CMS-P-0015A Emergency Utilization

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

(01) ER2 - PROVIDER_ER
(02)BOX ER6
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX ER6
(-9) BOX ER6

EMERGENCY ROOM UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after DUQ.

ERPROBE

ER1

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], [have you gone/has (SP) gone/did (SP) go] to a hospital emergency
room for medical care?

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]

PROVIDER_ER

ER2

roster

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

(01) continuous answer
(-8) Don't Know
(-9) Refused

ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER

N. [PROVIDER N]
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

(01-N) BOX ER1
(N+1) ER2-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
ER1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO ER2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL]
PROVNAME

ER2

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.

BOX ER1

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:

GROUPNAM

ER2

verbatim

GROUP:

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]

CRCTSPL-CRCTSPL

ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02.

CRCTSPL

CRCTSPL

BOX ER1

VAPLACE

ER3

verbatim

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

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
ER3 - VAPLACE.
ELSE GO TO BOX ER1B.

yes/no

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

(01) [Continuous Answer]

BOX ER1

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

BOX ER1B

Page 1 of 6

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX ER1B

HMOASSOC

HMOREFER

ER3A

ER3B

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

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 ER3A - 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 ER3B - HMOREFER.
ELSE GO TO ER4 - EVENT_ER.

yes/no

[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

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

roster

ERADD

ER4B

choose one

ERPMMEDS

ER4 - EVENT_ER

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

ER4

PRESFILL

(01) ER4 - EVENT_ER
(02) ER3B - HMOREFER
(-8) ER3B - HMOREFER
(-9) ER3B - HMOREFER

yes/no

EVENT_ER

PRESMDCN

Routing

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

When did [you/(SP)] go to the emergency room at (PROVIDER NAME)?

ERADMIT

Code List

Please tell me all the dates [since REFERENCE DATE/UTILDATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE SAMPLE PERSON SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE
ONLY ONCE.]
HAVE ALL DATES BEEN ENTERED?

(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:

ER4B-ERADD

(01) ADD ANOTHER
(02) ALL DONE

(01) ER6 -EVENT_ER
(02) ER6-ERADMIT

[Were you/Was (SP)] admitted to (PROVIDER NAME) from the emergency room?

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

(01) BOX ER4
(02) ER7 - PRESMDCN
(-8) ER7 - PRESMDCN
(-9) ER7 - PRESMDCN

yes/no

During [your/(SP’s)] visit to the emergency room, were any medicines prescribed for [you/(SP)]?

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

(01) ER8 - PRESFILL
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

ER8

yes/no

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
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 ER3A
(02) BOX ER4
(-8) BOX ER4
(-9) BOX ER4

BOX ER3A

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO ER8A - ERPMMEDS.
ELSE GO TO BOX PM2.

ER6

ER7

ER8A

yes/no

no entry

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

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.]

BOX PM 2

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

BOX PM2

MEDICINE_PM1

MEDICINE_PM1

BOX PM3

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.

code one

What is the name of the medicine?

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, STRENGTH, FORM,
AND QUANTITY FOR EACH.

BOX PM3

Page 2 of 6

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

BOX PM4

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

code one

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.

(01) YES
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) NO
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) NO BUT R CAN ANSWER QUESTIONS
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-9) REFUSED

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

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

PMEDNAME

MED

lookup

ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND
CORRECT, USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD

MED
MED
MED

lookup
lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]

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
(-9) Refused

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

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

[MEDICINE FORM OTHER SPECIFY]

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

(01) CONTINUOUS ANSWER

Page 3 of 6

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

FAMILYID

MED

numeric

PMKNWNM

PMKNWNM

code one

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

GETNUM

TABNUM

GETNUM

numeric

BOX PM5

routing

TABNUM

numeric

Question Text/Description

Medicine strength unit

Code List

Routing

(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
(-8) Don't Know
(-9) Refused

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

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

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

(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

[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH
THE LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

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)

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

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) continuous answer
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
(-9) Refused
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]
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-AMTUNIT.
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

8n

BOX PM5

BOX PM6

Page 4 of 6

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

Question Text/Description

Code List

Routing

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

(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

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

(01) CONTINUOUS ANSWER

PM12 - TABSADAY95

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

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

TABTAKE96

PMSATVA

PMSATHMO

PM13

numeric

(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
(-8) DON'T KNOW
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".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

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 [your/(SP’s)] (-9) REFUSED
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMSATHMO

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

PM13 - TABTAKE96

BOX PM7

BOX PM8

PMMORE-PMMORE

Page 5 of 6

2019 MCBS Community Questionnaire

Variable Name

PMMORE

ERMORE

MR Screen Name

ERQ - EMERGENCY ROOM UTILIZATION

Question Type

Question Text/Description
([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.])

Code List

Routing

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX ER4

PM17

yes/no

BOX ER4

Routing

IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO ER6-ERADMIT.
ELSE GO TO ER10-ERMORE.

ER10

yes/no

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to the emergency room at this or any
(-8) Don't Know
other hospital?
(-9) Refused

BOX ER5

routing

IF WINTER ROUND AND ((SP REPORTED AN EMERGENCY ROOM VISIT AT ER2) AND (SP IS ALIVE AND
NOT INSTITUTIONALIZED)), GO TO AC6A - EWAITUNT.
ELSE GO TO BOX ER6.

BOX ER6

routing

GO TO IPQ.

[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) ER2 - PROVIDER_ER
(02) BOX ER5
(-8) BOX ER5
(-9) BOX ER5

Page 6 of 6