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Request for Measures of Patients' Ambulatory Care Experiences

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Information about this document as published in the Federal Register.

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Agency for Healthcare Research and quality (AHRQ), DHHS.


Notice of request for measures.


The Agency for Healthcare Research and quality (AHRQ) is soliciting the submission of instruments or items that measure patients' perceptions of the quality of ambulatory care from researchers, health plans and other health care providers, stakeholders, vendors and other interested parties. This initiative is in response to input from stakeholders to revise the CAHPS® tool in order to measure different categories of ambulatory health care to provide useful information to multiple audiences, and to provide performance data that are more actionable for quality improvement than the previous CAHPS® instrument.

AHRQ is initiating the redesign of the CAHPS® health plan instrument to include different levels of ambulatory health care delivery, i.e., services provided by individual primary care clinicians (such as a physicians or nurse practitioners); sites of care (that is a particular geographic location or facility from which care is delivered); 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); through a review of existing instruments that capture the patients' ambulatory care experiences and perceptions at these different levels. 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. Our response to stakeholder input will ultimately provide users with a flexible, modular approach to be known as Ambulatory CAHPS (ACAHPS), to assess the quality of ambulatory care for all the functions listed above at the different delivery levels of the ambulatory care system. Presently, we are interested in receiving instruments and/or survey items that have been used for ambulatory care at the health plan level and that address any of the above-listed aspects of ambulatory care.

At a later time, we plan to ask for items that address a broader array of functions and topics at different delivery levels. However, at this time, please submit only those items directly relevant to the topics or functions specified below in the section on Submission Criteria.


Please submit instruments or items and supporting information on or before July 12, 2004. AHRQ will not respond individually to submitters, but will consider all submitted instruments and items and publicly report the results of the review of the submissions in aggregate.


Submissions should include a brief cover letter, a copy of an instrument or items for consideration and supporting statements and information as specified under the Submission Criteria below. Submissions may be in the form of a letter or e-mail, preferably as an electronic file with an E-mail attachment. Electronic submissions are strongly encouraged. Responses to this request should be submitted to: Charles Darby, Agency for Healthcare Research and quality, 540 Gaither Road, Rockville, MD 20850, Phone: (301) 427-1324, Fax: (301) 427-1341, E-mail:

To facilitate handling of submissions, please include full information about the instrument developer or contact: (a) Name, (b) title, (c) organization, (d) mailing address, (e) telephone number, (f) fax number, and (g) e-mail address. Also, please submit with a copy of the instrument or items for consideration, evidence that it/they meet(s) the criteria set out under the Submission Criteria section below. It is requested that citation of peer-reviewed journal article(s) pertaining to the instrument or item(s) include the title of the article, author(s), publication year, journal name, volume, issue, and page numbers where article appears, may be included but are not required. Please do not use acronyms in your submissions.

Submitters must also provide a statement of willingness to grant to AHRQ the right to use and authorize others to use submitted measures and their documentation as part of a new or revised CAHPS®-trademarked instrument. The new CAHPS® instrument for patient assessment of ambulatory care will, as in the past, be made publicly available, free of charge.

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Charles Darby, Center for Quality Start Printed Page 32560Improvement and Patient Safety, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850; Phone: (301) 427-1324; Fax: (301) 427-1341; E-mail:

Submission Criteria

Instruments submitted should focus on ambulatory care at the health plan level and for these functions:

  • Coordination of care between providers or sites of care for patients with chronic conditions;
  • Shared decision-making or patient involvement in decision-making about health care options and treatment;
  • Availability of information from the health plan to promote consumer decision-making about health care options and treatment;
  • Providing care that is culturally appropriate or that tries to meet the cultural and linguistic needs of patients;
  • Availability and usability of plan-level information on benefits, coverage and out-of-pocket cost to consumers for ambulatory medical services as well as pharmacy services;
  • Availability and usability of consumer information from the health plan that compares individual ambulatory care providers;
  • Availability and usability of consumer information from the health plan to assist consumers in the selection of an individual clinician (primary care or specialist); and,
  • Effectiveness of health plan call center staff and customer service staff.

Measures submitted must meet these criteria to be considered: Capture the patients' experience of ambulatory care; demonstrate a high degree of reliability and validity; and have been used widely, not just in one or two research studies. Submitter's willingness to grant to AHRQ the right to use and authorize others to use the instrument means that the CAHPS® trademark will be applied to a new instrument combining the best features of all the submissions as well as any ideas that may develop from reviewing them. Accordingly, to encourage universal use, free access to any final Ambulatory CAHPS instrument(s), and free access to the instrument's supportive/administrative information as done in the past, is planned. Thus, submitters of items that may be incorporated in the new ACAHPS documents will be required to permit such universal free access to their incorporated item(s). However, item ownership will be protected during testing of the new ambulatory care surveys. AHRQ, in collaboration with expert CAHPS grantees, will evaluate all submitted instruments or items and select one or more either in whole or in part for testing and, if required, modification. AHRQ will assume responsibility for the final instruments as well as any future modifications.

The final instruments will bear the CAHPS® trademark and they will be made freely available for use by all interested parties. Submitters will relinquish exclusive control of any items that appear in the final instrument. As a matter of quality control, there will be warnings that the CAHPS® identification may not be used if any changes are made to the instrument or final measure set without review and permission of the Agency.

Each submission should include the following information:

  • The name of the instrument;
  • Whether the instrument/item(s) is disease or condition specific;
  • Domain(s) of the instrument/items;
  • Language(s) the instrument/item(s) is available in;
  • Evidence of cultural/cross group comparability, if any;
  • Instrument reliability (internal consistency, test-retest, etc.);
  • Validity (content, construct, criterion-related);
  • Response rates;
  • Methods and results of cognitive testing and field-testing;
  • Description of sampling strategies and data collection protocols, including such elements as mode of administration, use of advance letters, timing and frequencies of contacts;
  • A list of where the instrument has been fielded and at what level it has been and/or is being used; and,
  • Evidence addressing the criteria should be demonstrated through submission of peer-reviewed journal article(s) or through the best evidence available at the time of submission.

Submission of copies and existing report formats developed to disclose findings to consumers and providers is desirable, but not required. Additionally, information about existing database(s) for the instrument(s) submitted is helpful, but also not required for submission.

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Since 1995, the only ambulatory CAHPS® survey has been focused on 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® survey beyond the health plan level specifically for group practices and clinician-level surveys.

The idea behind ACAHPS is to provide a 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® Health Plan Survey such as industry standardization and 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 survey instruments and data collection protocols. These surveys will be designed to address the most common applications 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

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Dated: June 3, 2004.

Carolyn M. Clancy,


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[FR Doc. 04-13104 Filed 6-9-04; 8:45 am]