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Request for Ambulatory Care CAHPS®

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


Notice of request.


The Agency for Healthcare Research and Quality (AHRQ) is soliciting volunteer sites for the testing of a draft Ambulatory CAHPS® (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® 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® 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® 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 Start Printed Page 51313be 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.


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


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 31/2 inch diskette. E-mail submissions are preferred and will be acknowledged upon receipt.

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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:

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.

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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.


Since 1995, the only ambulatory CAHPS® 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® 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® 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 Start Printed Page 51314survey 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

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Dated: August 7, 2004.

Carolyn M. Clancy,


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[FR Doc. 04-18851 Filed 8-17-04; 8:45 am]