Form #9 Form #9 Cognitive Interview Guide for CV Checklist

Attachment K

Cognitive Interview Guide for CV Checklist

A

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

ttachment K

Cognitive Interview Guide for CV Checklist

As you read an item, please tell me out loud any thoughts that go through your mind.

 

I have discussed the following with the patient:

	Item	Probe
☐	The possible or likely nature of the illness or disease;	What does "nature of the illness" mean to you?
☐	The degree of uncertainty of any diagnosis arrived at	What does "degree of uncertainty" mean to you? Should this be phrased positively instead of negatively? For example, "There is an X% chance the diagnosis is correct."
☐	Other options for investigation, diagnosis and treatment	What does "investigation" mean to you?
☐	The proposed approach to investigation, diagnosis and treatment What the proposed approach entails The expected benefits Common side effects Material risks of any intervention Whether the intervention is conventional or experimental Who will undertake the intervention	What does "material risks" mean to you? Should we use the word treatment instead of intervention?
☐	Other options for investigation, diagnosis and treatment
☐	The degree of uncertainty about the therapeutic outcome	Should this be phrased in the positive?
☐	The likely consequences of choosing or not choosing the proposed diagnostic procedure or treatment, or of not having any procedure or treatment at all	What do "consequences" mean to you? Do you think "consequences" also includes the financial impact to the patient?
☐	Any significant long term physical, emotional, mental, social, sexual, or other outcome which may be associated with a proposed intervention	What are some "other" outcomes that may occur?
☐	The time involved in treatment and recovery	What does "time involved" mean to you? When does "recovery" end? If you broke your leg would "time involved" be the time from when you saw the physician until the leg was healed or would it only be the time you spent in physical therapy?
☐	Explained how treatment choice could affect a patient's finances. Total costs of care Out of pocket costs. Costs of all medications Medication costs unlikely to be covered by insurance Costs of medical treatment (excluding medication treatments) options Costs of medical treatments (excluding medication treatments) unlikely to be covered by insurance Different costs based on location of treatment (nursing home, home, hospital) End of life care costs	What does "total costs of care" include? When you think of the costs of medical treatment do you usually include the cost of medications as part of the treatment costs?
☐	Whether the benefits of a given investigation/treatment/therapy merit the cost	How do you determine if the cost is too much?
☐	Provided the patient a list of financial resources (if necessary)	Can you give some examples of these financial resources?
☐	Asked the patient about their concerns and preferences
☐	Confirmed the patient’s understanding of the diagnosis and treatment	How might you go about confirming the patient's understanding?

1. Is the list complete (no significant omissions)?

2. Are there incomplete items?

3. Do any items overlap?

4. Are there unclear items?

5. Is the list concise?

6. Is it easy to use?

7. How long did it take you to use the checklist?

8. In general, can the checklist be completed in a reasonably brief period of time?

9. Does using the checklist fit the flow of work?

10. Are the items in the order you would like them? How might you reorder them?

11. Would you prefer to read each step, then do it or do the steps from memory, then pause and check?

12. Does the checklist cover costs to society of choosing particular types of investigation, treatment and recovery

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the interview. 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.