Attachment G R80 ACQ revisions (Feb 2017 non-sub change request)

Access to Care (ACQ): moved from Fall Round to Winter Round
Variable Name
MR Screen Name
Question text/description
ACINT
ACINTRO
The next questions are about health care services [you/(SP)] may have used since (REFERENCE DATE).
ERVISIT

AC1

Since (REFERENCE DATE), did [you/(SP)] go to a hospital emergency room?

EWAITUNT

AC6A

Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)]
have to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person?
Please include the time spent in the waiting room and exam room.

EWAITHRS

AC6A

EWAITMIN

AC6A
BOX AC1B

ERADMT

Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)]
have to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person?
Please include the time spent in the waiting room and exam room.
Think about the most recent time [you/(SP)] went to the hospital emergency room. How long did [you/(SP)]
have to wait during (your/his/her) visit before (you/he/she) saw a doctor or some other medical person?
Please include the time spent in the waiting room and exam room.
IF INTTYPE=7 AND SP DID NOT REPORT AN EVENT AT ER2, GO TO AC7 - ERADMT.
ELSE GO TO BOX AC1C.

AC7

[Were you/Was (SP)] admitted to the hospital from the emergency room?
[PROBE IF NECESSARY TO DETERMINE IF THE RESPONDENT WAS ACTUALLY ADMITTED OR ASK TO SEE THE
HOSPITAL BILL TO MAKE THE DETERMINATION.]

BOX AC1C

IF INTTYPE=7 AND SP DID NOT HAVE OP VISIT IN CURRENT ROUND, GO TO AC8 - OPDVISIT.
ELSE IF AC6A ASKED WHILE ADMINISTERING ER, GO TO BOX ER6.
ELSE IF (SP HAD AN OP VISIT IN THE CURRENT ROUND OR ANY OF THE 2 PREVIOUS ROUNDS) AND (AC9AC16A NOT ALREADY ASKED), GO TO AC9 - OPDREAS.
ELSE GO TO BOX AC1E.

OPDVISIT

AC8

OPDREAS

AC9

OPDOTHOS

AC9

Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) Don't Know
(-9) Refused
(01) continuous answer

(01) continuous answer

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
Since (REFERENCE DATE), did [you/(SP)] go to a hospital clinic or outpatient department?
(02) NO
DO NOT INCLUDE HOSPITAL INPATIENT STAYS.
(-8) Don't Know
(-9) Refused
(01) MEDICAL CONDITION NAMED
(02) TESTS
[I have a few more questions about visits that [you/(SP)] had in the past.]
(03) FOLLOW-UP
(04) CHECKUP
Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department. What was the
(05) REFERRAL
reason [you/(SP)] went to the hospital clinic or outpatient department?
(06) SURGERY
[PROBE FOR THE MOST RECENT VISIT IF RESPONDENT MENTIONS MORE THAN ONE. IF NEEDED, PROBE WITH
(07) PREVENTIVE SHOT
‘What did you have done during your most recent visit to the hospital clinic or outpatient department?’
(08) TREATMENT SHOT
SELECT ALL THAT APPLY.]
(09) TO GET OR REFILL PRESCRIPTION
[PROBE: Any other reason?]
(91) OTHER
CHECK ALL THAT APPLY.
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer

BOX AC1D

IF INTTYPE=7 AND SP DID NOT REPORT OUTPATIENT DEPARTMENT VISIT AT OP4) AND (RESPONSE TO AC9 OPDREAS INCLUDES 1/MedCondNamed OR 6/Surgery), GO TO AC12 - OPDAPPT.
ELSE IF INTTYPE=7 AND SP DID NOT REPORT OUTPATIENT DEPARTMENT VISIT AT OP4) AND (RESPONSE TO
AC9 - OPDREAS DOES NOT INCLUDE 1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO AC10 OPDSCOND.
ELSE GO TO AC12 - OPDAPPT.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) APPOINTMENT
(02) WALKED IN
(-8) Don't Know
(-9) Refused

OPDSCOND

AC10

Was that for a specific condition?

OPDAPPT

AC12

Did [you/(SP)] have an appointment for this visit to the hospital clinic or outpatient department, or did
(you/he/she) just walk in?

AC13

We are interested in knowing how the appointment was made for the visit to the hospital clinic or outpatient (01) SOMEONE MADE APPOINTMENT DURING
department you just told me about.
EARLIER VISIT
(02) SP CONTACTED OFFICE TO SET UP APPOINTMENT
Did someone make this appointment during an earlier visit, or did [you/(SP)] contact the hospital clinic or
(-8) Don't Know
outpatient department to set up the appointment ?
(-9) Refused

OPDDRTEL

OPDAWUNT

AC14

OPDAWDAY
OPDAWWKS
OPDAWMOS

AC14
AC14
AC14

OWAITUNT

AC16A

(00) DID NOT HAVE TO WAIT
(01) DAYS
(02) WEEKS
How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?
(03) MONTHS
(-8) Don't Know
(-9) Refused
How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?
(01) continuous answer
How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?
(01) continuous answer
How long did [you/(SP)] have to wait for the appointment -- about how many days, weeks, or months?
(01) continuous answer
(00) DID NOT HAVE TO WAIT
[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]
(01) HOURS ONLY
(02) MINUTES ONLY
How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she) saw a doctor (03) HOURS AND MINUTES
or some other medical person? Please include the time spent in the waiting room and exam room.
(-8) Don't Know
(-9) Refused
[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]

OWAITHRS

AC16A

How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she) saw a doctor
or some other medical person? Please include the time spent in the waiting room and exam room.

(01) continuous answer

[Think about the most recent time [you/(SP)] went to a hospital clinic or outpatient department.]
OWAITMIN

AC16A

How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she) saw a doctor
or some other medical person? Please include the time spent in the waiting room and exam room.

(01) continuous answer

BOX AC1E

NHRESEVR

AC17

NHLRESMM

AC18

NHLRESYY

AC18

MDVISIT

AC19

MDSPCLTY

AC20

MDSPCLOS

AC20

MDREAS

AC21

MDREAS

AC21

BOX AC1F

IF INTTYPE=7 AND (SP DID NOT REPORT A MEDICAL PROVIDER VISIT AT MP6 WHERE (MP6B - MPSDVIS ^=
1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR)) GO TO AC19-MDVISIT.
ELSE IF AC9-AC16A ASKED WHILE ADMINISTERING OP, GO TO BOX OP7.
ELSE IF (SP HAD AN MP VISIT IN THE CURRENT ROUND OR ANY OF THE 2 PREVIOUS ROUNDS) AND (AC20AC28A1 NOT ALREADY ASKED), GO TO AC20 - MDSPCLTY.
ELSE GO TO BOX AC1G.
(01) YES
(02) NO
[Have you/Has (SP)] ever been a resident or patient in a nursing home or similar place?
(-8) Don't Know
(-9) Refused
(01) continuous answer
When [were you/was (SP)] last a resident or patient in a nursing home or similar place?
(-8) Don't Know
(-9) Refused
(01) continuous answer
When [were you/was (SP)] last a resident or patient in a nursing home or similar place?
(-8) Don't Know
(-9) Refused
Next, I want to ask about [your/(SP)’s] visits to doctors since (REFERENCE DATE). [Have you/Has (SP)] seen a (01) YES
medical doctor since (REFERENCE DATE)? Please do not include a doctor seen at home, at an emergency
(02) NO
room or outpatient department, or while an inpatient at a hospital.
(-8) Don't Know
[IF NECESSARY, SAY, ‘Please look at show card AC1 for examples of types of medical doctors.’]
(-9) Refused
SHOW CARD AC1
(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
OTHER DR SPECIALTY (SPECIFY)
(01) continuous answer
(01) MEDICAL CONDITION NAMED
(02) TESTS
(03) FOLLOW-UP
(04) CHECKUP
What was the reason [you/(SP)] saw the doctor?
(05) REFERRAL
(06) SURGERY
[PROBE: ‘What did you have done during the visit?’ IF RESPONDENT DOES NOT UNDERSTAND WHAT IS BEING
(07) PREVENTIVE SHOT
ASKED. PROBE: ‘Any other reason?’ TO OBTAIN ALL REASONS.]
(08) TREATMENT SHOT
CHECK ALL THAT APPLY.
(09) TO GET OR REFILL PRESCRIPTION
(91) OTHER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer
IF INTTYPE=7 AND (SP DID NOT REPORT A MEDICAL PROVIDER VISIT AT MP6 WHERE (MP6B - MPSDVIS ^=
1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR))) AND (RESPONSE TO AC21- MDREAS INCLUDES
1/MedCondNamed OR 6/Surgery), GO TO AC24 - MDAPPT.
ELSE IF ( INTTYPE=7 AND (SP DID NOT REPORT A MEDICAL PROVIDER VISIT AT MP6 WHERE (MP6B - MPSDVIS
^= 1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR))) AND (RESPONSE TO AC21- MDREAS DOES NOT
INCLUDE 1/MedCondNamed AND DOES NOT INCLUDE 6/Surgery), GO TO AC22 - MDSCOND.
ELSE GO TO AC24 - MDAPPT.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) APPOINTMENT
(02) WALKED IN
(-8) Don't Know
(-9) Refused

MDSCOND

AC22

Was that for a specific condition?

MDAPPT

AC24

Did [you/(SP)] have an appointment for this visit with the doctor, or did (you/he/she) just walk in?

AC25

We are interested in knowing how the appointment was made for the visit to the doctor’s office you just told (01) SOMEONE MADE APPOINTMENT DURING
me about.
EARLIER VISIT
(02) SP CONTACTED OFFICE TO SET UP APPOINTMENT
Did someone make this appointment during an earlier visit, or did [you/(SP)] contact the doctor’s office to set (-8) Don't Know
up the appointment?
(-9) Refused

MDDRTEL

MDAWUNT

AC26

MDAWDAY

AC26

MDAWWKS

AC26

MDAWMOS

AC26

MWAITUNT

AC28A1

MWAITHRS

AC28A1

MWAITMIN

AC28A1

BOX AC1G

How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days,
weeks, or months?

How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days,
weeks, or months?
How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days,
weeks, or months?
How long did [you/(SP)] have to wait for the appointment with the medical doctor -- about how many days,
weeks, or months?
[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she)
saw a doctor or some other medical person? Please include the time spent in the waiting room and exam
room.
[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she)
saw a doctor or some other medical person? Please include the time spent in the waiting room and exam
room.
[Think about the most recent time [you/(SP)] saw a medical doctor somewhere other than at home or at a
hospital.] How long did [you/(SP)] have to wait during (your/his/her) most recent visit before (you/he/she)
saw a doctor or some other medical person? Please include the time spent in the waiting room and exam
room.
IF AC20-AC28A1 ASKED WHILE ADMINISTERING MP, GO TO MP18 - MPPRPRAC.
ELSE IF SP HAS A CURRENT MEDICARE MANAGED CARE PLAN, GO TO AC33 - MHREFDIF.
ELSE GO TO BOX AC3.

(00) DID NOT HAVE TO WAIT
(01) DAYS
(02) WEEKS
(03) MONTHS
(-8) Don't Know
(-9) Refused
(01) continuous answer
(01) continuous answer
(01) continuous answer
(00) DID NOT HAVE TO WAIT
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) Don't Know
(-9) Refused
(01) continuous answer

(01) continuous answer

The following questions are about health care that [you/(SP)] received through (CURRENT MEDICARE
MANAGED CARE PLAN NAME).

MHREFDIF

AC33

MHSPCLTY

AC34A

MHSPCLOS

AC34A

(01) YES
While a member of (CURRENT MEDICARE MANAGED CARE PLAN NAME), [have you/has (SP)] had difficulty in (02) NO
obtaining referrals for the services of a specialist or other medical person within (CURRENT MEDICARE
(03) N/A, HAVEN'T TRIED TO OBTAIN REFERRAL
MANAGED CARE PLAN NAME) that [you/(SP)] thought were necessary?
(-8) Don't Know
[IF NECESSARY, SAY: ‘The referral must have been for services provided by a specialist or medical provider
(-9) Refused
who is associated with your Medicare Managed Care plan, not a specialist or medical provider who is
"outside" of the plan.’]
(01) ALLERGY/IMMUNOLOGY
(03) CARDIOLOGY (HEART)
(05) DERMATOLOGY (SKIN)
(07) ENDOCRINOLOGY/METABOLISM
(DIABETES,THYROID)
(09) GASTROENTEROLOGY
(11) GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY - OBSTETRICS
(14) HEMATOLOGY (BLOOD)
(16) INTERNAL MEDICINE (INTERNIST)
(17) NEPHROLOGY (KIDNEYS)
SHOW CARD AC1
(18) NEUROLOGY
What kind of specialist or medical person was this?
(20) ONCOLOGY (TUMORS, CANCER)
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY
(21) OPHTHALMOLOGY (EYES)
LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS
(22) ORTHOPEDICS
SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR THAT
(24) OSTEOPATHY (DO)
SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR SPECIALTY'.]
(25) OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
(26) PATHOLOGY
(27) PHYS MED/REHAB
(28) PLASTIC SURGERY
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
(33) RHEUMATOLOGY (ARTHRITIS)
(35) UROLOGY
(36) AUDIOLOGIST
(37) CHIROPRACTOR
(38) DENTIST
OTHER (SPECIFY)
(01) continuous answer

What kind of difficulty did [you/(SP)] have?

(01) PLAN WOULDN’T AUTHORIZE SERVICE
(02) THE WAIT FOR APPOINTMENT WAS TOO LONG
(03) PROVIDER’S LOCATION WAS NOT CONVENIENT
(04) DOCTOR/PLAN WOULDN'T GIVE SP REFERRAL TO
SEE PROVIDER SP WANTED TO SEE
(05) SP DIDN'T LIKE/NOT CONFIDENT IN PROVIDER
PLAN REFERRED SP TO
(06) PROVIDER’S OFFICE HOURS WERE NOT
CONVENIENT
(91) OTHER
(-8) Don't Know
(-9) Refused

MHDIFCLT

AC35

MHOTHOS

AC35

OTHER (SPECIFY)

(01) continuous answer

AC36

Has (CURRENT MEDICARE MANAGED CARE PLAN NAME) ever refused to pay for emergency treatment that
[you/(SP)] felt was necessary?
[‘EMERGENCY TREATMENT’ REFERS TO URGENTLY NEEDED MEDICAL CARE THAT IS REQUIRED WHEN THE
BENEFICIARY IS OUTSIDE OF THE PLAN'S SERVICE AREA OR WHEN THE CARE IS REQUIRED DURING A TIME
THAT IS OUTSIDE THE PLAN'S NORMAL OPERATING HOURS.]

(01) YES
(02) NO
(03) N/A, HAVEN'T NEEDED EMERGENCY TREATMENT
(-8) Don't Know
(-9) Refused

MHREFPAY

[PROBE: Any other difficulty?]
CHECK ALL THAT APPLY.