Form #1 Form #1 Pretest

C

ID: ___________

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHPS III Reports Team Experimental Research:

Web Pre-Exposure Survey for Consumer Choice Study Round 2

1. A health care provider is a doctor, nurse practitioner, or physician’s assistant. Have

you ever had to pick a health care provider for your own medical care?

□ YES

□ NO

2. Information comparing different doctors, hospitals, or health insurance plans is available in different places. For example, it might be given out at work, come to your home by mail, appear in a newspaper or magazine, or be found on an Internet web site. In the past 12 months, do you remember seeing any information comparing different doctors, hospitals or health plans?

□ YES

□ NO  IF NO, GO TO #6

□ Not sure

3a. Did you see any information comparing the quality among different doctors in the past 12 months, or not?

□ YES

□ NO  IF NO, GO TO #4

□ Not sure

3b. If YES, which, if any, of the following specific information comparing the quality among different doctors have you seen in the past 12 months? [Check all that apply.]

□ Surveys about patients’ experiences with their doctor

From a scientific survey of each doctor’s patients.

□ Ratings of how well doctors care for people with particular illnesses

From records of the care doctors provide to patients with certain common medical conditions.

□ Written reviews from patients about their experiences with their doctor

These reviews are often posted on web sites by patients who take the time to provide feedback about their doctors.

□ I have not seen any of these types of information about doctors.

Public reporting burden for this collection of information is estimated to average 6 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

4. Did you see any information comparing the quality among different hospitals in the past 12 months, or not?

□ YES

□ NO

□ Not sure

5. Did you see any information comparing the quality among different health insurance plans in the past 12 months, or not?

□ YES

□ NO

□ Not sure

6. Based on what you’ve heard, read, or experienced yourself, please tell me if you think there are big differences, small differences, or no differences in the quality of care provided by family doctors, general practitioners, and other primary care doctors in your area. [Check one box only.]

□ Big differences

□ Small differences

□ No differences

□ Not sure

7. Imagine that you needed to choose a new doctor to provide you with most of your basic medical care. What would you look for in choosing that doctor?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

These last questions are about you and will help us to describe all the people we interview.

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

□ Excellent

□ Very good

□ Good

□ Fair

□ Poor

9. In the last 12 months, how many times did you go to a doctor’s office or clinic to get health care for yourself?

□ None

□ 1

□ 2

□ 3

□ 4

□ 5 to 9

□ 10 or more

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