Attachment D - BeneSurveyCrosswalk - for OMB Item 10 (Revised July 19, 2013)

Research Question	Dimension/ Composite	Old Item #	New Item #	Item Text/New Question	Item Text/Old Question	Comment	Corresponding ICH Item #	Corresponding ICH Question	Corresponding ICH Question Revised
	Access to Care
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Current treatment modality and facility	Q2	Q2	No change	Where do you currently get your dialysis treatments… [IF NEEDED: If you get dialysis treatments in more than one setting, please tell us where you usually get dialysis treatments.]	Performed as expected	ICH1	Where do you get your dialysis treatments?	Yes, this question was revised to add the word "currently" to ensure respondents were talking about their most recent dialysis care.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Frequency of treatment (times per week and length of treatment)	Q3	Q3	No change	How long have you been getting dialysis treatments at {home/a dialysis center, a hospital}? Would you say…	Performed as expected	ICH2	How long have you been getting dialysis at this dialysis center?	Yes, this question was revised to reflect different possible treatment modalities (home, dialysis center, hospital). The ICH CAHPS survey only requests responses from individuals getting dialysis at a dialysis center.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Current treatment modality and facility	Q4	Q4	What type of dialysis treatment do you currently get? Hemodialysis through the vein or peritoneal dialysis through the belly?	What type of dialysis treatment do you currently get? [IF NEEDED: Hemodialysis is dialysis given at an outpatient dialysis center or a hospital dialysis clinic. Peritoneal dialysis is dialysis given through the belly and is usually done at home.]	Simplified definitions and included them in the main question.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Current treatment modality and facility	Q5	Q5	No change	The dialysis center staff can connect you to the dialysis machine through a graft, fistula, or catheter. In the last 3 months, which one did they use most often to connect you to the dialysis machine?	Performed as expected	ICH20	In the last 3 months, which one did they use most often to connect you to the dialysis machine?	Yes, this question was revised to include the various dialysis connection modalities. The ICH CAHPS survey includes a screener question about whether could connect the patient to the dialysis machine through a graft, fistula, or catheter. [ICH 19]
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Frequency of treatment (times per week and length of treatment)	Q6	--	Dropped	How many days per week do you usually get dialysis?	Question dropped due to minimal response variability.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Frequency of treatment (times per week and length of treatment)	Q7	Q6	No change	How many hours do your dialysis treatments usual last?	Performed as expected
8. What is the beneficiary education, including discussion of modality choice, referral for renal transplant for appropriate patients, and home dialysis training under the ESRD PPS/QIP?	Changes to modality and/or facility	Q8	--	Dropped	Have you ever received dialysis treatment at home?	Question dropped due to minimal response variability.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Frequency of interactions with doctors, other medical staff	Q9	--	Dropped	Now we are going to ask you about your kidney doctors. “Your kidney doctors” are the doctors most involved in your dialysis care now. This could include kidney doctors that you see inside and outside of a clinic, hospital, or dialysis center. In the last 3 months how many times have you seen your kidney doctors?	Question dropped as most respondents reported seeing doctors as part of regular (on-going) dialysis; they did not make specific appointments to access care. Question was not measuring intended domain.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q10	--	Dropped	In the last 3 months, did you contact your kidney doctors to get an appointment for care you needed right away?	Question dropped as most respondents reported seeing doctors as part of regular (on-going) dialysis; they did not make specific appointments to access care. Question was not measuring intended domain.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q11	--	Dropped	In the last 3 months, when you contacted your kidney doctors for care you needed right away, how often did you get an appointment as soon as you needed?	Question dropped as most respondents reported seeing doctors as part of regular (on-going) dialysis; they did not make specific appointments to access care. Question was not measuring intended domain.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q12	--	Dropped	In the last 3 months, did you make any appointments for a check-up or routine care with your kidney doctors?	Question dropped as most respondents reported seeing doctors as part of regular (on-going) dialysis; they did not make specific appointments to access care. Question was not measuring intended domain.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q13	--	Dropped	In the last 3 months, when you made an appointment for a check-up or routine care with your kidney doctors, how often did you get an appointment as soon as you needed?	Question dropped as most respondents reported seeing doctors as part of regular (on-going) dialysis; they did not make specific appointments to access care. Question was not measuring intended domain.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Information/education regarding treatment modalities; Shared decision making	Q22	Q21	No change	Are you eligible for a kidney transplant?	Performed as expected	ICH37	Are you eligible for a kidney transplant?	No revisions to the question.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Information/education regarding treatment modalities; Shared decision making	Q23	Q22	In the last 3 months, did your kidney doctors or anyone on your kidney care team explain why you are not eligible for a kidney transplant?	In the last 3 months, have either your kidney doctors or dialysis center staff explained to you why you are not eligible for a kidney transplant?	Through testing determined that the kidney doctor may not be the only member of the team to initiate a discussion about transplant options. Question modified for consistent terminology and simplified language.	ICH38	In the last 12 months, have either your kidney doctors or dialysis center staff explained to you why you are not eligible for a kidney transplant?	Yes, this question was modified to direct respondents to answer if this happened within the last 3 months. The ICH CAHPS survey asks about the last 12 months. Also, dialysis center staff was replaced by kidney care team to make the question apply for those individuals that do not get in center hemodialysis.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Information/education regarding treatment modalities; Shared decision making	Q24	Q23	In the last 3 months, did your kidney doctors or anyone on your kidney care team talk with you as much as you wanted about a kidney transplant?	In the last 3 months, have your kidney doctors talked to you as much as you wanted about a kidney transplant?	Through testing determined that the kidney doctor may not be the only member of the team to initiate a discussion about transplant options. Question modified for consistent terminology.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Information/education regarding treatment modalities; Shared decision making	Q25	Q24	Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 3 months, did you kidney doctors or anyone on your kidney care team talk with you as much as you wanted about peritoneal dialysis?	Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 3 months, have your kidney doctors talked to you as much as you wanted about peritoneal dialysis?	Through testing determined that the kidney doctor may not be the only member of the team to initiate a discussion about dialysis options. Question modified for consistent terminology.	ICH39	Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis?	Yes, this question was modified to direct respondents to answer if this happened within the last 3 months. The ICH CAHPS survey asks about the last 12 months. Also, dialysis center staff was replaced by kidney care team to make the question apply for those individuals that do not get in center hemodialysis.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Access to prescription medicines; Shared decision making	Q26	Q11	No change	In the last 3 months, did you and your kidney doctors talk about starting or stopping a prescription medicine?	Performed as expected
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Shared decision making	Q27	Q12	Did you and your kidney doctors talk about the reasons why you might want to take a prescription medicine?	When you talked about starting or stopping a prescription medicine, how much did your kidney doctors talk about the reasons you might want to take a medicine?	Through testing determined that respondents were not uniformly differentiating between the response options. Simplified question and responses to yes/no format for consistent reporting.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Shared decision making	Q28	Q13	Did you and your kidney doctors talk about the reasons why you might not want to take a prescription medicine?	When you talked about starting or stopping a prescription medicine, how much did your kidney doctors talk about the reasons you might not want to take a medicine?	Through testing determined that respondents were not uniformly differentiating between the response options. Simplified question and responses to yes/no format for consistent reporting.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Shared decision making	Q29	Q14	No change	When you talked about starting or stopping a prescription medicine, did your kidney doctors ask what you thought was best for you?	Performed as expected
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Frequency of interactions with doctors, other medical staff	Q31	--	Dropped	Specialists are doctors like cardiologists, endocrinologists, and surgeons, and other doctors who specialize in one area of health care. In the last 3 months, did you see a specialist?	Since ESRD beneficiaries get the vast majority of their care from the dialysis team, coordination of care with specialists deemed to be a lesser interest - less relevant to measuring changes in the PPS/QIP program.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Access to testing/labs	Q51	--	Dropped	In the last 3 months, did your kidney doctors or anyone on your kidney care team order an x-ray, or other test for you?	Most common test was blood test and many were done as part of dialysis treatment. Not measuring a key domain related to changes in the PPS/QIP program.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Access to testing/labs; Shared decision making	Q52	--	Dropped	In the last 3 months, when your kidney doctors or someone on your kidney care team ordered a blood test, x-ray, or other test for you, how often did someone follow up to give you those results?	Most common test was blood test and many were done as part of dialysis treatment. Not measuring a key domain related to changes in the PPS/QIP program.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Access to testing/labs; Shared decision making	Q53	--	Dropped	In the last 3 months, how often did your kidney doctors or someone on your kidney care team explain blood test, x-ray, or other test results in a way that was easy to understand?	Most common test was blood test and many were done as part of dialysis treatment. Not measuring a key domain related to changes in the PPS/QIP program.
	Quality of Care
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q14	Q7	Now we are going to ask you about your kidney doctors. Your kidney doctors are the doctors most involved in your dialysis care now. This could include kidney doctors that you see inside and outside of a clinic, hospital, or dialysis center. In the last 3 months, how often did your kidney doctors listen carefully to you? Would you say...	In the last 3 months, how often did your kidney doctors listen carefully to you?	Moved definition as this is now the first question that uses "kidney doctors" as a referent.	ICH3	For the questions that follow, “your kidney doctors” means the doctor or doctors most involved in your dialysis care now. This could include kidney doctors that you see inside and outside the center. In the last 3 months, how often did your kidney doctors listen carefully to you?	Yes, this question was modified to expand the dialysis type to home dialysis as well as in center dialysis. The ICH CAHPS survey is only interested in in center hemodialysis.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q15	Q8	No change	In the last 3 months, how often did your kidney doctors explain things in a way that was easy to understand? Would you say...	Performed as expected	ICH4	In the last 3 months, how often did your kidney doctors explain things in a way that was easy to understand?	No revisions to the question.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q16	Q9	No change	In the last 3 months, how often did your kidney doctors show respect for what you had to say?	Performed as expected	ICH5	In the last 3 months, how often did your kidney doctors show respect for what you had to say?	No revisions to the question.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors	Q17	Q10	No change	In the last 3 months, how often did your kidney doctors spend enough time with you?	Performed as expected	ICH6	In the last 3 months, how often did your kidney doctors spend enough time with you?	No revisions to the question.
8. What is the beneficiary education, including discussion of modality choice, referral for renal transplant for appropriate patients, and home dialysis training under the ESRD PPS/QIP?	Treatment oversight/management of problems	Q18	--	Dropped	In the last 3 months, did your kidney doctors talk with you about changing your dialysis treatments?	Question removed due to limited variability in response to the question. Shared decision making measured using prescription medicine series as there was more variability in that series.
8. What is the beneficiary education, including discussion of modality choice, referral for renal transplant for appropriate patients, and home dialysis training under the ESRD PPS/QIP?	Treatment oversight/management of problems	Q19	--	Dropped	When you talked about changing your dialysis treatments, how much did your kidney doctors talk about the reasons you might want to change your treatments?	Question removed due to limited variability in response to the question. Shared decision making measured using prescription medicine series as there was more variability in that series.
8. What is the beneficiary education, including discussion of modality choice, referral for renal transplant for appropriate patients, and home dialysis training under the ESRD PPS/QIP?	Treatment oversight/management of problems, Information/education regarding treatment modalities; Shared decision making	Q20	--	Dropped	When you talked about changing your dialysis treatment, how much did your kidney doctors talk about the reasons you might not want to change your treatment?	Question removed due to limited variability in response to the question. Shared decision making measured using prescription medicine series as there was more variability in that series.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Treatment oversight/management of problems, Information/education regarding treatment modalities; Shared decision making	Q21	--	Dropped	When you talked about changing your dialysis treatment, did your kidney doctors ask you what you thought was best for you?	Question removed due to limited variability in response to the question. Shared decision making measured using prescription medicine series as there was more variability in that series.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?	Experience with doctors	Q30	Q15	No change	Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now?	Performed as expected	ICH8	Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now?	No revisions to the question.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?	Experience with doctors	Q32	--	Dropped	In the last 3 months, how often did your kidney doctors seem informed and up-to-date about the care you got from specialists?	Since ESRD beneficiaries get the vast majority of their care from the dialysis team, coordination of care with specialists deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with other providers / staff	Q33	--	Dropped	Now we are going to ask you to think about all the people on your kidney care team. This includes staff at your staff at the dialysis center, and/or staff at the hospital dialysis center. In the last 3 months, how often was your kidney care team as helpful as you though they should be?	Question dropped as respondents didn't have a consistent understanding of the question being asked, particularly relating to the concept "helpful".
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with other providers / staff	Q34	Q16	Did not change	Now we are going to ask you to think about all the people on your kidney care team. This includes nurses, technicians, and social workers at the [PROGRAMMER PLEASE INCLUDE DISPLAY FOR--dialysis center,/hospital dialysis center]. In the last 3 months, how often did your kidney care team treat your with courtesy and respect? Would you say...	Performed as expected
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with other providers / staff	Q35	Q17	No change	In the last 3 months, how often did your kidney care team spend enough time with you? Would you say…	Performed as expected	ICH13	In the last 3 months, how often did the dialysis center staff spend enough time with you?	Yes, we replaced dialysis center staff with kidney care team to apply this question to all dialysis patients, not just in center hemodialysis patients. The ICH CAHPS survey only targets in center hemodialysis patients.
4. What is the quality of dialysis services (e.g., dialysis length, frequency of dialysis, comfort, etc.) under the ESRD PPS/QIP ?	Management of physical comfort	Q36	Q18	No change	In the last 3 months, how often did your kidney care team make you as comfortable as possible during dialysis?	Performed as expected	ICH15	In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis?	Yes, we replaced dialysis center staff with kidney care team to apply this question to all dialysis patients, not just in center hemodialysis patients. The ICH CAHPS survey only targets in center hemodialysis patients.
4. What is the quality of dialysis services (e.g., dialysis length, frequency of dialysis, comfort, etc.) under the ESRD PPS/QIP ?	Treatment oversight/management of problems	Q37	Q19	No change	In the last 3 months, how often did your kidney care team check you as closely as you wanted while you were on the dialysis machine?	Performed as expected	ICH22	In the last 3 months, how often did dialysis center staff check you as closely as you wanted while you were on the dialysis machine?	Yes, we replaced dialysis center staff with kidney care team to apply this question to all dialysis patients, not just in center hemodialysis patients. The ICH CAHPS survey only targets in center hemodialysis patients.
4. What is the quality of dialysis services (e.g., dialysis length, frequency of dialysis, comfort, etc.) under the ESRD PPS/QIP ?	Treatment oversight/management of problems	Q38	--	Dropped	In the last 3 months, did any problems occur during your dialysis?	Question dropped as respondents didn't have a consistent understanding of the question being asked, particularly relating to the concept "problems".
4. What is the quality of dialysis services (e.g., dialysis length, frequency of dialysis, comfort, etc.) under the ESRD PPS/QIP ?	Treatment oversight/management of problems	Q39	--	Dropped	In the last 3 months, how often was your kidney care team able to help you manage problems during your dialysis? Would you say…	Question dropped as respondents didn't have a consistent understanding of the question being asked, particularly relating to the concept "problems".
4. What is the quality of dialysis services (e.g., dialysis length, frequency of dialysis, comfort, etc.) under the ESRD PPS/QIP ?	Experience with other providers / staff	Q40	Q20	No change	Using any number from 0 to 10, where 0 is the worst kidney care team possible and 10 is the best kidney care team possible, what number would you use to rate your kidney care team?	Performed as expected	ICH32	Using any number from 0 to 10, where 0 is the worst dialysis center staff possible and 10 is the best dialysis center staff possible, what number would you use to rate your dialysis center staff?	Yes, we replaced dialysis center staff with kidney care team to apply this question to all dialysis patients, not just in center hemodialysis patients. The ICH CAHPS survey only targets in center hemodialysis patients.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?; 2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors; Experience with other providers / staff	Q41	--	Dropped	In the last 3 months, were you ever unhappy with the care you received from your kidney doctors or from anyone on your kidney care team?	Question series dropped. Not providing consistent actionable information.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors; Experience with other providers / staff	Q42	--	Dropped	In the last 3 months, did you ever talk to your kidney doctors or anyone on your kidney care team about this?	Question series dropped. Not providing consistent actionable information.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?	Experience with doctors; Experience with other providers / staff	Q43	--	Dropped	In the last 3 months, how often were you satisfied with the way your kidney doctors or kidney care team handled these problems?	Question series dropped. Not providing consistent actionable information.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q44	Q25	No change	In the last 3 months, did your kidney doctors or anyone on your kidney care team talk to you about what you should eat and drink?	Performed as expected	ICH26	Please remember that, for these questions, dialysis center staff do not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center. In the last 3 months, did dialysis center staff talk to you about what you should eat and drink?	Yes, this question was modified to expand the dialysis type to home dialysis as well as in center dialysis. The ICH CAHPS survey is only interested in in center hemodialysis.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q45	--	Dropped	In the last 3 months did you and your kidney doctors or anyone on your kidney care team talk about how you are monitoring your health?	Question dropped. The concept "monitoring your health" was not uniformly understood.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q46	Q26	No change	In the last 3 months, did your kidney doctors or anyone on your kidney care team work with you to set specific goals for managing your health?	Performed as expected
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	--	Q27	In the last 3 months, did you kidney doctors or anyone on your kidney care team offer you help to reach these goals?	N/A	Question added to clarify content about health care goal counseling.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q47	Q28	No change	In the last 3 months, did your kidney doctors or anyone on your kidney care team ask you about your mental or emotional health?	Performed as expected
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q48	--	Dropped	In the last 3 months, did your kidney doctors or anyone on your kidney care team ask you if there are things that make it hard for you to manage your health?	Question dropped. Added another question (Q27) that could better address this content. Respondents had difficulty describing episodes - respondents found being on dialysis already a hindrance to managing their health.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q49	--	Dropped	In the last 3 months, did your kidney doctors or anyone on your kidney care team offer you help for the things that make it hard for you to manage your health?	Question dropped. Added another question (Q27) that could better address this content. Question was unclear during cognitive testing as respondents considered brochures and not persons helping them manage their health.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Self-management support	Q50	--	Dropped	In the last 3 months, did you and your kidney doctors or anyone on your kidney care team talk about all the prescription medicines you were taking?	Question dropped. During cognitive testing, respondent confused who they were speaking with about prescription medicines resulting in inconsistent reporting.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Experience with doctors; Treatment oversight/management of problems	Q60	Q29	No change	In the last 3 months, did your kidney doctors or anyone on your kidney care team ask you about how your kidney disease affects other parts of your life?	Performed as expected	ICH18	In the last 3 months, has anyone on the dialysis center staff asked you about how your kidney disease affects other parts of your life?	Yes, this question was revised to combine physicians and kidney care team in the treatment of dialysis. The terminology was broadened to capture all dialysis patients, not just in center dialysis. The ICH CAHPS survey only captures in center hemodialysis patients.
2. What is the beneficiary experience of care under the ESRD PPS/QIP ?	Coordination of care	Q58	--	Dropped	In the last 3 months, who helped to coordinate your care?	Question dropped as respondents had people inside and outside the dialysis center that coordinated their care and the question gave non-ESRD answers such as "wife", "sister", etc.
1. What is beneficiary satisfaction under the ESRD PPS/QIP?	Coordination of care	Q59	--	Dropped	How satisfied are you with the help you received to coordinate your care in the last 3 months?	Question dropped as respondents had people inside and outside the dialysis center that coordinated their care and the question gave non-ESRD answers such as "wife", "sister", etc. Responding to satisfaction of coordination of care by family members does not affect the quality of the ESRD PPS/QIP program.
	Outcomes
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Quality of life measures	Q61	--	Dropped	In the last 3 months how often were you limited in the kind of work or other activities you could do because of your physical health?	Quality of life measures streamlined by selecting items with the greatest consistency in understanding as well as response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Quality of life measures	Q62	Q30		In the last 3 months, how often have you been bothered by fluid restriction? Would you say…	Performed as expected
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Quality of life measures	Q63	Q31		In the last 3 months, how often have you been bothered by dietary restriction? Would you say…	Performed as expected
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Quality of life measures	Q64	--	Dropped	In the last 3 months how often have you been bothered by your inability to work around the house?	Quality of life measures streamlined by selecting items with the greatest consistency in understanding as well as response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Quality of life measures	Q65	--	Dropped	In the last 3 months how often have you been bothered by being dependent on doctors and other medical staff?	Quality of life measures streamlined by selecting items with the greatest consistency in understanding as well as response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Physical health	Q66	--	Dropped	In the last 3 months, how often did pain interfere with your normal work including both work outside the home and housework?	Question dropped due to minimal response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Physical health	Q67	--	Dropped	In the last 3 months how often has your physical health or emotional problems interfered with your social activities like visiting with friends, relatives?	Question dropped due to minimal response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Mental health	Q68	--	Dropped	In the past 3 months how often have you felt calm and peaceful?	Mental health measures streamlined by selecting items with the greatest consistency in understanding as well as response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Mental health	Q69	--	Dropped	In the last 3 months how often did you have a lot of energy?	Mental health measures streamlined by selecting items with the greatest consistency in understanding as well as response variability.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Mental health	Q70	Q32	No change	In the last 3 months how often have you felt downhearted and blue?	Performed as expected
9. What is the beneficiary perception of their outcomes (e.g. experience of infections, hospitalizations, and/or emergency department visits, etc.) under the ESRD PPS/QIP?	Hospital stays	Q92	Q33	No change	In the last 3 months, how many days total did you stay in any hospital overnight?	Performed as expected
9. What is the beneficiary perception of their outcomes (e.g. experience of infections, hospitalizations, and/or emergency department visits, etc.) under the ESRD PPS/QIP?	ER visits	Q93	Q34	No change	Excluding scheduled treatments, tests, or dialysis, in the last 3 months, how many days total did you receive care at a hospital but came home the same day?	Performed as expected
9. What is the beneficiary perception of their outcomes (e.g. experience of infections, hospitalizations, and/or emergency department visits, etc.) under the ESRD PPS/QIP?	Infections	Q94	Q35	No change	In the last 3 months how many dialysis related infections did you have?	Performed as expected
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Physical health	Q95	Q36		In general, how would you rate your overall physical health? Would you say..	Performed as expected	ICH45	In general, how would you rate your overall health?	This question was modified from the ICH CAHPS survey to focus on physical health. A subsequent question captures response about mental health.
3. What is beneficiaries’ perception of their quality of life under the ESRD PPS/QIP?	Mental health	Q96	Q37	In general, how would you rate your overall mental or emotional health? Would you say…	In general, how would you rate your overall mental or emotional health? Would you say…	Performed as expected	ICH46	In general, how would you rate your overall mental or emotional health?	No revisions to the question.
	Costs
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q54	--	Dropped	In the last 3 months, were you ever worried or concerned about the cost of your blood tests, x-rays, or other tests?	Cost of treatment questions streamlined to simplify and capture the extent to which Beneficiaries are impacted by the cost of care.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Discussion of costs with providers	Q55	--	Dropped	In the last 3 months, did you and your kidney doctors or anyone on your kidney care team talk about the cost of your blood tests, x-rays, or other tests?	Cost of treatment questions streamlined to simplify and capture the extent to which Beneficiaries are impacted by the cost of care.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q56	--	Dropped	During the last 3 months, did you delay or not get blood tests, x-rays, or other tests that were ordered for you?	Cost of treatment questions streamlined to simplify and capture the extent to which Beneficiaries are impacted by the cost of care.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q57	--	Dropped	Was cost or lack or insurance a reason why you delayed or did not get the tests?	Cost of treatment questions streamlined to simplify and capture the extent to which Beneficiaries are impacted by the cost of care.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Part D coverage, other insurance coverage (Medicgap)	Q78	Q38	Some people who are eligible for Medicare or Medicaid also have another type of insurance. Do you have any of the following types of health insurance?	Some people who are eligible for Medicare and Medicaid also have private insurance. This insurance may be through an employer, through the VA, purchased directly, or may be a supplemental plan like Medigap or Medicare Supplement or Medicare Special Needs Plan or Medicare Advantage Plan Other than Medicare and Medicaid, do you have any type of health insurance?	Question rewritten to simplify concept.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Part D coverage, other insurance coverage (Medicgap)	Q80	Q39	No change	Are you covered for your prescription drugs through any of the following health plans? [YES/NO/REFUSED/DON’T KNOW TO EACH] 1□ Medicare Part D [IF NEEDED: The Medicare prescription drug plan]? 2□ Medicaid? 3□ Low Income Subsidy? 4.□A private prescription drug plan or any kind of plan?	Performed as expected
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Reimbursement process	Q79	--	Dropped	Do you pay any or all of the premium or cost for this health plan? Do not include the cost of any co-pays or deductibles you or your family may have had to pay. [IF NEEDED: Copays are the partial payments you make for your health care each time you see a doctor or use the health care system, while someone else pays for your main health care coverage. A deductible is the amount you pay for medical care before your health plan starts paying. Premium is the monthly charge for the cost of your health insurance plan.]	Question dropped as during cognitive testing respondents were confused about what they were and were not paying for insurance.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Cost of prescription meds	Q81	Q40	In the last three months were you ever worried or concerned about the costs of your dialysis treatments, tests or prescription medicines?	In the last 3 months, were you ever worried or concerned about the cost of your prescription medicine?	Combined and rewrote Old Q81 and Old Q85 as during cognitive testing, the variability on these questions was minimal.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q85			In the last 3 months, were you ever worried or concerned about the cost of dialysis treatments?	Combined and rewrote Old Q81 and Old Q85 as during cognitive testing, the variability on these questions was very little and the questionnaire was minimal.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Cost of prescription meds	Q82	Q41	In the last three months, did you and your kidney doctors or anyone on your kidney care team talk about the costs of your dialysis treatments, tests, or prescription medicines?	If the 3 months, did you and your kidney doctors or anyone on your kidney care team talk about the cost of your prescription medicine?	Combined and rewrote Old Q82 and Old Q85 as during cognitive testing, the variability on these questions was minimal.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q86			If the 3 months, did you and your kidney doctors or anyone on your kidney care team talk about the cost of dialysis treatments?	Combined and rewrote Old Q82 and Old Q85 as during cognitive testing, the variability on these questions was minimal.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Cost of prescription meds	Q83	Q42	In the last three months, did you delay or not get dialysis treatments, tests, or medicines prescribed for you?	During the past 3 months, did you delay or not get a medicine that a doctor prescribed for you?	Combined and rewrote Old Q83 and Old Q87 as during cognitive testing, the variability on these questions was minimal.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q87			During the past 3 months, did you delay or not get dialysis treatment that was recommended for you?	Combined and rewrote Old Q83 and Old Q87 as during cognitive testing, the variability on these questions was minimal.
6. What is the experience of ESRD beneficiaries in obtaining ESRD-related oral drugs under the ESRD PPS/QIP? Are there any issues with obtaining ESRD-related medications? Are there any issues with accessing pharmacies? Is there confusion among the beneficiaries on oral medications covered by Part D and ESRD-related medications not covered by Part D?	Cost of prescription meds	Q84	Q43	Was cost or lack of insurance a reason why you delayed getting dialysis treatments, tests, or prescription medicines?	Was cost or lack of insurance a reason why you delayed or did not get the prescription?	Combined and rewrote Old Q84 and Old Q88 as during cognitive testing, the variability on these questions was minimal.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q88			Was cost or lack of insurance a reason why you delayed or did not get the dialysis treatment?	Combined and rewrote Old Q84 and Old Q88 as during cognitive testing, the variability on these questions was minimal.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q89	--	Dropped	In the past month, how much of your own money have you spent on … [IF NEEDED: Do not include costs or money that was reimbursed or paid back to you.] a. Prescription medicines? b. Blood tests, x-rays, or other tests? c. Medical supplies? d. Co-payments for doctor or clinic visits? e. Insurance premiums? f. Other medical costs related to your dialysis care and treatments? {Specify} g. Other medical costs related to your dialysis care and treatments? {Specify}	Question dropped as during cognitive testing respondents had difficulty calculating the total amount paid for dialysis care in the last month.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q90	--	Dropped	By my calculations, you paid a total of {total from a-g} of your own money in the past month on your medical care, tests, and treatments. Does that sound right?	Question dropped as during cognitive testing respondents had difficulty calculating the total amount paid for dialysis care in the last month.
7. What are the beneficiary out-of-pocket (OOP) costs compared to out-of-pocket (OOP) costs under the ESRD PPS/QIP the ESRD PPS/QIP?	Cost of treatment, out of pocket expenses	Q91	--	Dropped	How much would you say you paid of your own money in the past month on your medical care, tests, and treatments?	Question dropped as during cognitive testing respondents had difficulty calculating the total amount paid for dialysis care in the last month.
	Demographics
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Race/ethnicity	Q97	Q44	No change	Are you of Hispanic or Latino origin or descent?	Performed as expected	ICH53	Are you of Hispanic or Latino origin or descent?	No revisions to the question.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Race/ethnicity	Q98	Q45	No change	Please tell me which one or more of the following you would use to describe yourself. Would you describe yourself as:	Performed as expected	ICH54	What is your race? Please mark one or more.	The ICH CAHPS survey is administered by paper. This survey is a telephone survey and the question captures race correctly.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Education	Q99	Q46	No change	What is the highest grade or level of school that you have completed?	Performed as expected	ICH52	What is the highest grade or level of school that you have completed?	No revisions to the question.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Living arrangements / Marital status	Q100	Q47	No change	Are you now 1□ married, 2□ living with a partner in a marriage-like relationship, 3□ widowed, 4□ divorced, 5□ separated, 6□ never married -7□ REFUSED -8□ DON’T KNOW	Performed as expected
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Income	Q101	Q48	No change	What was your household annual income from all sources before taxes?	Performed as expected
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Income	Q102	Q49	No change	Including yourself, how many people living in your household are supported by your total household income?	Performed as expected
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Income	Q103	--	Dropped	How many of these {INSERT NUMBER FROM Q88} people are children under the age of 18?	Question dropped to streamline instrument.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q71	--	Dropped	About how many close friends and close relatives do you have, that is, people you feel at ease with and can talk to about what is on your mind?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q72	--	Dropped	Someone to help you if you were confined to bed?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q73	--	Dropped	Someone you can count on to listen to you when you need to talk?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q74	--	Dropped	Someone to take you to the doctor if you needed it?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q75	--	Dropped	Someone to prepare your meals if you were unable to do it yourself?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q76	--	Dropped	Someone to help with daily chores if you were sick?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.
5. Do vulnerable populations (e.g., minorities, the elderly, beneficiaries living in rural areas, etc.) or for smaller segments of the dialysis population (e.g., home hemodialysis patients, peritoneal dialysis patients, etc.) have unintended consequences under the ESRD PPS/QIP? What are the unintended consequences?	Support structure	Q77	--	Dropped	Someone to do something enjoyable with?	Since the survey targets the impact of the ESRD PPS/QIP program on beneficiaries, this question deemed to be a lesser interest and less relevant to measuring changes in the PPS/QIP program.