The 2021 Physician Pain Management Questionnaire Pilot 

Study: Lessons Learned and Future Implications

Brian W. Ward and Doreen Gidali

Division of Health Care Statistics

National Center for Health Statistics

2023 FCSM Research & Policy Conference 

October 26, 2023

Session I-6

National Center for Health Statistics

All views expressed in this presentation are those of the authors and do not necessarily reflect those of the Centers for 

Disease Control and Prevention or the National Center for Health Statistics.
Physician Pain Management Questionnaire (PPMQ):

Background

2
Background:

The Opioid Epidemic: Three Waves of Opioid Overdose Deaths 

3
Background: Strategies & Guidelines

 Strategies were developed to focus on effective and safe treatment of 

chronic pain, while reducing opioid misuse and overdose

CDC Guideline for Prescribing Opioids for Chronic Pain (2016; revised 2022) 

 National guideline for prescribing opioids for chronic pain

HHS National Pain Strategy (2011)

 Strategy with goals of safe delivery of pain therapies

Independent prescription guidelines: 

 U.S. states, health organizations, and health practices established their own 

guidelines

4
Background: PPMQ Rationale and Goals

 The need for a survey to assess 

physician’s awareness and use of 

guidelines was identified by: 

 The NIH National Center for 

Complementary and Integrative Health 

(NCCIH) 

 Interagency Pain Research Coordinating 

Committee (IPRCC) 

 NIH Pain Consortium

 NCCIH funded NCHS to conduct the 

PPMQ pilot study with the following goals 

Evaluate survey questions on 

physician knowledge, awareness, and 

use of guidelines for prescribing 

opioids.

Conduct a pilot study to assess the 

feasibility of a national physician 

survey to understand physician 

opioid prescribing practices for pain 

management.

NCHS-specific goal: explore the use 

of widely available national provider 

databases for sampling physicians. 

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PPMQ Pilot Study: Questionnaire Design

6
Background: The Opioid Epidemic – 3 Waves

National Pain Strategy 

Implementation Team

Developed new questions 1

National Center for 

Health Statistics

Adapted questions from 

the National Health Care 

Surveys (NAMCS, NEHRS)

3

Pre-existing Surveys

Adapted questions from 

established surveys on pain 

and pain management

2

National Center for 

Health Statistics

Developed new eligibility 

questions specific for 

PPMQ

4

 Multiple sources were used to develop the initial PPMQ questions.

Questionnaire Design: Question development

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Questionnaire Design: Cognitive Interview Testing

 NCHS Collaborating Center for Questionnaire Design and Evaluation 

Research (CCQDER) performed 60-minute cognitive interviews.

 20 interviews were conducted among physicians and physician associates 

(PAs) who prescribed opioids among non-cancer patients.

 All questions were tested and analyzed for:

 Overall performance 

 Question-by-question performance

8
Questionnaire Design: Cognitive Interview Testing (cont.)

 Three broad patterns emerged:

 No differentiation between acute vs. chronic pain

 Response error

 Assessment of quantity using percentages

 Increased burden

 Response error

 Number of opioid guidelines

 Increased burden

 Response error

 Social bias

Complete cognitive testing results 

are available at: 

https://wwwn.cdc.gov/QBank/Search/

Reports.aspx#/Reports/1218. 

9
Questionnaire Design: Applying Cognitive Test Results

10
PPMQ Pilot Study: Sample Design

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Sample Design: Data Source

 The purpose of the study was methodological.

 Results would not be weighted or nationally representative 

 In accordance with General Information Clearance OMB approval

 Opportunity to explore the use of the National Plan and Provider Enumeration 

System (NPPES), developed by CMS.

 Not the database traditionally used by NCHS for its physician surveys

 NPPES includes the National Provider Identifier (NPI) database of healthcare 

providers used to assign a unique NPI to healthcare providers, as mandated by 

the Health Insurance Portability and Accountability Act of 1996.

12
Sample Design: Eligibility Criteria

 NCHS and NCCIH collaboratively decided upon eligibility criteria for 

inclusion in the study universe.

Eligible Ineligible

 MD or DO

 Active NPI

 Active medical license

 Practicing in the 50 U.S. states/ District of 

Columbia (DC)

 Specialized in select specialties

E.g., anesthesiology, family medicine, pain 

medicine, etc.

× Practicing in U.S territories/ abroad

× Federally employed physicians

× Specialties unlikely to treat pain

× Unlicensed 

× Retired

× Revoked licensure in the sampled state

13
Sample Design: Drawing the Sample

 Stratified random sampling with proportional allocation.

 Strata: U.S. Census region, U.S. state (including DC), and physician specialty.

14
PPMQ Pilot Study: Data Collection & Fielding

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Data Collection

 Self-administered, paper questionnaire mailed to 

physicians’ current practice as listed in the 

NPPES.

 Although not mixed-mode, the survey drew 

from the Tailored Design Method:

 Personalized letters

 Prepaid return envelopes included with mailed 

questionnaire

 Thank you/reminder postcards

 Multiple survey packets sent to nonrespondents 

over set time intervals

16
The Tailored Design Method & Fielding Timeline

June 2021 February 2022 

February 2022

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Mailing Address Tracing & Locating

 284 of 1,000 mailed surveys were returned as 

undeliverable.

 65% due to change in address

 Undeliverable surveys are common

 Literature supports tracing as an important role 

in increasing response rates.

 Multiple tracing strategies used to locate 

physicians:

 Monthly NPI datafile updates

 Web searching

 Federation of State Medical Boards

 Doximity

Undeliverable 

Surveys 

(n=284)

Unlocated

(n=39)

Ineligible

(n=65)

Located

(n=180)

Locating 

Activities

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PPMQ Pilot Study: Results

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Study Results: Eligibility Status and Disposition

Eligibility Status & Disposition Count %

Eligible (n=149)

Eligible and complete 144 14.4

Eligible, responded as refused 3 0.3

Eligible and partial complete 2 0.2

Ineligible (n=108)

Ineligible based on survey responses 43 4.3

Ineligible based on locating activities 65 6.5

Unknown eligibility (n=743)

Unknown eligibility, refused 703 70.3

Unknown eligibility, partial complete 1 0.1

Unknown eligibility, unlocatable 39 3.9

144

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Study Results: Survey Outcome Rates

Notes: Counts and percentages are unweighted. All rates are calculated using AAPOR standards. 

AAPOR Response Rate 3 reported.

Source: NCHS, PPMQ, 2021.

Total Sample

(n)

Contact Rate

(%)

Cooperation Rate

(%)

Sample Released, 

Minus Ineligible 

(n)

Response Rate

(%)

1,000 16.7 96.6 149 16.1

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Study Results: Comparison of Respondents vs. Nonrespondents

Notes: Counts and percentages are unweighted. p-values from chi-square test. Source: NCHS, PPMQ, 2021.

Characteristic Respondents Nonrespondents p-value

% %

Physician Sex

Female 37.1 38.8

Male 62.9 61.2

Physician Type

MD 86.5 84.4

DO 13.5 15.6

Region of Practice

Northeast 20.4 22.4

Midwest 20.8 26.5

South 32.7 26.5

West 26.1 24.5

Sampled specialty category

Primary Care 39.9 39.5

Surgical Specialty 10.8 6.1

Medical Specialty 49.3 54.4

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 Item nonresponse rates were overall low (<5.0%)

 Range from 0.0% to 4.4%

 Only 3 items >3.0%

Study Results: Item Nonresponse

How many of your pain patients are currently 

being treated with opioids prescribed by you?

All eligible physician respondents 

who treat pain (n=121) 4.1

Denominator/ Universe %

All eligible physician respondents 

who prescribe opioids (n=90) 4.4

All eligible physician respondents 

who prescribe opioids (n=90) 3.3

After you start opioid therapy on a pain 

patient, when do you re-evaluate him/ her?

When you prescribe opioids to your pain 

patients, how many days on average does the 

prescription cover?

Question

Notes: Percentages are unweighted. Source: NCHS, PPMQ, 2021.

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PPMQ Pilot Study: Limitations & Lessons Learned

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 Low response rates

 Retired physicians

 Single mode of administration

 Timing 

 Seasonal impact

 COVID-19 pandemic

 Limited resources

Summary: Limitations

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Objective: Evaluate survey questions on physician knowledge, awareness, and use 

of prescription opioid guidelines.

 Evaluation of questions is important! 

 Issues found in multiple questions (even previously used)

 Several changes were necessary 

 Revised questions performed well in the field

Low item nonresponse rates!

 Lessons from cognitive testing. 

 The topic of pain management and guidelines for prescribing opioids are difficult concepts 

to capture in survey questions. 

Summary: Lessons Learned

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Objective: Conduct a pilot study to assess the feasibility of a national physician survey to gain a better understanding of physician opioid prescribing practices for pain 

management. 

 NPI Datafile decent source for sampling providers IF 

 Have a supplement data source for 

 Age, addresses, medical license information 

 Multiple modes of administration important for improving:

 Response rates

 Analytical statistical power

 Tracing and use of secondary sources are important! 

 Increase contact rate and possibly response rates

63.4% of physicians’ mailing addresses were found through tracing!!

Summary: Lessons Learned (cont.)

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 Although the opioid epidemic remains a public health concern, there are 

no plans for fielding a nationally representative PPMQ.

 Recognizing the need remains for capturing the understanding of 

physician opioid prescribing practices for pain management, a ninequestion module based on the PPMQ was added beginning with the 

2023 NAMCS.

Summary: Moving Forward

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Thank you!

Gidali DM, Ward BW. The 2021 Physician Pain Management 

Questionnaire pilot study. Vital and Health Statistics 

2023;2(204):1-36. 

https://www.cdc.gov/nchs/data/series/sr_02/sr02-204.pdf

For more info: Brian W. Ward (bwward@cdc.gov) 

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For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention.