Post-Hospital Transition of Care Data - PCNASP Awardee - hospital respondents

DRAFT Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Post-Hospital Data Elements

Public reporting of this collection of information is estimated to average xx minutes/hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxxx-xxxx)

HOSPITAL DISCHARGE DATE	<DscDateD>	Patient's date of hospital discharge:		__/__/____		Date MMDDYYYY		Required
HOSPITAL ADMISSION DATE	<HospadD>	Hospital Admission Date (part of in-hospital dataset):		__/__/____		Date MMDDYYYY		Optional
FOLLOW-UP	<FLCOMP>	Date follow-up completed:		__/__/____		Date MMDDYYYY		Required		4/12/19 Was previously missing from CDC data dictionary. Added 4/12 to reflect IQVIA mapping and GWTG
	<LGPER>	Select Period:		Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Required		5/22/19 CDC decided to include all “Select Period” variables from GWTG in data dictionary for clarity
	<FLMTHD>	Follow up Conducted (check all that apply):		Numeric # = 1-digit		2 = Phone call; 3 = Patient’s current residence; 4 = Chart review; 5 = Health facility; 7 = Other; 8 = Unable to reach		Required		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
LOCATION OF PATIENT	<CurrLoc>	Where is the patient at the time of follow-up?		Numeric # = 1-digit		1 = Home; 2 = Acute care facility/Hospital; 3 = Rehabilitation Facility; 4 = Chronic Health Care Facility ; 5 = Unknown/ND; 6=Skilled nursing facility		Required		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
INFORMANT	<Informnt>	Who provided responses to this follow-up?		Numeric # = 1-digit		1 = Patient; 2 =Caregiver; 3 = Chart Review; 5 = EMS; 6 = Family; 7 = Home Health Aide; 8 = Other		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
REHAB	<Rehab>	Which rehab services were provided at discharge?	Numeric # = 1-digit		1 = Patient received rehabilitation services during hospitalization; 2 = Patient transferred to rehabilitation facility; 3 = Patient referred to rehabilitation services following discharge; 4 = Patient ineligible to receive rehabilitation services because symptoms resolved; 5 = Patient ineligible to receive rehabilitation services due to impairment (i.e.: poor prognosis, patients unable to tolerate rehabilitation therapeutic regimen); 6 = patient ordered rehab, but patient declined services; 7 = Patient not assessed for rehabilitation during their previous inpatient visit		Required		6/18/19 CDC changed legal values so mapping can be direct with IQVIA
	<RehabOff>	What type of rehab was ordered?	Numeric # = 1-digit		1 = Occupational Therapy; 2 = Physical Therapy; 3 = Speech Therapy		Optional
	<RehabT>	Select the period of time at which rehab was ordered.	Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Optional
	<RehabSt>	Current Therapy Status: (check all fields that apply)	Numeric # = 1-digit		1 = Rehabilitation Facility; 3 = Home with outpatient therapy; 4 = Home Therapy; 5 = Home with no therapy; 6 = Unknown/ND		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
RANKIN	<mRsPer>	Modified Rankin Scale – Total Score		Numeric # = 1-digit		1 = No symptoms at all; 2 = No significant disability despite symptoms, able to carry out all usual duties and activities; 3 = Slight disability, unable to carry out all previous activities, but able to look after own affairs without assistance; 4 = Moderate disability, requiring some help, but able to walk without assistance; 5 = Moderately severe disability, unable to walk without assistance and unable to attend to own bodily needs without assistance; 6 = Severe disability; bedridden, incontinent and requiring constant nursing care and attention; 7 = Dead; 8 = Unknown/ND		Required		5/22/19 CDC added to data dictionary since previous modified rankin question (mRS30Day) was the sole Rankin measure in the data dictionary and time period calculations are being done manually now. Same selection options as previous mRS variable.
TOBACCO	<TobacUse>	Was patient identified as a tobacco user at time of stroke? (Tobacco use includes: cigarettes, cigars/cigarillos, little cigars, pipes, smokeless tobacco (chew, dip, snuff, and snus), hookah/water pipe, and electronic vapor products (e-cigarettes, e-hookah, vape pens).		Numeric # = 1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Required
	<CurTobac>	If patient was identified as a tobacco user at the time of their stroke, have they used tobacco (cigarettes, cigars/cigarillos, little cigars, pipes, smokeless tobacco (chew, dip, snuff, and snus), hookah/water pipe, and electronic vapor products (e-cigarettes, e-hookah, vape pens) since discharge?		Numeric # = 1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Required		FYI 6/5/19 IQVIA maps “Yes at 30, 60, or 90” to 1 = Yes for CDC
	<CurTobDa>	Is the patient using tobacco products (cigarettes, cigars/cigarillos, little cigars, pipes, smokeless tobacco (chew, dip, snuff, snus), hookah/water pipe, and electronic vapor products (e-cigarettes, e-hookah, vape pens) every day or some days?		Numeric # = 1-digit		1=Daily; 2 = Some days; 3 = Unknown/ND; 4 = Never		Optional		6/5/19 CDC updated legal values to align with IQVIA mapping (3 and 4 were switched)
	<SmkMeds>	If patient was a tobacco user (cigarettes, cigars/cigarillos, little cigars, pipes, smokeless tobacco (chew, dip, snuff, snus), hookah/water pipe, and electronic vapor products (e-cigarettes, e-hookah, vape pens) at the time of their stroke, are they using any medications to stop using tobacco?		Numeric # =1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Optional
	<StopSmk>	Since discharge, has the patient stopped smoking for one day or longer because they were trying to quit smoking?		Numeric # =1-digit		1=Yes; 2=No; 3=Unknown/ND		Optional
	<Quitat>	If yes, how many times?		Numeric # =2-digit		1-100		Optional
	<TobEdu>	Was the patient provided tobacco cessation counseling and/or referred to a cessation program?		Numeric # =1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Optional
ED VISITS	<EDYN>	Has patient been seen in ED since discharge?		Numeric # =1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Optional
	<EDYNP>	Select Period:		Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Required		5/22/19 CDC decided to include all “Select Period” variables in data dictionary for clarity
	<EDGaDate>	Date of 1st ED visit:		__/__/____		Date MMDDYYYY; Date Not Documented		Optional		5/22/19 CDC added “date not documented” as selection option (<EDGaDND>)
	<EDNum>	How many ED visits since discharge?		Numeric # =1-digit		1 = 1; 2 = 2; 3 = 3 or more; 4 = Unknown/ND		Optional
	<EDDate>	If ED visit after 30 days, date of ED visit:		__/__/____		Date MMDDYYYY; Date Not Documented		Optional		5/22/19 CDC added “date not documented” as selection option (<EDDND>)
	<EDReasn>	If yes, what was reason for first ED visit:		Numeric # =1-digit		1=Falls; 2 = Transient Ischemic Attack; 3 = Recurrent Stroke; 4 = Pneumonia; 5 = Urinary Tract Infection; 6 = DVT/PE/Blood Clot; 7 = Acute Myocardial Infarction; 8 = Heart Failure; 9 = Infection/Sepsis; 10 = Carotid Intervention; 11= Surgery; 13 = Other		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA (#12 is intentionally missing)
	<EDDisp>	Patient’s disposition for ED visit:		Numeric # =1-digit		1 = Admitted to hospital; 2 = Discharged to home; 3 = Discharged to SNF/long-term care; 4 = Held for observation; 5 = Unknown/ND		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
BLOOD PRESSURE	<BPMonitr>	Has the patient been monitoring their blood pressure outside of their healthcare provider office visits (at home or in the community)		Numeric # =1-digit		1 = Yes; 2 = No; 3=Unknown/ND		Required
	<BPSys>	If yes, most recent systolic blood pressure?		Numeric # = 3-digit		Number: (Range; 50-220)		Optional
	<BPDia>	If yes, most recent diastolic blood pressure?		Numeric # = 3-digit		Number (Range: 30-160)		Optional
	<BPReport>	If yes, has the patient reported their blood pressure to their health care provider since discharge?		Numeric # = 1-digit		1 = Yes; 2 = No; 3=Unknown/ND		Required
	<BPUsual>	Is this blood pressure usual for you?		Numeric # = 1-digit		1=Yes; 2=No; 3 = Unknown/ND		Optional
FALLS	<FallPer>	Select Period:		Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Required		5/22/19 CDC decided to include all “Select Period” variables in data dictionary for clarity
	<DCFalls>	Occurrence of Falls?		Numeric # = 1-digit		1=Yes; 2=No; 3 = Unknown/ND		Required
	<FallNum>	If yes, number of falls?		Numeric # = 2-digit		Number (Range: 1-99)		Required
	<FallRep>	Was your fall reported to a healthcare provider?		Numeric # = 1-digit		1=Yes; 2=No; 3 = Unknown/ND		Optional
	<StMedPer>	Select Period:		Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Required		5/22/19 CDC decided to include all “Select Period” variables in data dictionary for clarity
	<NoStopM>	No Medication Stoppage?		Numeric # = 1-digit		1 = Yes; 2 = No		Optional		5/22/19 CDC added so information can be collected about medication stoppage (previously captured in 30-day variable StpMed30>
MEDICATION	Medications prescribed at discharge?			Numeric # = 1-digit		1 = Yes; 0 = No				FYI 6/5/19 IQVIA updated logic so if legal value can be 1 or 0 for all inputted med codes for “medications prescribed at discharge?”
	<DCBPMed>	Antihypertensive (legal value =1)						Optional
	<DCStatn>	Statin (legal value =2)
	<DCDiab>	Antidiabetic agent (legal value =3)
	<DCAsprn>	Aspirin or other antiplatelet (legal value =4)
	<DCACoag>	Anticoagulant (legal value =5)
	Are you currently taking:			Numeric # = 1-digit		1 = Yes; 0 = No				FYI 6/5/19 IQVIA updated logic so if legal value can be 1 or 0 for all inputted med codes for “are you currently taking?”
	<BPMedNow>	Antihypertensive (legal value =1)
	<StatnNow>	Statin (legal value =2)						Optional
	<DiabNow>	Antidiabetic agent (legal value =3)
	<AsprnNow>	Aspirin or other antiplatelet (legal value =4)
	<ACoagNow>	Anticoagulant (legal value =5)
	<CurMedAt>	Same as prescribed at discharge		Numeric # = 1-digit		1 = Yes; 0 = No (check if “Yes”)		Optional		6/5/19 This was added to align with IQVIA mapping specs sent 6/5 and GWTG
	<RevMed>	Did staff review your medications with you before discharge?		Numeric # = 1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Optional
	(If NO to <NoStopM>), indicate any medication(s) patient stopped without instruction from their medical provider:			Numeric # = 1-digit		1-Yes; 0-No				5/22/19 CDC changed legal values so mapping can be direct with IQVIA CDC added specific legal values for medication types to align with IQVIA 11/5/2019 CDC changed prompt and response options to correctly reflect instructions for indicating which medications were stopped if there was medication stoppage (NoStopM)
	<StopBP>	Antihypertensive						Optional
	<StopStn>	Statin
	<StopDiab>	Antidiabetic agent
	<StopASA>	Aspirin or other antiplatelet
	<StopCoag>	Anticoagulant
	<StopOth>	Stopped taking another medication
	<BPRsn>	Stoppage reason for Antihypertensive				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
	<StnRsn>	Stoppage reason for Statin				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
	<DibRsn>	Stoppage reason for Antidiabetic				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
	<ASARsn>	Stoppage reason for Aspirin or other antiplatelet				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
	<CogRsn>	Stoppage reason for Anticoagulant				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
	<OthRsn>	Stoppage reason for other medication				1 = Side effects; 2 = Cost; 3 = Frequently forget; 4 = Other; 5 = Not documented/ND; 6 = No transportation; 7 = Ran out; 8 = Traveling		Optional		11/5/19 CDC added stoppage reason variables to compensate for issue identified with stoppage variables not having separate reason questions
FOLLOW UP APPOINTMENT	<DApptYN>	Was an appointment made prior to discharge to follow up with a healthcare provider?		Numeric # = 1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Required
	<DAppKep>	For 1st post-discharge appointment scheduled, what was the outcome?		Numeric # = 1-digit		1 = initial appointment completed with provider; 2 = initial appointment scheduled, but has not seen provider; 3 = unknown/ND; 4 = initial appointment cancelled, but rescheduled for later date; 5 = initial appointment cancelled and not rescheduled; 6 = no appointment scheduled to date; 7 = initial appointment rescheduled and completed visit		Required		6/5/19 CDC changed mapping and question wording to align with mapping specs IQVIA provided 6/5/19
	<DAppRes>	Indicate reason(s) for not re-scheduling appointment:		Numeric # = 1-digit		0 = same reason as cancellation for initial appointment; 1 = No transportation; 2 = No reminder call; 3 = Patient not aware of initial appointment; 4 = Cost; 5 = Distance to provider; 6 = Scheduling conflict; 7 = Sick; 8 = Other		Required
	<DAppNKep>	If yes, was the appointment not kept:		Numeric # = 1-digit		1=Not kept; 2=not kept and not rescheduled; 3=Unknown/ND		Required
	<DAppPend>	If no, has an appointment been scheduled since discharge?		Numeric # = 1-digit		1 = Yes; 2 = No; 3 = Unknown/ND		Required
	<DAppType>	Who did patient see or will see?		Numeric # = 1-digit		1 = Primary Care Physician; 2 = Cardiologist; 3 = Neurologist; 4 = Endocrinologist; 5 = Other		Optional		6/5/19 CDC changed mapping to align with mapping specs IQVIA provided 6/5/19
	<DAppCan>	If the appointment wasn't attended, why?		Numeric # = 1-digit		1 = No transportation; 2 = No reminder call; 3 = Patient not aware of initial appointment; 4 = Cost; 5 = Distance to provider; 6 = Scheduling conflict; 7 = Sick; 8 = Other		Optional
	<DAppDate>	Date of first follow up appointment		__/__/____		Date MMDDYYYY		Optional
READMISSIONS	< ReAd>	Has patient been readmitted to a hospital since discharge?		Numeric # = 1-digit		1 = Yes, within 30 days post discharge; 2 = No; 3 = Unknown/ND; 4 = Yes, within 60 days post-discharge; 5 = Yes, within 90 days post-discharge		Required		5/22/19 CDC changed legal values so mapping can be direct with IQVIA and capture time points of readmissions since discharge
	<ReAdDate>	Date of first readmission		__/__/____		Date MMDDYYYY; Date Not Documented		Optional		5/22/19 CDC added “date not documented” as selection option (<ReAdDND>)
	<ReAdWhy>	Reason for Readmission:		Numeric # = 1-digit		2 = Pneumonia; 3 = Deep vein thrombosis/pulmonary embolism/blood clot; 4 = Transient Ischemic Attack; 5 = Carotid Intervention; 6 = Atrial Fibrillation/Flutter; 7 = Acute Myocardial Infarction; 8 = Other cardiac surgery; 9 = Heart failure; 10 = Peripheral Intervention; 11 = Other cardiac event; 12 = Other surgical procedure; 13 = Infection/sepsis; 14 = Urinary tract infection; 15 = Unknown/ND; 16 = Fall		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
	<ReAdNum>	Total number of readmissions since discharge:		Numeric # = 1-digit		1 = 1; 2 = 2; 3 = 3 or more; 4 = Unknown/ND; 5 = 0		Optional		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
	<DiePer>	Select Period:		Numeric # = 1-digit		1 = Within 30 days post-discharge; 2 = Within 60 days post-discharge; 3 = Within 90 days post-discharge		Required		5/22/19 CDC decided to include all “Select Period” variables in data dictionary for clarity
	<CurExp>	Has patient died?		Numeric # = 1-digit		1 = Yes; 2 = No/ND		Required		5/22/19 This variable was previously missing from the data dictionary.
	<DieDate>	If patient died, date of death		__/__/____		Date MMDDYYYY; Date Not Documented		Required		5/22/19 CDC added “date not documented” as selection option (<DieDND>)
	<DieCause>	If patient died, cause of death		Numeric # = 1-digit		1 = New ischemic stroke; 2 = DVT/PE; 3 = Pneumonia/respiratory failure; 5 = Myocardial infarction; 7 = Heart failure; 8 = Sepsis/infection; 9 = Other Cardiovascular; 10 = Intracranial Hemorrhage (SAH, ICH, SDH, etc.); 11 = Unknown/ND; 12 = Other		Required		5/22/19 CDC changed legal values so mapping can be direct with IQVIA
MENTAL HEALTH	Over the past 2 weeks how often have you been bothered by any of the following problems: Not at all, several days, more than half the days, and nearly every day.							Optional
	<MenHea1>	Little interest or pleasure in doing things		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea2>	Felling down, depressed, or hopeless		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea3>	Trouble falling asleep, staying asleep or sleeping too much		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea4>	Feeling tired or having little energy		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea5>	Poor appetite or overeating		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea6>	Feeling bad about yourself or that you're a failure or have let yourself or your family down		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea7>	Trouble concentrating on things, such as reading the newspaper or watching television		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea8>	Moving or speaking so slowly that others could have noticed. Or, the opposite, being so fidgety or restless that you have been moving around more than usual		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3
	<MenHea9>	Thoughts that you would be better off dead or of hurting yourself in some way		Numeric # = 1-digit		1=not at all, 2= Several days, 3=More than half the days, 4=Nearly everyday		Optional		4/24/19 CDC changed legal values to 1,2,3,4 instead of 0,1,2,3