CMS-P-0015A Comm2017R79IPQ

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

IPQ-Inpatient Utilization

Question Text/Description

Code List

Routing

INPATIENT UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C008, C009, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: If INTTYPE in(C008), SP must have ongoing IP event.
PLACEMENT
If INTTYPE in(C008), administer after ENS.
If INTTYPE in(C001, C002, C004, C005, C006, C007, C009, C010), administer after ERQ.

BOX IP1

EVENDMM

EVENDDD

IPS1

IPS1

routing

IF THE SP WAS STILL IN A HOSPTIAL AT THE TIME OF THE PREVIOUS ROUND INTERVIEW, GO TO IPS1 EVENDMM.
ELSE IF SP IS IN THE EXIT SAMPLE AND ROUND IS NOT 71 AND PREVIOUS ROUND INTERVIEW WAS
NOT SKIPPED, GO TO BOX IP6.
ELSE GO TO BOX IP1AB.

date

(01) [Continuous answer.]
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
(-7) Empty
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
(-8) Don't Know
stay?
(-9) Refused

IPS1 - EVENDDD

date

(01) [Continuous answer.]
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
(-7) Empty
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
(-8) Don't Know
stay?
(-9) Refused

IPS1 - EVENDYY

(01) [Continuous answer.]
Last time [you/(SP)] had been admitted to (HOSPITAL NAME) on (ADMISSION DATE) and [were/was] still a
(-7) Empty
patient there on (REFERENCE DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for that
(-8) Don't Know
stay?
(-9) Refused

IPS1 - STILLHOSP

EVENDYY

IPS1

date

STILLHOSP

IPS1

date

BOX IP1A

routing

IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IPS1, GO TO BOX IP6.
ELSE GO TO IP7 - ANYOPERS.

BOX IP1AB

routing

IF THE SP HAD AT LEAST ONE EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN
THE SP BEING ADMITTED TO A HOSPITAL, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.

BOX IP1AA

routing

CREATE EVENT FOR FIRST/NEXT ER VISIT ADDED WHERE SP WAS ADMITTED TO HOSPITAL
GO TO IP1A - EVENDMM.

EVENDMM

EVENDDD

EVENDYY

STILLHOSP

(01) SP IS STILL IN HOSPITAL
(-7) Empty

BOX IP1A

date

You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on
(ADMISSION DATE)?

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

IP1A - EVENDDD

date

You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on
(ADMISSION DATE)?

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

IP1A - EVENDYY

date

You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on
(ADMISSION DATE)?

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

IP1A - STILLHOSP

IP1A

date

You told me [you were/(SP) was] admitted to (HOSPITAL NAME) from the emergency room on (ADMISSION
DATE). When [were you/was (SP)] discharged from (HOSPITAL NAME) for the stay that started on
(ADMISSION DATE)?

(01) SP IS STILL IN HOSPITAL
(-7) Empty

BOX IP1B

BOX IP1B

routing

IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP1A, GO TO BOX IP5.
ELSE GO TO IP7 - ANYOPERS.

IP1A

IP1A

IP1A

Page 1 of 8

2017 MCBS Community Questionnaire

Variable Name

IPPROBE

MR Screen Name

IP1

Question Type

yes/no

IPQ-Inpatient Utilization

Question Text/Description
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you been/has (SP) been/was (SP)] [admitted to a
hospital/admitted any other time to this or any other hospital] as an inpatient -- either for an overnight stay or for
a "same day" procedure?
IF HAD SAME DAY PROCEDURE AND IS NOT SURE IF ADMITTED OR NOT, TREAT AS OUTPATIENT
EVENT AND ENTER WHEN YOU GET TO OP UTILIZATION.

Code List

Routing

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused

(01) IP2 - PROVIDER_IP
(02) BOX IP6
(03) DO NOT DISPLAY.
DATA EDITING ONLY.
(-8) BOX IP6
(-9) BOX IP6

[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]

PROVIDER_IP

IP2

roster

Where [were you/was (SP)] admitted -- to which hospital?
SELECT OR ADD ONLY ONE HOSPITAL.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
IF EXISTING PROVIDER SELECTED, GO TO BOX IP2.
1. [PROVIDER 1]
ELSE IF "ADD ANOTHER" SELECTED, GO TO IP22. [PROVIDER 2]
PROVNAME
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE HOSPITAL BELOW
PROVNAME

IP2

verbatim

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.

IP2-GROUPNAM

NAME:

GROUPNAM

IP2

BOX IP2

VAPLACE

IP3

BOX IP2AA

HMOASSOC

IP3A

verbatim

GROUP:

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO IP3 VAPLACE.
ELSE GO TO BOX IP2AA.

yes/no

Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A., facility?

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO IP3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND
(THIS PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO IP3B - HMOREFER.
ELSE GO TO IP4 - EVBEGMM.

yes/no

Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?

BOX IP2

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

BOX IP2AA

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

(01) IP4 - EVBEGMM
(02) IP3B - HMOREFER
(-8) IP3B - HMOREFER
(-9) IP3B - HMOREFER

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

IP4 - EVBEGMM

MM:

IP4 - EVBEGDD

HMOREFER

IP3B

yes/no

EVBEGMM

IP4

date

EVBEGDD

IP4

date

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?

DD:

IP4 - EVBEGYY

EVBEGYY

IP4

date

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?

YY:

IP4 - EVENDMM

[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]
When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
Admission Date:

Page 2 of 8

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

EVENDMM

IP4

date

EVENDDD

IP4

date

IPQ-Inpatient Utilization

Question Text/Description

Code List

Routing

MM:

IP4 - EVENDDD

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?

YY:

IP4 - EVENDYY

IP4 - STILLHOSP

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?
Dishcarge Date:

EVENDYY

IP4

date

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

STILLHOSP

IP4

date

When [were you/was (SP)] admitted to and discharged from (HOSPITAL NAME)?

(01) SP IS STILL IN HOSPITAL
(-7) Empty

BOX IP2A

BOX IP2A

routing

IF INPATIENT ADMISSION AND DISCHARGE DATE OVERLAP AN EXISTING IP STAY, GO TO IP4_ERR IPOVERLP.
ELSE GO TO BOX IP3.

IPOVERLP

IP4_ERR

code 1

INVALID DATE. THIS DATE OVERLAPS AN EXISTING IP STAY FROM (ADMISSION DATE) TO
[(DISCHARGE DATE)/SP STILL IN HOSPITAL].

(01) CORRECT DATES
(02) CONTINUE INTERVIEW

(01) IP4 - EVBEGMM
(02) BOX IP3

IPADD

IP5

(01) ADD ANOTHER
(02) ALL DONE

(01) IP4-EVBEGMM
(02) IP5-NAVIGATOR

NAVIGATOR

ANYOPERS

SPECCOND

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

IP5_IN

YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP (01) EVENT1
OR PRESS [PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) EVENT2
instance navigator
…
[DISPLAY ALL EVENTS ADDED AT IP4]
(N) EVENT N
[EVENT DATE, PROVIDER]
(N+1) CONTINUE INTERVIEW

BOX IP3

routing

IP7

IP10

BOX IP4A

PRESMDCN

HAVE ALL DATES BEEN ENTERED?

IP13

yes/no

IF SP WAS REPORTED AS STILL IN THE HOSPITAL AT IP4, GO TO BOX IP5.
ELSE GO TO IP7 - ANYOPERS
Were any operations performed on [you/(SP)] during the hospital stay that was (ADMISSION DATE) to
(DISCHARGE DATE)?
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths, or
any cutting of the skin.]

yes/no

[Was this visit/Were any of these visits] to the outpatient department for any specific condition?

routing

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE IF SP IS IN THE EXIT SAMPLE AND ROUND IS NOT 71 AND PREVIOUS ROUND INTERVIEW NOT
SKIPPED, GO TO BOX IP6.
ELSE GO TO IP13 - PRESMDCN.

yes/no

At the time [you were /(SP) was] discharged, were any medicines prescribed for [you/(SP)]?

Were any of the prescriptions filled?
PRESFILL

IP14

yes/no

BOX IP4B

routing

(01-N) BOX IP3
(N+1) IP16-IPMORE

[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN
IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT
THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]

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

(01) BOX IP4A
(02) IP10 - SPECCOND
(-8) IP10 - SPECCOND
(-9) IP10 - SPECCOND

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

BOX IP4A

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

(01) IP14 - PRESFILL
(02) BOX IP5
(-8) BOX IP5
(-9) BOX IP5

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

(01) BOX IP4B
(02) NAVIGATOR
(-8) BOX IP5
(-9) BOX IP5

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO IP14A - IPPMMEDS.
ELSE GO TO BOX PM2.

Page 3 of 8

2017 MCBS Community Questionnaire

Variable Name

IPPMMEDS

MR Screen Name

IP14A

IPQ-Inpatient Utilization

Question Type

Question Text/Description

no entry

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]

Code List

Routing

BOX PM2

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.

BOX PM2

MEDICINE_PM1

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.

BOX PM3

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

BOX PM4

PMBOTTLE

PMBOTTLE

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE BOX BELOW.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME

MED

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

lookup
[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME

MED

lookup

[PM BRAND NAME]

PMGNNAME

MED

lookup

[PM GENERIC NAME]

Page 4 of 8

2017 MCBS Community Questionnaire

IPQ-Inpatient Utilization

Variable Name

MR Screen Name

Question Type

Question Text/Description

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

PMFMCODE

MED

lookup

Medicine Form [FDB LIST FORM CODE]

Code List

Routing

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS

PMFORMMC

MED

code one

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know

PMFORMOS

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]

(01) CONTINUOUS ANSWER

PMFORMFN

MED

verbatim

[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW

STRNNUMBB

MED

numeric

Medicine strength number

(01) CONTINUOUS ANSWER

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

Medicine strength unit

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS

(01) YES
(02) NO
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

Page 5 of 8

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

IPQ-Inpatient Utilization

Question Text/Description

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

OTHER (SPECIFY)

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM

TABNUM

GETNUM

numeric

[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]

Code List

Routing

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

BOX PM5

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

BOX PM6

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6

AMTUNIT

PM16

quantity unit

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW

AMTUNOS

PM16

text

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

AMTNUM

PM16

numeric

(01) CONTINUOUS ANSWER

BOX PM6

BOX PM6

routing

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

Page 6 of 8

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

IPQ-Inpatient Utilization

Question Text/Description

Code List

Routing

HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN (01) CONTINUOUS ANSWER
A DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT
"OTHER DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE

PM13

numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".

TABTAKE96

PMSATVA

PMSATHMO

PMMORE

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PM8

PM13

code one

BOX PM7

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN
ANYTIME DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMSATHMO

PM17

yes/no

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

(01) ADD ANOTHER
(02) ALL DONE

PMMORE-PMMORE

(01) BOX PM2
(02) BOX IP5

Page 7 of 8

2017 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX IP5

IPMORE

IP16

IPQ-Inpatient Utilization

Question Type

Question Text/Description

routing

IF ASKING ABOUT ONGOING IP STAY FROM THE PREVIOUS ROUND, GO TO BOX IP1AB.
ELSE IF ASKING ABOUT AN EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN AN
IP STAY, THEN
IF SP HAS ANOTHER EMERGENCY ROOM VISIT IN THE CURRENT ROUND THAT RESULTED IN AN IP
STAY THAT HAS NOT BEEN ASKED ABOUT, GO TO BOX IP1AA.
ELSE GO TO IP1 - IPPROBE.
ELSE GO TO IP16 - IPMORE.

yes/no

IF RESPONDENT HAS ALREADY MENTIONED ANOTHER INPATIENT STAY, ENTER “YES” WITHOUT
ASKING. OTHERWISE, ASK:
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you had/has (SP) had/did (SP) have] any other admissions to this
or any other hospital as an inpatient -- either for an overnight stay or for a "same day" procedure?
IF HAD SAME DAY PROCEDURE AND IS NOT SURE IF ADMITTED OR NOT, TREAT AS OUTPATIENT
EVENT AND ENTER WHEN YOU GET TO OP UTILIZATION.

Code List

Routing

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

(01) IP2 - PROVIDER_IP
(02) BOX IP6
(-8) BOX IP6
(-9) BOX IP6

[ENTER A STAY AT A DRUG AND REHABILITATION CENTER AS AN IP EVENT, NOT AN IU EVENT.]

BOX IP6

routing

IF INTTYPE in(C001, C002, C004, C005, C006, C007, C009), GO TO OPQ.
IF INTTYPE in(C008), GO TO MBQ.

Page 8 of 8