60-day Response to Comment Document

CMS Responses to Public Comments Received for the Patient-Reported Indicator Survey (PaRIS) - CMS-10792

The Centers for Medicare and Medicaid Services (CMS) received a letter from the Academy of Nutrition and Dietetics (the Academy) related to the Patient-Reported Indicator Survey (PaRIS) information collection request (86 FR 62173). This document reconciles the comments from the Academy’s letter.

The PaRIS Survey has been developed by a collaborative workgroup under the auspices of the Organization for Economic Cooperation and Development (OECD). A primary goal of the PaRIS Survey is to provide a standardized set of items to measure outcomes and experiences of health care. The OECD working group allows participating countries to adjust survey questions in minor ways for contextual understanding within their country. However, whenever possible, it is important for items to be consistent across participating countries to provide policy makers with the most meaningful data possible and to avoid significant increases to respondent burden. With this in mind, comments from the Academy were reviewed by the OECD workgroup, which coordinates questionnaire development for all countries participating in the PaRIS Survey. Localizations for the U.S. survey were accommodated whenever possible.

Comment:

The Academy recommended that the response option for “Cardiovascular or heart condition” at item Q_CHRONCOND (Q50¹) include in parentheses “e.g., high cholesterol, high triglycerides or heart failure.”

Response:

CMS and OECD appreciate the suggestion. This addition will be made as a localization in the U.S. version of the PaRIS survey.

Comment:

The Academy recommended that the response option “chronic kidney or liver disease” at question Q_CHRONCOND (Q50) be separated into two separate response options.

Response:

This change was also recommended via pilot testing conducted by other participating countries. This change has been incorporated for all countries.

Comment:

The Academy recommended adding in parentheses to Q_EHISFR (Q22, in regard to the frequency of fruit consumption) saying “including fresh, frozen, canned or dried”. Similarly, the Academy recommended adding in parentheses to Q_EHISVG (Q23, in regard to the frequency of vegetable consumption) “including fresh, frozen or canned”.

Response:

This addition will be made as a localization in the U.S. version of the PaRIS survey.

Comment:

The Academy recommended adding a question regarding patient access to tools and resources to implement dietary recommendations. Such a question could be worded as “If a health professional did talk with you about healthy eating, which tools and resources were provided to you, either by the professional directly and/or by a referred dietitian/dietitian nutritionist?” Furthermore, even if the patient was provided such resources, a question about barriers is also suggested. This question could be worded as “What barriers, if any, did you face in adopting these healthy eating recommendations?”

Response:

The PaRIS Survey asks about several topics related to primary health care, such as the respondent’s health, health behaviors, patient activation and confidence in managing their health care, experiences with health care and health providers including access to health care, quality of life, physical functioning, and psychological well-being. Given the survey’s broad focus on health, asking additional questions specific to certain types of health services would necessitate detailed follow-up items about other types of health services and behaviors as well. This level of detail is unfortunately not possible without overburdening respondents and is likely to introduce inconsistencies across participating countries.

Comment:

The Academy also notes that dietary recommendations intended to reduce risk of the chronic cardiovascular conditions referenced earlier also includes whole grains, the importance of which is also noted in the Dietary Guidelines for Americans. According to the USDA’s Healthy Eating Index and the Dietary Guidelines for Americans, whole grain intake among older adults is only about 30 - 40% of recommended. Thus, the Academy recommended the addition of a question seeking to define frequency of respondents’ whole grain intake. Suggested wording could parallel Q_EHISFR (Q21) and Q_EHISVG (22): “How often do you eat whole grains (including 100% whole grain bread, cereal or pasta, or cooked whole grains, such as brown rice, barley, kasha or quinoa)?”

Response:

CMS and OECD appreciate the suggestion. However, in an effort to main consistency across participating countries, CMS and OECD do not plan to add this item.

Comment:

The Academy recommended adding a question addressing binge drinking or heavy drinking, which may increase risk of several of the chronic conditions referenced, including heart disease, stroke, cancer, and liver disease.

Response:

CMS and OECD appreciate the suggestion. However, in an effort to main consistency across participating countries, CMS and OECD do not plan to add this item.

Comment:

The Academy recommended rewording question PN10 (Q38) to better understand respondents’ experience with healthcare and their assessment of the results of that care.

Response:

This item was sourced from the Porter Novelli Consumer Preferences Scale, which has been validated and widely tested. Changes to this item may introduce measurement error and would make results less comparable to other sources. Therefore, CMS and OECD do not recommend rewording the question as suggested.

Comment:

Since prevention, treatment, and management of many of the chronic conditions referenced are related to dietary habits and patterns, as well as other aspects of lifestyle, the Academy recommended the addition of a question seeking to define access to other specialized health professionals. The question could be worded as “Do you have access to (or have you been seen in the last twelve months by) either of the following specialty health care professionals?”

Response:

CMS and OECD appreciate the suggestion. However, in an effort to main consistency across participating countries, CMS and OECD do not plan to add this item.

Comment:

The Academy recommended adding questions regarding respondents’ knowledge of access to a dietitian/dietitian nutritionist for diabetes and kidney disease. Such questions could be worded as “Did you know that Medicare will cover seeing a dietitian/dietitian nutritionist for diabetes?” and “Did you know that Medicare will cover seeing a dietitian/dietitian nutritionist for kidney disease?”

Response:

These items are specific to the U.S. health care system and therefore are not suitable for inclusion on the PaRIS survey for all participating countries. Given the survey’s broad focus on health, asking additional questions specific to certain types of health services would necessitate detailed follow-up items about other types of health services and behaviors as well. Adding this level of detail to the PaRIS survey is unfortunately not possible without overburdening respondents.

Comment:

The Academy recommended modifying the preface to Q_PURPOS (Q80) to list “dietitian/dietitian nutritionist,” among other providers.

Response:

Given the PaRIS Survey’s broad focus on health, including specific provider types in introductory text would necessitate similar details for other provider types. Adding this level of detail to the PaRIS survey is unfortunately not possible without overburdening respondents and is likely to introduce inconsistencies across participating countries.

Comment:

The Academy recommended modifying the response option at Q_ OECDACC7a from “dietician” to “dietitian/dietitian nutritionist”.

Response:

CMS and OECD appreciate the suggestion. This addition will be made as a localization in the U.S. version of the PaRIS survey and will be considered for all countries in the future.

Comment:

The Academy recommended replacing “nutritious” with “healthy” at item MONMEAL.

Response:

This change was also recommended via pilot testing conducted by other participating countries. This change has been incorporated for all countries.

1 The latest version of the PaRIS Survey specifications uses updated variable names (see Attachment 2). For ease of reference, the previous variable names are provided in parentheses.

3