Crosswalk post-patient survey questions

OMB Patient Survey Questions Crosswalk: Attachment E2 Post-Discharge patient questionnaire

Current Survey questions	Response	Final Question
Since you left the hospital/In the last month, 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	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.	Since you left the hospital/In the last month, 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
28. Since you left the hospital/In the last month, how often did your physical health or emotional problem(s) interfere with your social activities (like visiting with friends, relatives, etc.)?	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.	Since you left the hospital/In the last month, how often did your physical health or emotional problem(s) interfere with your social activities (like visiting with friends, relatives, etc.)?
Thinking about the time since you left the hospital/ In the last month: Do you use any equipment such as a cane, crutches, or walker to walk? 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	Aligned tense to questions 29-33 #33: changed wording to state “or” instead of “and”	Thinking about the time since you left the hospital/ In the las month: 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 time since you left the hospital/ In the last month, 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 and Retirement Survey)	Thinking about the time since you left the hospital/In the last month: , 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
40. During your stay in the hospital, 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 “check all that apply” to question Corrected spelling to practitioner	During your stay in the hospital, who has talked to you about your risk of falling? Check all that apply Doctor, Nurse practitioner/Physician assistant, Nurse, Another Health care provider, Family Member or Caregiver, Other, No one has talked to me
During your stay in the hospital, 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 Corrected spelling to practitioner Added in check all that apply option	During your stay in the hospital, who talked to you about medicines, such as pain medicines, that might make you fall? Check all that apply Doctor, Nurse practitioner/Physician assistant, Nurse, Another Health care provider, Family Member or Caregiver, Other, No one has talked to me
During your stay in the hospital (or as part of you discharge instructions), did a healthcare provider recommend any of the following to help your strength and balance or to reduce risk of falling?	Added in check all that apply option	During your stay in the hospital (or as part of you discharge instructions), did a healthcare provider recommend any of the following to help your strength and balance or to reduce risk of falling? Check all that apply
Since you left the hospital, who has talked to you about your risk of falling? Doctor, Nurse practitioner/Physician assistant, Nurse, Another Health care provider, Family Member or Caregiver, Other, No one has talked to me	Made suggested word edits Corrected spelling to practitioner Added in “check all that apply” option	Since you left the hospital, who talked to you about your risk of falling? (select all that apply) Doctor, Nurse practitioner/Physician assistant, Nurse, Another Health care provider, Family Member or Caregiver, Other, No one has talked to me
Since you left the hospital, has any health provider recommended any of the following to help your strength, balance, or to reduce risk of falling? Physical therapy Occupational therapy Exercise programs (or yoga or Tai Chi) Visiting an eye doctor Visiting a foot doctor Medication changes None	Added in “check all that apply” option	Since you left the hospital, has any health provider recommended any of the following to help your strength, balance, or to reduce risk of falling? Check all that apply Physical therapy Occupational therapy Exercise programs (or yoga or Tai Chi) Visiting an eye doctor Visiting a foot doctor Medication changes None
If physical therapy = yes either questions then ask “In the last two weeks, how many times have you attended physical therapy sessions to help your strength, balance, or to reduce risk of falling? None One Two Three More than 3	The study team does not anticipate any issues as this is something we are trying to explore if a recommendation is made and prescribed, to determine if patient follows through with the recommendation.	If physical therapy = yes either questions then ask “In the last two weeks, how many times have you attended physical therapy sessions to help your strength, balance, or to reduce risk of falling? None One Two Three More than three
If occupation therapy = yes either questions then ask “In the last two weeks, how many times have you attended occupational therapy sessions to help your strength, balance, or to reduce risk of falling? None One Two Three More than 3	The study team does not anticipate any issues as this is something we are trying to explore if a recommendation is made and prescribed, to determine if patient follows through with the recommendation.	If occupation therapy = yes either questions then ask “In the last two weeks, how many times have you attended occupational therapy sessions to help your strength, balance, or to reduce risk of falling? None One Two Three More than 3
If exercise program = yes either questions then ask “In the last two weeks, how many times have you attended an exercise program to help your strength, balance, or to reduce risk of falling? None One Two Three More than 3	The study team does not anticipate any issues as this is something we are trying to explore if a recommendation is made and prescribed, to determine if patient follows through with the recommendation.	If exercise program = yes either questions then ask “In the last two weeks, how many times have you attended an exercise program to help your strength, balance, or to reduce risk of falling? None One Two Three More than 3
If eye doctor = yes on either question, ask “In the last two weeks, have you visited an eye doctor to evaluate your vision or reduce your risk of falling? Yes No I plan to	The study team does not anticipate any issues as this is something we are trying to explore if a recommendation is made and prescribed, to determine if patient follows through with the recommendation.	If eye doctor = yes on either question, ask “In the last two weeks, have you visited an eye doctor to evaluate your vision or reduce your risk of falling? Yes No I plan to
If foot doctor = yes on either question, ask “In the last two weeks, have you visited a foot doctor to evaluate your feet or reduce your risk of falling? Yes No I plan to	The study team does not anticipate any issues as this is something we are trying to explore if a recommendation is made and prescribed, to determine if patient follows through with the recommendation.	If foot doctor = yes on either question, ask “In the last two weeks, have you visited a foot doctor to evaluate your feet or reduce your risk of falling? Yes No I plan to
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 and have been cognitively tested and administered for several years to all ages of adults. This is used as a standard in the field. Wording changed to match BRFSS	During the past 30 days 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
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
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. 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 ever gotten enough pain medication to bring your pain to a tolerable level (as prescribed)? Yes No	Question 49 and 50 from pre-discharge survey added to post-discharge survey (# 67 & 68). 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 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