Form 1 Expert Survey

APPENDIX B

expert survey

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

EVALUATION OF
AHRQ HEALTHCARE HORIZON SCANNING SYSTEM

EXPERT SURVEY

Sponsored by the Agency for Healthcare Research and Quality

Conducted by

Mathematica Policy Research

Public reporting burden for this collection of information is estimated to average XX 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.

T he Agency for Healthcare Research and Quality (AHRQ) is sponsoring this survey as part of the evaluation of the AHRQ Healthcare Horizon Scanning System. Mathematica Policy Research, an independent social policy research company, is conducting the survey for the evaluation. The survey will help AHRQ assess the Potential High Impact Interventions report series issued by the AHRQ Healthcare Horizon Scanning System.

Thank you for taking the time to complete the survey. Your participation and input is very important. It should take you about 20 minutes to complete this survey. In appreciation of your effort, we will provide a payment of $75.

The survey is divided into two sections:

• The first section asks for your feedback on the report on [NAME OF INTERVENTION] that we sent you. You can also access the report through the report link in the online survey.

• The second section asks for your assessment of the overall potential impact of a set of 20 emerging and new health interventions.

Please be assured that:

• All responses will be combined and data will be reported in the aggregate. No names of individuals or organizations will be used in any reports.

Before you begin the survey, please:

• Make sure you have read the report

• Have the report in front of you so you can refer to it easily. If you do not have the report available, please click on this link [LINK] to access the report.

• Answer the questions to the best of your knowledge. We ask you to not conduct any research on the content or subject of the report but to provide us your immediate perceptions of the report.

For questions, please call XXX toll free or click here [EMAIL ADDRESS] to send an email.

Please click on the SUBMIT button at the bottom of this screen when you are ready to begin the survey.

The first few questions are about the overall report on [INTERVENTION NAME]. These questions should be answered based on the information about [INTERVENTION NAME] that was available when the report was developed inDecember 2014.

A1. Based on the information available in December 2014 about [INTERVENTION NAME], does the report contain any inaccuracies?

 Yes 1

 No 0 SKIP TO A2

 Don’t Know 0 SKIP TO A2

A1a. Please provide an example of an inaccurate statement from the report.

INACCURATE STATEMENT

A2. Based on the information available in December 2014about [INTERVENTION NAME], is the report missing any important information?

 Yes 1

 No 0 SKIP TO A3

 Don’t Know 0 SKIP TO A3

A2a. Please provide an example of important information that was missing from the report.

MISSING IMPORTANT INFORMATION

A3. This question is about the section of the report titled “Clinical Pathway at Point of This Intervention.” Based on the information available in December 2014about [INTERVENTION NAME], does this section accurately reflect the prevailing view at that time about how [INTERVENTION NAME] may be used in clinical care?

 Yes 1 SKIP TO A4

 No 0

A3a. Please explain how this section does not accurately reflect the prevailing view on how this intervention may be used in clinical care.

REASON WHY SECTION IS INACCURATE

A4. Please provide any additional comments about the report that you would like to share.

ADDITIONAL COMMENTS

B1. This question is about your assessment of the overall potential impact of 12 emerging and new health interventions in the area of [PRIORITY CONDITION].

• We define overall potential impact as the potential for high impact on U.S. healthcare when considering all the factors below:

• Potential importance of the unmet need it intends to address

• Potential to improve patient health

• Potential to affect health disparities

• Potential to disrupt the healthcare delivery system

• Potential for acceptance/adoption by patients and clinicians

• Potential impact on healthcare costs

• Overall potential to fulfill the unmet need.

• We define emerging and new health interventions to include new (and new uses of existing) pharmaceuticals, medical devices, diagnostic tests and procedures, therapeutic interventions, rehabilitative interventions, behavioral health interventions, health care delivery innovations, and public health and health promotion activities intended for use in the U.S. health care system.

• Please think about all of the emerging and new health interventions with which you are familiar in the [PRIORITY CONDITION] area and consider the overall potential impact of each of these interventions on U.S. healthcare.

• Then, for each of the interventions listed below, select the quartile you would rank the intervention in terms of its overall potential impact on U.S. healthcare when compared to Phase III emerging and new health interventions in the [PRIORITY CONDITION].

	SELECT ONE PER ROW
	In terms of its overall potential impact, relative to all emerging and new health interventions in [PRIORITY AREA], this intervention would be in the . . .
	Top Quartile (i.e., large impact relative to other emerging health interventions)	Second Quartile (i.e., medium impact relative to other emerging health interventions)	Third or Fourth Quartile (i.e., small impact relative to other emerging health interventions)	Not Sure/No Opinion
a. Intervention 1	1 	2 	3 	4 
b. Intervention 2	1 	2 	3 	4 
c. Intervention 3	1 	2 	3 	4 
d. Intervention 4	1 	2 	3 	4 
e. Intervention 5	1 	2 	3 	4 
f. Intervention 6	1 	2 	3 	4 
g. Intervention 7	1 	2 	3 	4 
h. Intervention 8	1 	2 	3 	4 
i. Intervention 9	1 	2 	3 	4 
j. Intervention 10	1 	2 	3 	4 
k. Intervention 11	1 	2 	3 	4 
l. Intervention 12	1 	2 	3 	4 
t. Intervention 20	1 	2 	3 	4 

These last questions are about you.

C1. What is your area of expertise in the health care field?

SELECT ONE ONLY

 Government policy and regulation 1

 Clinical expertise 2

 Insurance 3

 Manufacturing or marketing of health care products 4

 Financial performance or investment outlook 5

 Health systems 6

 Other

S pecify

C2. Please disclose below your academic, professional, and manufacturer affiliations.

AFFILIATIONS

C3. Please disclose below any potential intellectual or financial conflicts of interest, such as research in progress, consulting arrangements, or other financial involvements with companies related to technologies, services, or programs evaluated in the report.

 I have no conflict of interest Section D

CONFLICTS OF INTEREST

C4. Do you consult for developers or manufacturers that do or would compete with this intervention?

 Yes 1

 No 0

C4a. If yes, please specify the nature of your consultation below.

NATURE OF CONSULTATION

T hank you for completing this important survey. We would like to send you a check for $40.00.

D1. Please provide the name you would like to appear on the check.

F irst Name:

M iddle Initial:

L ast Name:

D2. Please provide the address where we should send the check to.

O ffice/Business Name:

S treet Address 1:

S treet Address 2:

Apt #:

C ity:

State:

Z ip:

D3. Please provide your contact information. We will only contact you if we have any questions about the answers you provided on the survey.

WORK

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EMAIL ADDRESS

Thank you for completing the survey.