Crosswalk pre-patient survey questions

OMB Patient Survey Questions Crosswalk: Attachment E1 Pre-Discharge patient questionnaire

Current Survey questions	Response	Final Question
In the month or so before you came to the hospital, how often did you have any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? 6. Accomplish less than you would like SF12_emot_accomplish_lesS_int Did work or activities less carefully than usual SF_12_emot_carefullY_int All of the time Most of the time Some of the time A little of the time None of the time	Made suggested word edit This question came from SF12 Short-Form Health History Intake and has been cognitively tested using this wording. No changes made to “emotional problems”. References: Ware J., Kosinski M., Keller S. (1996). A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity. Medical Care. 34(3):220-233 Luo X., George ML., Kakouras L., et al. (2003). Reliability, validity, and responsiveness of the short form 12-item survey (SF-12) in patients with back pain. Spine;28(15):1739-45. Gandek B., Ware JE., Aaronson NK. (1998). Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol: 51(11):1171-8.	In the month or so before you came to the hospital, how often did you have any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? Accomplish less than you would like SF12_emot_accomplish_lesS_int Did work or activities less carefully than usual SF_12_emot_carefullY_int All of the time Most of the time Some of the time A little of the time None of the time
Thinking about the month or so before you came to the hospital: Did you use any equipment to walk, such as a cane, crutches, or walker? ADL_CANE_int Did you need help washing or bathing yourself? ADL_BATHE_int Did you need help dressing and undressing? ADL_DRESS_int Did you need help eating, including cutting food? ADL_EAT_int Did you need help getting in and out the bed and the chair? ADL_BED_int Yes No DK Refused NA	Made suggested word edits #17: changed wording to state “or” instead of “and”	Thinking about the month or so before you came to the hospital: Did you use any equipment to walk, such as a cane, crutches, or walker? ADL_CANE_int Did you need help washing or bathing yourself? ADL_BATHE_int Did you need help dressing and undressing? ADL_DRESS_int Did you need help eating, including cutting food? ADL_EAT_int Did you need help getting in and out the bed or the chair? ADL_BED_int Yes No DK Refused NA
Thinking about the month or so before you came to the hospital, were you able to do the following things without help or with difficulty, and or did you need help from others Shop for groceries or clothes? IADL_SHOP_int Prepare, serve and provide meals for yourself? IADL_COOK_int Do light housework, such as dusting or doing dishes? IADL_HOUSEWORK_int Get to places out of walking distance by using public transportation or driving a car? IADL_CAR_int Take pills or medicines in the correct amounts and at the correct times? IADL_MEDS_int Needed no help Needed some help Unable to do Do not do	Simplified question by removing ending of sentence (“and or did you need help from others”) Changed response options to original tool response options (University of Michigan Health Retirement Survey and)	Thinking about the month or so before you came to the hospital, were you able to do the following things without help or difficulty? Shop for groceries or clothes? IADL_SHOP_int Prepare, serve and provide meals for yourself? IADL_COOK_int Do light housework, such as dusting or doing dishes? IADL_HOUSEWORK_int Get to places out of walking distance by using public transportation or driving a car? IADL_CAR_int Take pills or medicines in the correct amounts and at the correct times? IADL_MEDS_int Yes No Cannot do Do not do
(IF ANSWERS ‘Need No Help’ or NO to 14-23) If you needed help with basic personal care activities like eating or dressing, do you have relatives or friends (besides your spouse/partner) who would be willing and able to help you over a long period of time? Yes No Don’t know Refuse NA	Made suggested word edits Defined “long period of time” by adding “3 months or more”	(IF ANSWERS ‘Need No Help’ or NO to 14-23) If you needed help with basic personal care activities like eating or dressing, do you have relatives or friends (besides your spouse/partner) who would be willing and able to help you over a long period of time (3 months or more)? Yes No Don’t know Refuse NA
In the past 12 months how many times have you fallen? 0, 1, 2, 3, 4+	No change to this question; This question was taken from the Behavioral Risk Factor Surveillance Survey. It has been cognitively tested and has been asked since 2012 (on even years). We realize there maybe recall issues, but it is a commonly used in the older adult falls field. Most recent MMWR publication using this data: https://www.cdc.gov/mmwr/volumes/65 /wr/mm6537a2.htm?s_cid=mm6537a2_w	In the past 12 months how many times have you fallen?
In the past 12 months, has anyone talked to you about your risk of falling? Doctor, NP/PA, Nurse, Another HCP, Family Member or Caregiver, Other, No one has talked to me	Made suggested word edits Added in “select all that apply” to question	In the past 12 months, has anyone talked to you about your risk of falling? (Select all that apply)
In the past 12 months, has anyone talked to you about medicines, such as pain medicines, that might make you fall? Doctor, NP/PA, Nurse, Another HCP, Family Member or Caregiver, Other, No one has talked to me	Made suggested word edits Added in “select all that apply” to question	In the past 12 months, has anyone talked to you about medicines, such as pain medicines, that might make you fall? (select all that apply) Doctor, NP/PA, Nurse, Another HCP, Family Member or Caregiver, Other, No one has talked to me
On a scale from 1 to 5, where 1 means “strongly disagree” and 5 means “strongly agree”, indicate your agreement with the following statement: “Older people fall and there is nothing that can be done about it.” 1 (Strongly disagree)  5 (Strongly Agree)	Question moved up as suggested from Question #31 to #28	On a scale from 1 to 5, where 1 means “strongly disagree” and 5 means “strongly agree”, indicate your agreement with the following statement: “Older people fall and there is nothing that can be done about it.” (Strongly disagree)  5 (Strongly Agree)
30. On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "most likely," how likely are you to fall? 1 (Not at all likely)  5 (Very Likely)	Question comes from New South Wales Fall Prevention Survey (https://www.health.nsw.gov.au/surveys/other/Publications/falls-prevention-survey.pdf) and wording changed to match original question	In general, how would you rate your likelihood of falling? Would you say it is… High Moderate Low Non-existent Don’t Know Refused OR CAN WE KEEP THIS On a scale from 1 to 5, where 1 means not at all likely and 5 means most likely, how likely are you to fall? (Not at all likely) 5 (Very Likely)
31. On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "most likely," if you fell, how likely would you be get hurt? (Not at all likely)  5 (Very Likely)	Added in types of injuries	On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "most likely," if you fell, how likely would you be to get any type of injury? By injury that means anything from bruises and cuts to broken bones or concussion? (Not at all likely)  5 (Very Likely)
In the last three months, on average, how many days per week have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? Zero or less than 1day/wk 1day/wk 2days/wk 3 or more days per week Don’t know Prefer not to answer	These come from the Behavioral Risk Factor Surveillance Survey HYPERLINK "https://www.cdc.gov/brfss/questionnaires/pdf-ques/2019-BRFSS-Questionnaire-508.pdf" and have been cognitively tested and administered for several years to all ages of adults. Again, used as a standard in the field. Wording changed to match BRFSS	in the 30 day before you came to the hospital, how many days per week did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? Zero or less than 1day/wk 1day/wk 2days/wk 3 or more days per week Don’t know Prefer not to answer
What number best describes how, during the past week, pain has interfered with your enjoyment of life? (from 0=does not interfere to 10=completely interferes) 0-10 scale	No changes as wording came from Prescription Opioid Misuse Index Reference: Knisely J., Wunsch M., Cropsey K., et al. (2008). Prescription Opioid Misuse Index: A brief questionnaire to assess misuse. Journal of substance abuse treatment. 35. 380-6. 10.1016/j.jsat.2008.02.001.	What number best describes how, during the past week, pain has interfered with your enjoyment of life? (from 0=does not interfere to 10=completely interferes) scale
39. Do you do any of the following for your pain; Yoga, stretching, or ROM exercises Massage or chiropractic Acupuncture or cupping Meditation or counseling Prayer or spiritual practices Marijuana in any form	Added “select all that apply” to stem of question Added “Other” response option	Do you do any of the following for your pain (select all that apply) Yoga, stretching, or range of motion exercises Massage or chiropractic Acupuncture or cupping Meditation or counseling Prayer or spiritual practices Marijuana in any form Other
IF YES, which kinds of medications do you take for pain (Check all that apply)?	This question was shared with Kristen Miller’s group and NCHS. We changed it according to their suggestion to model according to their question #2. See Attachment NCHS email	In the past 12 months, which, if any, of these pain relievers have you used? (Select all that apply) Ibuprofen (e.g. Motrin, Advil) or acetaminophen (e.g. Tylenol) or naproxen (e.g. Aleve) Oxycodone (e.g. Roxycodone, Percocet) or hydrocodone (e.g. Lortab or Vicodin), or hydromorphone (e.g. Dilaudid) Long acting morphine (e.g. MSContin), fentanyl patch, or Methadone Gabapentin (e.g. Neurontin), or nortriptyline, or baclofen Marijuana in any form (prescription or recreational)
How long have you taken these pain medications? Less than a week More than a week less than a month More than a month	Changed question to reflect timeframe	What is the longest you have taken any one of these pain medications for the last 12 months? Less than a week More than a week less than a month More than a month
Have you tried to decrease your prescribed pain medication on your own? Yes No Refuse	Added in the word “ever”	Have you ever tried to decrease your prescribed pain medication on your own? Yes No
Have you ever gotten enough pain medication to bring your pain to a tolerable level (as prescribed)? Yes No Refuse	SAMSHA was consulted, but question was not changed, as it came straight from the Opioid Misuse Index, see Attachment POMI-test-article. This question was shared with NCHS, but they did not feel they had any reliable questions available as they are continuing to conduct cognitive testing on these questions.	Have you ever gotten enough pain medication to bring your pain to a tolerable level (as prescribed)? Yes No Refuse
Do you ever take your pain medication because you are upset, using the medication to relieve or cope with problems other than pain? Yes No	SAMSHA was consulted, but would like to keep the question as is, as it came straight from the Opioid Misuse Index, see Attachment POMI-test-article. This question was shared with NCHS, but they did not feel they had any reliable questions available as they are continuing to conduct cognitive testing on these questions.	Do you ever take your pain medication because you are upset, using the medication to relieve or cope with problems other than pain?
Do you ever use pain medications or drugs obtained outside of a medical doctor’s directions (e.g. pills taken from friends, or purchased illegally)? Yes No	The questions provided by SAMHSA would increase the length of the survey and capture data that is beyond the scope of our study.  The suggested SAMHSA questions were adapted and modified to meet the study’s purpose. See Attachment #3 SAMHSA email This question was shared with NCHS, but they did not feel they had any reliable questions available as they are continuing to conduct cognitive testing on these questions.	Do you ever take prescription pain relievers in any way that a doctor did not direct you to use them (e.g. taken medications from a friend or relative, or purchased them illegally)? Yes No