Crosswalk

ATTACHMENT 5
Crosswalk between Data Collection Instruments from 60-day to 30-Day Notice
This document provides a crosswalk between the data collection instrument dated 11/12/13 and the revised data collection
instruments dated 3/11/14. Since the original submission, Westat has conducted a cognitive testing of the newly
developed items of the Baseline National Survey to assess respondents’ understanding of the questions, and a timed
testing of the survey to estimate the necessary time to complete it. In addition, Westat provided all original draft surveys
of program participants to representatives of potential Wellness program partners for review and comment. Changes
made to the package are based on results of the cognitive tests and feedback from prospective Wellness program partners.
In general, the revised OMB application includes the following changes:
1) Reduced the number of survey questions. The number of questions in the baseline and the follow-up surveys of
program participants and national Medicare beneficiaries was reduced to diminish survey burden.
2) Eliminated the Disenrollee Survey. A separate Disenrollee Survey has been eliminated in order to reduce
administrative burden on wellness program partners in identifying program disenrollees. A limited set of
questions has been included in the 6-month Follow-up Participant Survey enabling participants to self-report
their program completion status, and reasons for non-completion (for those respondents who report that they have
not completed the full program).
The following tables outline the specific changes to each component of the OMB application:
• Table 1. Changes in the Number of Questions by Survey
• Table 2. Revisions to Part A, Attachment 2: Baseline National Survey
• Table 3. Revisions to Part A, Attachment 2: 6- and 12-month National Follow-up Surveys
• Table 4. Revisions to Part A, Attachment 3: Baseline Participant Survey
• Table 5. Revisions to Part A, Attachment 3: 6-Month Follow-up Participant Survey
• Table 6. Revisions to Part A, Attachment 3: 12-Month Follow-up Participant Survey

1

Table 1: Changes in the Number of Questions by Survey
Survey
Baseline
6-mo Followup
12-mo
Follow-up
Disenrollee

1

Original Survey
11/12/13
146

Participant Survey: Number of Questions
Revised Survey
Total Eliminated
3/11/14
108
38

National Survey: Number of Questions
Original Survey
Revised Survey
Total Eliminated
144

114

30

105

84

42

105

60

45

105

62

43

105

60

45

NA 1

NA

NA

21

Selected questions were combined with the 6-mo Follow-up
Survey

NA = Not applicable

2

Table 2: Revisions to Part A, Attachment 2: Baseline National Survey
Issue
#
1

Page #
Original
11/12/13
11-12

Page #
Revised
3/11/14
NA

2

12

NA

3

12

12

4

13-14

12

5

NA

13

6

NA

13

Changes Made to the Application

Reason for the Change

Eliminated questions 19-21 (binge
drinking) from the original Baseline
National Survey, and renumbered the
survey questions accordingly.
Eliminated questions 23-25d (receipt
of preventive services) from the
original Baseline National Survey,
and renumbered the survey questions
accordingly.
Changed section label
“Lifestyle Modification” of the
original survey to “Making
Changes to Stay Healthy”
Eliminated Lifestyle
Modification questions 26a30a and changed questions
26b- 30b of the original
baseline survey to questions
22-26 of the revised Baseline
National Survey.
Added the transitional sentence
“the next question is about
actions your health care
provider may have suggested
that you take to improve your
health” prior to question 27.
Added the transitional sentence “the
next few questions are about your
awareness of and enrollment in
wellness programs to help you make a
change based on your need.” Added
also a definition for wellness
programs.

The questions that would identify binge drinkers were eliminated in order to reduce survey
burden. Other matching/control variables of greater importance were retained (e.g. vision,
hearing, and smoking status).
The main purpose of adding questions about vaccinations and health screenings was to
measure respondents’ attitudes toward prevention. Questions about receipt of pneumonia
vaccination, mammogram screening, and colon cancer screening were eliminated in order to
reduce survey burden; instead a question on flu vaccination (Question. 22: “Have you had a
flu shot in the past year?”) will be used as a proxy measure for attitudes towards prevention.
This change was made to simplify the language and was based on the cognitive testing.

Questions 26b to 30b of the original baseline survey were changed to questions 22 to 26 of
the revised baseline survey. Questions 26a to 30a were eliminated after a response option of
“I don’t need to make a change like this” was included in the revised version. These changes
were based on the results of the cognitive testing.

This transitional sentence was added to facilitate the survey flow. These changes were based
on the results of the cognitive testing

These changes were added to facilitate the survey flow and to gain consistency on the
interpretation of wellness programs by respondents. These changes were based on the results
of the cognitive testing.

3

Table 2: Revisions to Part A, Attachment 2: Baseline National Survey (Continued)
Issue
#
7

Page #
Original
11/12/13
14-15

Page #
Revised
3/11/14
13-14

Changes Made to the
Application

Reason for the Change

Reordered questions 32a to 35 of
the original Baseline National
Survey to questions 28 to 33 of
the revised Baseline National
Survey.
Revised question 32a of
the original survey to
question 28 of the revised
survey. Two “yes”
response options were
included: “yes, in my
community” and “yes,
online”.
Changed question 33a of
the original survey to
question 32 of the revised
survey.

These questions were reordered to facilitate the survey flow and to reduce the number of skipped
instructions. These changes were based on the results of the cognitive testing

8

14

13

9

14

13

10

14

14

Changed question 33b of the
original survey to question 33 of
the revised survey.

11

15

13

Changed question 34c of
the original survey to
question 30 of the revised
survey.

Based on additional information about prospective Wellness program partners, participants can
enroll in a wellness program either online or in person. As such, the single “yes” response option
of question 32a in the original survey was changed to include two “yes” response options for
question 28 in the revised version: “yes, in my community” and “yes, online”. This change is
necessary to distinguish between the two program modes of delivery.

Question 32 of the revised survey (“Have you participated in a wellness program in your
community or online to help you make this kind of change in the past 24 months?) clarifies the
timeframe for recall. Without this revision, Medicare beneficiaries might be screening out (for
matching purposes) who participated in a wellness program in the distant past (in their 20's or
30's, for example), which would preclude their eligibility for matching with the wellness program
participants. In addition, we included a response option of “other” to the question. This change is
necessary to allow the response options to be exhaustive, as suggested by the results of the
cognitive testing.
Question 33b is a follow-up to question 33a in the original survey. It asks the respondent to
identify in what kind of program he/she has participated previously. Given the revision to this
question about the timeframe, question 33 references the same timeframe from “participation
ever” to “participation in the past 24 months”.
The response option of “None” in the original survey was changed to “None of these” in the
revised survey. In addition, we added an “other” category to the response options. These
changes were made based on the results of the cognitive testing to allow the response options to
be exhaustive.

4

Table 2: Revisions to Part A, Attachment 2: Baseline National Survey (Continued)
Issue
#

2
3

12

Page #
Original
11/12/13
16

Page #
Revised
3/11/14
14

13

16-17

15

14

18

16

15

18

NA

16

18

16

17

19

NA

Changes Made to the
Application

Reason for the Change

Changed question 41 of
the original survey to
question 39 of the revised
survey.
Eliminated questions 46c
to 46h from the original
baseline survey and
renumbered the questions
accordingly. Questions
46a and 46b from the
original version became
questions 44a and 44b in
the revised version.
Changed question 49 of
the original baseline
survey to question 46b in
the revised version.
Eliminated question 53
from the original baseline
survey.
Revised the instructions for
measures of confidence in
balance.

We changed question 41 of the original survey (“I believe I can succeed at almost any endeavor
to which I set my mind”) to question 39 of the revised survey (“I believe I can succeed at almost
anything that I set my mind to”). This change was necessary to facilitate respondents’
understanding of the question. This revised question was based on the cognitive testing.
Questions 46a-46h (PHQ8) were used as an outcome measure: the mental health component
score of the SF-36 (in lieu of the PHQ8 measure) will be used to evaluate depression as an
outcome. Questions 46a and 46b (PHQ2), representing depression as a control variable, were
retained.

Eliminated questions 55
(sleep disturbance visual
scale measure) and 56
(pain interference visual
scale measure) from the
original baseline survey.

Based on the results to the cognitive testing question 49 was changed from the original survey
(“How many of these falls resulted in an injury?) to question 46b of the revised version (“How
many of these falls caused you to limit your regular activities for at least a day or to see a
doctor?) This change was necessary to better define and identify “injury”.
According to Powell & Meyers (1995) 2, the single fear item (question 52) can discriminate
between high and low mobility group. Therefore, question 53 was eliminated to reduce survey
burden.
Based on the cognitive testing, the instructions were revised for clarification purposes. The
revised instructions now read: “The next questions are about keeping your balance in different
situations. You may have to imagine yourself in these situations if you have not encountered
them recently. For each one, choose any number between 0 (no confidence) and 100 (complete
confidence) to say how confident you are that you could keep your balance. If you normally use
a cane or walker or hold on to someone, answer as if you had that help.”
According to Lyons and Fielder (1993), the SF-36 distinguishes well between people who had
and had not been treated for sleeping disorders. 3 Question 8 from SF-36 captures pain
interference. Therefore, questions 55 and 56 were eliminated from the original survey to reduce
survey burden

Powell, LE & Myers, AM (1995). The activities-specific balance confidence (ABC) scale. Journal of Gerontology: Medical Sciences, 50, M28-M34.
Lyons et al (1993). The SF-36 health survey questionnaire. Questionnaire does detect poor sleep. BMJ. British Medical Journal, 307(6901):449.

5

Table 2: Revisions to Part A, Attachment 2: Baseline National Survey (Continued)
Issue
#
18

Page #
Original
11/12/13
20

Page #
Revised
3/11/14
NA

19

21

18

20

22

19

21

22

NA

22

NA

19

Changes Made to the
Application

Reason for the Change

Eliminated questions 58a
to 58d (“what you eat”)
from the original survey.
Added “Demographics” to
label the demographic
section. Added a
transitional sentence “the
next two questions are
about Hispanic origin and
race” before question 57.
Reordered questions 60-63
of the original baseline
survey to questions 56-59
in the revised version.
Eliminated asking
respondents to specify
“other” insurance. The
revised version only asks
them to check “other”
Eliminated question 76 from the
original baseline survey.

In an effort to reduce survey burden, questions on nutrition intake were eliminated. These
questions were prioritized as less important than other outcome measures (i.e. health-related
quality of life, physical activity, confidence in balance, and medication adherence).
These are editorial changes made to improve the survey flow.

Added question 72 (date of
completing this survey) to
the revised baseline
survey.

This revision was made to reduce survey burden.

Question 76 (“How hard is it for you to pay for the very basics like food, housing, medical care,
and heating?) was eliminated to reduce survey burden. The income question will serve as a
proxy measure for ability to pay for basics.
This question was added in order to identify the date when the respondent completed the survey.
This is necessary for comparing data across pre- and post-implementation periods.

6

Table 3: Revisions to Part A, Attachment 2: 6- and 12-month Follow-up National Surveys
The purpose of the 6- and 12-month Follow-up surveys of the National Medicare beneficiaries and the program participants is to repeat the same outcome measures
collected at baseline in order to compare pre-post enrollment changes between the two groups. The 6-month Follow-up National Survey is the same as the 12-month
Follow-up National Survey. If an outcome measure was changed in the baseline survey, the same change was made in the follow-up survey for consistency.
Issue
#
1

Page #
Original
11/12/13
31

Page #
Revised
3/11/14
NA

2

33

28

3

33

NA

4

33

28

5

33-34

NA

6

34

NA

7

35-38

29

Changes Made to the Application

Reason for the Change

Eliminated questions 12a-h from the
original 6-and 12- month Follow-up
survey.
Revised question 15 in the
original follow-up survey to
question 14 of the revised
follow-up survey.
Eliminated question 18 from
the original follow-up survey.
Revised the instructions for measures
of confidence in balance.
Eliminated questions 20 (sleep
disturbance visual scale
measure) and 21 (pain
interference visual scale
measure) from the original
follow-up survey.
Eliminated questions 23a to
23d (“what you eat”) from the
original follow-up survey.
Eliminated questions 24a-30 of
the original follow-up survey.
Replaced them with questions
22-23 of the revised follow-up
survey.

These questions were eliminated from the Baseline National survey. As such, these questions
are not required in the follow-up survey.
This change was necessary for consistency with the revision in the Baseline National Survey.

This change was necessary for consistency with the revision in the Baseline National Survey.
This change was necessary for consistency with the revision in the Baseline National Survey.
This change was necessary for consistency with the revision in the Baseline National Survey.

This change was necessary for consistency with the revision in the Baseline National Survey
Instead of asking the respondents to report whether they participated in each of the five types
of wellness programs under evaluation (diet and nutrition, weight management, strength and
fitness, fall prevention, and chronic diseases management), and how satisfied they were with
the program if they attended one, questions 24a-30 were streamlined into one question
(question 22) to identify all the wellness programs they attended in the past 24 months. This
change was made to reduce survey burden for respondents. Question 23 was added to collect
the date of survey completion.

7

Table 4: Revisions to Part A, Attachment 3: Baseline Participant Survey
Issue
#
1

Page #
Original
11/12/13
12

Page #
Revised
3/11/14
NA

2

12

NA

3

12-14

NA

4

NA

12

5

NA

12

6

14

12

Changes Made to the Application

Reason for the Change

Eliminated questions 19-21 (binge drinking)
from the original Baseline Participant
Survey, and renumbered the survey
questions accordingly.
Eliminated questions 23-25d (receipt of
preventive services) from the original
Baseline Participant Survey, and
renumbered the survey questions
accordingly.
Eliminated questions 26a – 30b
(changes to help you stay healthy)
from the original Baseline Participant
Survey and renumbered the survey
questions accordingly.
Added the transitional sentence “the
next question is about actions your
health care provider may have
suggested that you take to improve
your health” prior to question 22.
Added the transitional sentence “the next
few questions are about your awareness of
and enrollment in wellness programs to help
you make a change based on your need.”
Added also a definition for wellness
programs.
Changed question 32a from the original
Baseline Participant Survey to question 23
of the revised Baseline Participant Survey.

This change was necessary for consistency with the revision in the Baseline National
Survey.
This change was necessary for consistency with the revision in the Baseline National
Survey.

In the interest of reducing survey burden, we eliminated questions 26a-30b given that
participants, by definition, have made the decision to engage in a wellness program.

This transitional sentence was added to facilitate the survey flow.

This change was necessary for consistency with the revision in the Baseline National
Survey.

In the interest of being able to distinguish between awareness of online programs and
community-based programs, question 32a in the original version was modified to
question 23 in the revised version to enable this distinction.

8

Table 4: Revisions to Part A, Attachment 3: Baseline Participant Survey (Continued)
Issue
#
7

Page #
Original
11/12/13
14-15

Page #
Revised
3/11/14
NA

8

15

12

9

16

13

10

17

14

11

18

15

12

19

NA

13

19

15

14

19-20

NA

15

20-21

NA

Changes Made to the Application

Reason for the Change

Eliminated questions 32b, 33a,
33b, 34b, and 34c from the
original survey and renumbered
the remaining questions
accordingly.
Replaced question 34a and 35 in
the original Baseline Participant
Survey with questions 24 and 25
in the revised version,
respectively.
Changed question 41 of the
original survey to question 31 of
the revised survey.

Questions 32b (willingness to sign up in the next 6 months), 33a (past program
enrollment), 33b (type of program enrollment in the past), 34b (willingness to
participate if Medicare covers the program), and 34c (type of program to sign up if
Medicare covers it) were eliminated to reduce survey burden and given that
participants have made the decision to engage in a wellness program.
These changes were made to clarify that program enrollment can be either in person
or online.

Eliminated questions 46c to 46h
from the original baseline survey
and renumbered the questions
accordingly. Questions 46a and
46b from the original version
became questions 36a and 36b in
the revised version.
Changed question 49 of the
original baseline survey to
question 38b in the revised
version.
Eliminated question 53 from the
original baseline survey.
Revised the instructions for measures of
confidence in balance.
Eliminated questions 55 (sleep
disturbance visual scale measure)
and 56 (pain interference visual
scale measure) from the original
baseline survey.
Eliminated questions 58a to 58d
(“what you eat”) from the original
survey.

This change was necessary for consistency with the revision of the Baseline National
Survey.

This change was necessary for consistency with the revision in the Baseline National
Survey.

This change was necessary for consistency with the revision in the Baseline National
Survey
This change was necessary for consistency with the revision in the Baseline National
Survey
This change was necessary for consistency with the revision in the Baseline National
Survey
This change was necessary for consistency with the revision in the Baseline National
Survey.

This change was necessary for consistency with the revision in the Baseline National
Survey

9

Table 4: Revisions to Part A, Attachment 3: Baseline Participant Survey (Continued)
Issue
#
16

Page #
Original
11/12/13
21

Page #
Revised
3/11/14
16

17

22

17

18

23

NA

19

NA

18

Changes Made to the Application

Reason for the Change

Added “Demographics” to
label the demographic section.
Added a transitional sentence
“the next two questions are
about Hispanic origin and
race” before question 57.
Reordered questions 60-63 of
the original baseline survey to
questions 48-51 in the revised
version.
Eliminated asking respondents
to specify “other” insurance.
The revised version only asks
them to check “other”.
Eliminated question 76 from the
original baseline survey.
Added question 65 (date of
completing this survey) to the
revised baseline survey.

This change was necessary for consistency with the revision in the Baseline National
Survey

This change was necessary for consistency with the revision in the Baseline National
Survey
This change was necessary for consistency with the revision in the Baseline National
Survey
This change was necessary for consistency with the revision in the Baseline National
Survey

10

Table 5: Revisions to Part A, Attachment 3: 6-Month Follow-up Participant Survey
Below are the changes to the 6-month Follow-up Participant Survey. Selected questions from the original Disenrollee Survey were included in the revised 6-month
Follow-up Participant Survey to reduce burden on participants.
Issue
#
1

Page #
Original
11/12/13
31

Page #
Revised
3/11/14
NA

2

33

27

3

33

NA

4

33

27

5

33-34

NA

6

34-35

NA

7

35-38

29

8

NA

30

Changes Made to the Application

Reason for the Change

Eliminated questions 12a-h from the
original 6- & 12- month Follow-up
Survey.
Modified question 15 in the
original follow-up survey to
question 14 of the revised
follow-up survey.
Eliminated question 18 from
the original follow-up survey.
Revised the instructions for measures
of confidence in balance.
Eliminated questions 20 (sleep
disturbance visual scale
measure) and 21 (pain
interference visual scale
measure) from the original
follow-up survey.
Eliminated questions 23a to
23d (“what you eat”) from the
original follow-up survey.
Eliminated questions 24a-30
from the original follow-up
survey. Replaced them with
questions 22-23b of the revised
follow-up survey.
Added question 26 (date of
filling out survey)

This change was necessary for consistency with the revision in the Baseline Participant
Survey.
This change was necessary for consistency with the revision in the Baseline Participant
Survey.
This change was necessary for consistency with the revision in the Baseline Participant
Survey.
This change was necessary for consistency with the revision in the Baseline Participant
Survey.
This change was necessary for consistency with the revision in the Baseline Participant
Survey.

This change was necessary for consistency with the revision in the Baseline Participant
Survey.
This change was necessary for consistency with the revision in the Baseline Participant
Survey.

Question 26 was added to collect the date of survey completion.

11

Table 5: Revisions to Part A, Attachment 3: 6-Month Follow-up Participant Survey (Continued)
Selected questions from the original Disenrollee Survey were added to the 6-month Follow-up Participant Survey. Specific changes to those questions and new
questions to self-identify participation completion status were added, as described below.
Issue
#
9

Page #
Original
11/12/13
NA

Page #
Revised
3/11/14
29

10

NA

30

11

NA

30

Changes Made to the Application

Reason for the Change

Questions 5c (“How much
would you be willing to pay in
total for the program that you
enrolled in?”) and 10 (“What
would you say was the best
thing about the program?”)
from the original Disenrollee
Survey (Attachment 4, version
11/12/2013) were added as
questions 24 and 25,
respectively, in the 6-month
Follow-up Participant Survey.
Added new questions 27-28 to
the revised 6-Month Follow-up
Participant Survey.

These questions were extracted from the original Disenrollee Survey to combine with the
6-month Follow-up Participant Survey in order to reduce survey burden on participants
(one fewer survey for completion by participants).

Question 6 of the original
Disenrollee Survey
(Attachment 4, version
11/12/2013) was added as
question 29 of the revised 6month Follow-up Participant
Survey.

This question was extracted from the original Disenrollee Survey to combine with the 6month Follow-up Participant Survey in order to reduce survey burden on participants (one
fewer survey for completion by participants). An editorial change was made by replacing
“not to finish” with “leave” in the revised question 29 (“Did you decide to leave the
program because of your ill health?”)

Questions 27 and 28 were added to screen participants whether they still participate in the
program or stopped participating in the program. These screening questions are needed to
instruct participants to skip questions that are not relevant to them.

12

Table 5: Revisions to Part A, Attachment 3: 6-Month Follow-up Participant Survey (Continued)
Issue
#
12

Page #
Original
11/12/13
NA

Page #
Revised
3/11/14
30

13

NA

31

14

NA

32

15

NA

32

Changes Made to the Application

Reason for the Change

Questions 4a and 4b of the
original Disenrollee Survey
(Attachment 4, version
11/12/2013) were added as
questions 30a and 30b of the
revised 6-month Follow-up
Participant Survey.
Question 8 of the original
Disenrollee Survey
(Attachment 4, version
11/12/2013) was added as
question 31 of the revised 6month Follow up Participant
Survey. Question 5a (cost) of
the original Disenrollee Survey
was added as question 31m in
the revised 6-month Follow-up
Participant Survey.
Question 7 of the Disenrollee
Survey was added as question
32 in the revised 6-month
Follow-up Participant Survey.
Question 9 of the Disenrollee
Survey was added as question
33 in the revised 6-month
Follow-up Participant Survey.

These questions were extracted from the original Disenrollee Survey to combine with the 6month Follow-up Participant Survey in order to reduce survey burden on participants (one
fewer survey for completion by participants). An editorial change was made by replacing
“not to finish” with “leave” in the revised question 30a (“Did you decide to leave the
program because it did not meet your health needs?). An editorial change was also made to
revised question 30b by making it an open-ended question: “In what ways did the program
fail to meet your health needs? Please specify in the space below.”
These questions were extracted from the original Disenrollee Survey to combine with the 6month Follow-up Participant Survey in order to reduce survey burden on participants (one
fewer survey for completion by participants). The layout was modified from the list format to
a table format to improve presentation and for ease of completion.

Editorial changes were also made to revised question 32 from “If there were other reasons
you decided to withdraw from the program, please list them below” to “Please use the space
below to describe any other reasons you had for deciding to leave the program” for ease of
understanding.
Instead of providing options for five reasons to resume program participation, revised
question 33 is open-ended.

13

The revised 12-month Follow-up Participant Survey repeats the same outcome measures collected at baseline and 6-month follow-up. Unlike the revised 6-month
Follow-up Participant Survey, the revised 12-month Follow-up Survey does not include disenrollment questions. The Wellness program evaluation project only
includes a one-time survey of the disenrollees.
Table 6: Revisions to Part A, Attachment 3: 12-Month Follow-up Participant Survey
Issue
#
1

Page #
Original
11/12/13
31

Page #
Revised
3/11/14
NA

2

33

37

3

33

NA

4

33

37

5

33-34

NA

6

34-35

NA

7

35-38

29

8

NA

39

Changes Made to the Application

Reason for the Change

Eliminated questions 12a-h from the
original 6- & 12- month Follow-up
Survey.
Revised question 15 in the
original follow-up survey to
question 14 of the revised
follow-up survey.
Eliminated question 18 from
the original follow-up survey.
Revised the instructions for measures
of confidence in balance.
Eliminated questions 20 (sleep
disturbance visual scale
measure) and 21 (pain
interference visual scale
measure) from the original
follow-up survey.
Eliminated questions 23a to
23d (“what you eat”) from the
original follow-up survey.
Eliminated questions 24a-30 of
the original follow-up survey.
Replaced them with questions
22-23b of the revised followup survey.
Added question 24 (date of
completing this survey) to the
revised follow-up survey.

This change was made for consistency with the Baseline Participant Survey.
This change was made for consistency with the Baseline Participant Survey.

This change was made for consistency with the Baseline Participant Survey.
This change was made for consistency with the Baseline Participant Survey.
This change was made for consistency with the Baseline Participant Survey.

This change was made for consistency with the Baseline Participant Survey.
This change was made for consistency with the 6-month Participant Follow-up Survey.

This question was added to capture date of survey completion.

14