CMS-10549.GenIC#3 Questionnaire

Generic Clearance for Questionnaire Testing and Methodological Research for the Medicare Current Beneficiary Survey (MCBS) (CMS-10549)

CMS-10549.GenIC#3 - Att. E Questionnaire

CMS-10549.GenIC#3 - MCBS Cognitive Testing Self-Management Items

OMB: 0938-1275

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MATERIALS NEEDED FOR INTERVIEW

    • INTERVIEWER PROTOCOL BOOKLET (THIS BOOKLET) AND SHOWCARD

    • INFORMED CONSENT (TWO COPIES)

    • ONE ENVELOPE WITH $40 CASH IN IT

    • ONE PAYMENT RECEIPT

    • DIGITAL RECORDER AND EXTRA BATTERIES

    • PENS AND PENCILS

STEP 1: INFORMED CONSENT

PROVIDE RESPONDENT WITH A COPY OF THE INFORMED CONSENT. ANSWER ANY QUESTIONS THE BENEFICIARY MAY HAVE.


  • COPY OF INFORMED CONSENT GIVEN TO BENEFICIARY


  • IF THE BENEFICIARY HAS CONSENTED TO RECORDING, START THE RECORDER.

STEP 2: COMPLETION OF THE QUESTIONNAIRE

The Medicare Current Beneficiary Survey (MCBS) asks Medicare beneficiaries about their health status, sources of health care, satisfaction with care, and health care expenditures. In today’s interview I will be asking you about your recent health care and some of your medical conditions.

After we have finished the survey, I would like to talk with you about some of the questions in the survey. Getting your feedback on the questions can help make the questions better.

[INTERVIEWER: EACH TEST QUESTION IN THE PROTOCOL IS IMMEDIATELY FOLLOWED BY A SET OF EXAMPLE PROBES AND INTERVIEWER NOTES DESIGNED TO AID THE DEBRIEFING PROCESS; WHILE SPECIFIC PROBES WILL VARY, THE EXAMPLES PROVIDED IN THE PROTOCOL ARE MEANT TO BE A STARTING POINT FOR DIALOG WITH THE RESPONDENT. ALTHOUGH THESE PROBES APPEAR ADJACENT TO THE QUESTIONS THEMSELVES, IT IS GENERAL PRACTICE TO ADMINISTER THE QUESTIONNAIRE IN FULL BEFORE USING THE EXAMPLE PROBES AND INTERVIEWER NOTES TO DEBRIEF THE RESPONDENT. REMIND THE RESPONDENT OF THE QUESTION AND HIS/HER RESPONSE IN ADVANCE OF USING PROBES.

IN ADDITION, THIS INTERVIEW WILL ASK THE RESPONDENT ABOUT TWO CHRONIC CONDITIONS, IF APPLICABLE. NOTE THAT MANY OF THE PROBES ARE REPEATED ALONG WITH QUESTIONS IN THE PROTOCOL FOR THE SECOND CHRONIC CONDITION. THESE PROBES MAY OR MAY NOT BE APPLICABLE AS YOU ASK THE RESPONDENT ABOUT HIS/HER SECOND CHRONIC CONDITION.]



STEP 3: DEBRIEFING

Now I would like to talk with you about some of the survey questions you just answered.


GENERAL PROBES: Suggested general neutral probing for issues that arise.

  • How did you decide on that answer?

  • Can you tell me more about that?

  • Can you give me an example of that?

  • Tell me what you are thinking.

  • What did you think about when I asked that question?

  • What did you think about in deciding on your answer?

  • What doctors did you include when you answered this question?

  • What does [QUESTION/TERM] mean to you?


OPTIONAL VS REQUIRED PROBES:

  • Probes with a regular round bullet point are optional

  • Probes with an arrow bullet point are required.



Var Name

MR Screen Name

Question text/description

Code list

Routing

DUINT

DUINTRO

The first questions are about health care services you may have used between January 1, 2018 and today.

First we’ll talk about dental care.

(01) CONTINUE

Next question

Observations:

DUPROBE

DU1

Since January 1, 2018, have you gone to a dentist or any other person for dental care?

[Dental providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]

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

Next question

Observations:

ERPROBE

ER1

Since January 1, 2018, did you go to, have you gone to a hospital emergency room for medical care?

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

Next question

Observations:

MPPRMDOC

MP1

Since January 1, 2018 have you seen any medical doctors?

INCLUDE ANY VISITS FOR TESTS/X-RAYS.

[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

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

Next question

Observations:

OCHBP

HFJ2

Has a doctor or other health professional ever told you that you have hypertension, sometimes called high blood pressure?

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

Next question

Observations:

OCCHD

HFJ6

Has a doctor or other health professional ever told you that you had angina pectoris or coronary heart disease?

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

Next question

Observations:

OCCFAIL

HFJ8

Has a doctor or other health professional ever told you that you had congestive heart failure?

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

Next question

Observations:

OCSTROKE

HFJ16

Has a doctor or other health professional ever told you that you had a stroke, a brain hemorrhage, or a cerebrovascular accident?

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

Next question

Observations:

OCCHOLES

HFJ17A

Has a doctor or other health professional ever told you that you had high cholesterol?

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

Next question

Observations:

OCCANCER

HFJ20

Has a doctor or other health professional ever told you that you had any kind of cancer, malignancy, or tumor other than skin cancer?

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

Next question

Observations:

OCARTHRH

HFJ24

Has a doctor or other health professional ever told you that you had rheumatoid arthritis?

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

Next question

Observations:

OCOSARTH

HFJ24B

Has a doctor or other health professional ever told you that you had osteoarthritis?

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

Next question

Observations:

OCARTH

HFJ25

Has a doctor or other health professional ever told you that you had arthritis, other than rheumatoid or osteoarthritis?

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

Next question

Observations:

OCALZMER

HFJ29A

Has a doctor or other health professional ever told you that you had Alzheimer's disease?

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

Next question

Observations:

OCDEMENT

HFJ29B

Has a doctor or other health professional ever told you that you had any type of dementia other than Alzheimer's disease?

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

Next question

Observations:

OCDEPRSS

HFJ30AA

Has a doctor or other health professional ever told you that you had depression?

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

Next question

Observations:

OCOSTEOP

HFJ32

Has a doctor or other health professional ever told you that you had osteoporosis, sometimes called fragile or soft bones?

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

Next question

Observations:

OCEMPHYS

HFJ36

Has a doctor or other health professional ever told you that you had emphysema, asthma, or COPD?

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

Next question

Observations:

OCBETES

HFJ41A

Has a doctor or other health professional ever told you that you had any type of diabetes, including: sugar diabetes, high blood sugar, borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline diabetes, or pre-diabetes?

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

(01) HFJ41B - OCDTYPE
(02) Q1A
(-8) Q1A
(-9) Q1A

Observations:

OCDTYPE

HFJ41B

SHOW CARD HF5

Looking at this card, please tell me which type of diabetes the doctor or other health professional said that you have.

[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]

(01) TYPE 1
(02) TYPE 2
(03) BORDERLINE
(04) PRE-DIABETES
(05) GESTATIONAL (PREGNANCY-RELATED)
(91) SOME OTHER TYPE
(-8) Don't Know
(-9) Refused

Next question

Observations:

 

Q1A

Now I would like to talk to you about your chronic conditions. Earlier, you said that you have (TEXT FILL ALL CHRONIC CONDITIONS IDENTIFIED DURING INTERVIEW).

READ IF NECESSARY: AT THIS TIME WE ARE INTERESTED IN ONLY THE CONDITIONS WE ASKED ABOUT EARLIER IN THIS INTERVIEW.

(01) CONTINUE

Next question

Observations:

 

BOX A

If R has more than one chronic condition go to Q1B, else go to Q2.

 

 

Observations:

 

Q1B

Which of these conditions concerns you most? LIST CONDITIONS IDENTIFIED DURING THE INTERVIEW.

(01) CONTINUOUS ANSWER

Next question

Observations:


Example probes:

  • Please tell me in your own words what you think this question is asking.

  • What did you think about when answering this question?

  • How did you decide on your answer?


Interviewer notes: PROBE ONLY IF RESPONDENT EXPRESSES CONFUSION OR UNCERTAINTY ABOUT THE QUESTION. How does the respondent conceptualize “concern”? Did he/she use any specific criteria to determine which condition was most concerning?


 

Q2

In the last 3 months, do you feel your (CONDITION #1) has gotten better, worse, or stayed the same?

(A) BETTER
(B) WORSE
(C) STAYED THE SAME
(D) DON’T KNOW
(E) REFUSED

A. Q3
B. Q3
C. Q3
D. BOX X
E. BOX X

Observations:


Example probes:

  • When I asked if you feel that your CONDITION has gotten better, worse, or stayed the same in the last 3 months, you responded [ANSWER].

    • Please tell me in your own words what you think this question is asking.

    • What factors did you consider when answering this question?

  • How easily were you able to think about whether your CONDITION [got better/got worse/stayed the same] in the last 3 months?

  • How did your condition change in the last 3 months?

  • What about changes that took place more than 3 months ago? Please think about the last year. In the last year, has your condition gotten better, worse, or stayed the same? What changed?

  • What about changes that took place less than 3 months ago? Please think about the last 3-4 weeks. In the last 3-4 weeks, has your condition gotten better, worse, or stayed the same? What changed?


Interviewer notes: If the respondent is confused about how to answer this question or asks whether we want them to think about what their doctor says versus some other criteria, repeat the question emphasizing “do you feel” to indicate that we are focused on perception.


 

Q3

Given that your (CONDITION #1) has (gotten better/stayed the same/gotten worse), have you changed anything about how you manage it?

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

A. Q4
B. BOX X
C. BOX X
D. BOX X

Observations:


Example probes:

  • Please tell me in your own words what you think this question is asking.

  • What did you think about when answering this question? What factors did you consider?


 

Q4

What have you changed about how you manage your (CONDITION #1)?

[PROBE: Anything else?]

(01) CONTINUOUS ANSWER

BOX X

Observations:


Example probes:

  • When I asked you what you have changed about how you manage your CONDITION, you answered [ANSWER].

    • Please tell me in your own words what you think this question is asking.

    • How did you come up with your answer?

  • When did you start making (this change/these changes)?

  • (Is this change/Are these changes) something you usually make when your CONDITION (gets better/gets worse/stays the same)?

  • How easy or difficult was it for you to think about changes you have made in the last 3 months, as opposed to changes you may have made earlier?


 

BOX X

If CONDITION #1 is diabetes or R reports taking a class at Q4, go to BOX Y.
Else, go to Q5.

 

 

Observations:

 

Q5

Do you know of any courses or classes in your community to help people manage (CONDITION #1)?

[READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with (CONDITION #1), or anything else that you think could help with (CONDITION #1).]

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

Q6

Observations:


Example probes:

  • When I asked about your knowledge of courses and classes, you answered [ANSWER].

    • What did you think about when answering this question?

    • How did you decide on your answer to this question?

  • We’re interested in how you think about what “counts” as a course or class. When I asked you what you thought about when answering this question, you said [ANSWER]. Can you tell me more about what you think does count as a course or class versus what does not count as a course or class?

  • IF R DOES NOT MENTION THE ITEMS BELOW, PROBE ABOUT EACH. Do you think [BULLETS BELOW] also count? Why or why not?

    • Exercise classes for older adults

    • Seminars to learn about the signs and symptoms of certain conditions

    • Diabetes (or other condition) Health and Wellness Fair

    • Support groups targeting people affected by certain conditions

    • Workshops that help you learn how to manage your CONDITION


Interviewer notes: Please indicate whether you read the READ IF NECESSARY help text at this item. Also indicate whether the help text clarified the meaning of the item for the respondent. Did R request guidance or clarification on the types of things we are interested in? Did R restrict his/her thinking to formalized trainings and classes, or did they also mention things like yoga, Pilates, and other exercise groups?


 

Q6

Have you ever participated in a course or class on how you can manage your (CONDITION #1)?

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

A. BOX Y
B. Q7
C. BOX Y
D. BOX Y

Observations:


Example probes:

  • When I asked you whether you have ever participated in a course or class on how you can manage your condition you answered [ANSWER].

  • Please tell me about the course or class you took. What kind of course or class was it? Where did you take it? When was that?

  • How did you decide on your answer to this question?


 

Q7

There are many reasons people do not participate in a course or class to help them manage their (CONDITION #1). Why have you not attended a course or class to help you manage that condition?

[PROBE: Anything else?]

(01) CONTINUOUS ANSWER

BOX Y

Observations:


Example probes:

  • How did you decide what information to share with me?

  • When I asked you this question, did you feel any pressure to respond in a particular way? Did you think I might make a judgment about your response?


 

BOX Y

If R has exactly two chronic conditions, go to Q9.
Else if R has more than two chronic conditions, go to Q8.
Else, go to BOX YY.

 

 

Observations:

 

Q8

Earlier you told me that you have (TEXT FILL ALL CHRONIC CONDITIONS), and you told me that your (CONDITION #1) concerns you most.

After your (CONDITION #1), which of your other conditions concerns you most? LIST CONDITIONS IDENTIFIED DURING THE INTERVIEW, EXCLUDING CONDITION #1.

(01) CONTINUOUS ANSWER

Next question

Observations:


Example probes:

  • Please tell me in your own words what you think this question is asking.

  • What did you think about when answering this question?

  • How did you decide on your answer?


Interviewer notes: PROBE ONLY IF RESPONDENT EXPRESSES CONFUSION OR UNCERTAINTY ABOUT THE QUESTION. How does the respondent conceptualize “concern”? Did he/she use any specific criteria to determine which condition was most concerning?


 

Q9

In the last 3 months, do you feel your (CONDITION #2, IDENTIFIED IN Q8) has gotten better, worse, or stayed the same?

(A) BETTER
(B) WORSE
(C) STAYED THE SAME
(D) DON’T KNOW
(E) REFUSED

A. Q10
B. Q10
C. Q10
D. BOX XX
E. BOX XX

Observations:


Example probes:

  • When I asked if you feel that your CONDITION has gotten better, worse, or stayed the same in the last 3 months, you responded [ANSWER].

    • Please tell me in your own words what you think this question is asking.

    • What factors did you consider when answering this question?

  • How easily were you able to think about whether your CONDITION [got better/got worse/stayed the same] in the last 3 months?

  • How did your condition change in the last 3 months?

  • What about changes that took place more than 3 months ago? Please think about the last year. In the last year, has your condition gotten better, worse, or stayed the same? What changed?

  • What about changes that took place less than 3 months ago? Please think about the last 3-4 weeks. In the last 3-4 weeks, has your condition gotten better, worse, or stayed the same? What changed?


Interviewer notes: If the respondent is confused about how to answer this question or asks whether we want them to think about what their doctor says versus some other criteria, repeat the question emphasizing “do you feel” to indicate that we are focused on perception.


 

Q10

Given that your (CONDITION #2) has (gotten better/stayed the same/gotten worse), have you changed anything about how you manage it?

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

A. Q11
B. BOX XX
C. BOX XX
D. BOX XX

Observations:


Example probes:

  • Please tell me in your own words what you think this question is asking.

  • What did you think about when answering this question? What factors did you consider?


 

Q11

What have you changed about how you manage your (CONDITION #2)?

[PROBE: Anything else?]

(01) CONTINUOUS ANSWER

BOX XX

Observations:


Example probes:

  • When I asked you what you have changed about how you manage your CONDITION, you answered [ANSWER].

    • Please tell me in your own words what you think this question is asking.

    • How did you come up with your answer?

  • When did you start making (this change/these changes)?

  • (Is this change/Are these changes) something you usually make when your CONDITION (gets better/gets worse/stays the same)?

  • How easy or difficult was it for you to think about changes you have made in the last 3 months, as opposed to changes you may have made earlier?


 

BOX XX

If CONDITION #2 is diabetes or R reports taking a class at Q11, go to BOX YY.
Else, go to Q12.

 

 

Observations:

 

Q12

Do you know of any courses or classes in your community to help people manage (CONDITION #2)?

[READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with (CONDITION #2), or anything else that you think could help with (CONDITION #2).]

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

Q13

Observations:


Example probes:

  • When I asked about your knowledge of courses and classes, you answered [ANSWER].

    • What did you think about when answering this question?

    • How did you decide on your answer to this question?

  • We’re interested in how you think about what “counts” as a course or class. When I asked you what you thought about when answering this question, you said [ANSWER]. Can you tell me more about what you think does count as a course or class versus what does not count as a course or class?

  • IF R DOES NOT MENTION THE ITEMS BELOW, PROBE ABOUT EACH. Do you think [BULLETS BELOW] also count? Why or why not?

    • Exercise classes for older adults

    • Seminars to learn about the signs and symptoms of certain conditions

    • Diabetes (or other condition) Health and Wellness Fair

    • Support groups targeting people affected by certain conditions

    • Workshops that help you learn how to manage your CONDITION


Interviewer notes: Please indicate whether you read the READ IF NECESSARY help text at this item. Also indicate whether the help text clarified the meaning of the item for the respondent. Did R request guidance or clarification on the types of things we are interested in? Did R restrict his/her thinking to formalized trainings and classes, or did they also mention things like yoga, Pilates, and other exercise groups?


 

Q13

Have you ever participated in a course or class on how you can manage your (CONDITION #2)?

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

A. BOX YY
B. Q14
C. BOX YY
D. BOX YY

Observations:


Example probes:

  • When I asked you whether you have ever participated in a course or class on how you can manage your condition you answered [ANSWER].

  • Please tell me about the course or class you took. What kind of course or class was it? Where did you take it? When was that?

  • How did you decide on your answer to this question?


 

Q14

There are many reasons people do not participate in a course or class to help them manage their (CONDITION #2). Why have you not attended a course or class to help you manage that condition?

[PROBE: Anything else?]

(01) CONTINUOUS ANSWER

BOX YY

Observations:


Example probes:

  • How did you decide what information to share with me?

  • When I asked you this question, did you feel any pressure to respond in a particular way? Did you think I might make a judgment about your response?


 

BOX YY

If R has a diabetes other than gestational diabetes go to HFP4-DIAINSUL. Else, go to END.

 

 

Observations:

DIAINSUL

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

take insulin?

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

Next question

Observations:

DIAMEDS

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

take prescription diabetes pills or oral diabetes medicine?

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

Next question

Observations:

DIATEST

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

test your blood for sugar or glucose?

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

Next question

Observations:

DIASORES

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

check for sores or irritations on your feet?

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

Next question

Observations:

DIAPRESS

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

measure your blood pressure at home?

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

Next question

Observations:

DIAASPRN

HFP4

Please tell me whether you use any of the following ways to manage your diabetes. Do you…

take aspirin regularly for your diabetes?

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

Next question

Observations:

 

NEWVAR1

Do you know of any courses or classes in your community to help people manage diabetes?

[READ IF NECESSARY: Examples of courses and classes include exercise classes, workshops and seminars for people with diabetes, or anything else that you think could help with diabetes.]

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

Q16

Observations:

 

NEWVAR2

Have you ever participated in a course or class on how you can manage your diabetes?

(A) YES
(B) NO
(C) DON’T KNOW
(D) REFUSED

A. HFP18-DIATRAIN
B. Q17
C. HFP19-DIAKNOW
D. HFP19-DIAKNOW

Observations:

 

NEWVAR3

There are many reasons people do not participate in a course or class to help them manage their diabetes. Why have you not attended a course or class to help you manage that condition?

[PROBE: Anything else?]

(01) CONTINUOUS ANSWER

HFP19-DIAKNOW

Observations:


NEWVAR4

When was the most recent time that you participated in a diabetes self-management course or class or received special training on how you can manage your diabetes?

[IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING, PROBE FOR THE MOST RECENT TIME.]

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS AGO
(03) 2 YEARS TO LESS THAN 3 YEARS AGO
(04) 3 YEARS TO LESS THAN 5 YEARS AGO
(05) 5 OR MORE YEARS AGO
(-8) Don't Know
(-9) Refused

Next question

Observations:



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