

    998 Don’t Know

    Fill in percentage for each row. Total must equal 100%.

      Percentage of Revenue
    a. Fee-for-Service %
    b. Capitation %
    c. Other (Please specify): %
    Total 100%
  3. D3. In this office, what types of coverage do your insured patients have? (If no patients have insurance, please indicate N/A)

    998 Don't Know

    Check one box in each row.

      0–5% 6–25% 26–50% 51–75% 76–100% N/A
    a. Managed Care (HMO/POS) 1 2 3 4 5 0
    b. Managed Care (PPO) 1 2 3 4 5 0
    c. Other (Please specify): 1 2 3 4 5 0
  4. D4. Does this office bill for visits that involve counseling for diet, physical activity, and weight control? (Under some systems, services are provided under capitation and are not billed).
    a. Yes, billed as treatment for a chronic or acute condition 1
    b. Yes, billed as part of preventive medicine/well-patient visit 2
    c. No, not billed 0
    d. Don’t know 8
  5. D5. Do physicians working in this office receive any incentive payments to engage in the following?

    Check one box in each row.

      Yes No Don't Know
    a. Diabetes screening 1 0 8
    b. Cancer screening 1 0 8
    c. Heart disease screening 1 0 8
    d. Diet counseling 1 0 8
    e. Physical activity counseling 1 0 8
    f. Weight counseling 1 0 8

Section E. Personal Characteristics

  1. E1. What is your position or title?
  2. E2. How long have you been with the practice?

    Months or Years (Circle One)

  3. E3. If this survey were available on the Internet as a web-based questionnaire, would you prefer to fill it out online, or is a paper and pencil survey more convenient for you?

    Check one.

    1. 1 I prefer paper and pencil
    2. 2 I prefer a web-based questionnaire
    3. 3 I have no preference
    4. 4 Other (Please specify):

Please add any comments in the space provided. We appreciate your participation and feedback.

Thank you very much. We greatly appreciate your participation. Please return your completed survey in the enclosed postage-paid envelope.

Last Modified: 11 Apr 2014