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ECRI Health Technology Assessment Group. Determinants of Disability in Patients With Chronic Renal Failure. Rockville (MD) : Agency for Healthcare Research and Quality (US); 2000 May. (Evidence Reports/Technology Assessments, No. 13.)
This publication is provided for historical reference only and the information may be out of date.
Note: All lists within a given question, if representing separate variables each, if labelled 1 to X, are changed to "a" to X in the data file This is not the case for numbered codes (such as race and ethnicity) which are contained within the same variable.
DMMS Wave 2 Medical Questionnaire
DW2 M A. Patient and Facility Identification
| Variable Name | Question Asked |
| TREATMO | |
| COMPDPT | |
| SSMTH SSYR | Study Start Date: |
| ETHNIC | 3. Ethnicity :....................................................................... |
| 1 - Hispanic Origin 2 - Not of Hispanic Origin | |
| S_RACE | 4. Race:.............................................................................. |
| 1 - White 2 - Black 3 - Asian 4 - Native American 5 - Other | |
| 5. Patient's Zip Code: | |
| FDIALMTH | 6. Date of first regular dialysis for chronic renal failure: (at least once weekly; regardless of setting) Please exclude intermittent dialysis treatments only for fluid overload or heart failure. |
| FDIALYR | 7. Study Start Date (Date #A6 plus 60 days): |
| 8. Was date of earliest known dialysis - same as #A6?.......... | |
| (i.e. were there no intermittent treatments prior to date at A6?) | |
| 1 - Yes 2 - No | |
| (If item 8 is "no," give earliest date): | |
| 9. Insurance (answer all that apply in both columns): | |
| in the month at or near | |
| 1 - Yes 2 - No before date A6 date A7 | |
| MEDICAR1 | a. Blue Cross/Blue Shield : ................. ........................ |
| MED2_1 | b. Private (other than BC/BS): . ................. ...................... |
| MEDICAR2 | c. Medicare: .......................................... ........................ |
| MEDPEND | if :"no," is Medicare pending? ................................. |
| MED2_2 | if "yes," is Medicare secondary? ............................. |
| d. Medicaid: .................................... ................................ | |
| e. VA:................................................................................ | |
| f. Other: ........ .................... .................... ........................ | |
| g. None: .................... .................... .................................. | |
| h. Enrolled in an HMO? .................... .............................. | |
DW2M B. Patient History Within 10 Years Prior to Study Start Date (date A7)
| PC_DIS | 1. Primary cause of ESRD:............................................................... |
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| SMOKING | 2. Regular cigarette smoking status:........................................... |
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| 3. History of Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD) | |
| For a through g code 1 - Yes 2 - Suspected 3 - No | |
| CHD_CAD | a. Prior diagnosis of CHD/CAD:............................. |
| ANGINA | b. Angina:................................................................ |
| MI | c. Myocardial infarction (MI):................................. |
| CABG | d. Bypass surgery (CABG):...................................... |
| ANGIOPLA | e. Coronary angioplasty (PTCA): ............................. |
| ANGIOGRA | f. Coronary angiography:.......................................... |
| AN_GRABN | Abnormal?...................................................... |
| CARDARR | g. Cardiac arrest: ...................................................... |
| 4. History of Cerebrovascular Disease: | |
| CEREBROV | For a & b code 1 - Yes 2 - Suspected 3 - No CVA or TIA |
| a. Diagnosis of Cerebrovascular Accident (CVA, Stroke) ................................................ | |
| (If item 4a is "yes," skip to item 5.) | |
| TIA | b. Any Transient Ischemic Attacks (TIA)? ............. .... |
| 5. History of Peripheral Vascular Disease (PVD, PVOD): | |
| For a through e code 1 - Yes 2 - Suspected 3 - No | |
| PVD | a. Prior diagnosis of PVD:....................................... |
| AMPUTATA | b. Amputation due to PVD:...................................... |
| LIMBAMP | c. Limb amputation (other): ........................................ |
| ABS_PULS | d. Absent foot pulses: ............................................... |
| CLAUDIC | e. Claudication: ........................................................ |
| 6. Hx of Heart Disease (other than CAD/CHD): | |
| For all code: 1 - Yes 2 - Suspected 3 - No | |
| CONG_H | a. Congestive heart failure:................................................ |
| PERICARD | b. Pericarditis : .................................................................. |
| PULMED | c. Pulmonary edema: ......................................................... |
| 7. Prior diagnosis of diabetes:............................................... | |
| DX_DIAB | 1 - Yes 2 - Suspected 3 - No |
| If item 7 is "no," skip to item 8. | |
| a. Insulin therapy:.............................................................. | |
| INSULIN | 1 - Active 2 - Former 3 - Never |
| b. Diabetes pills:................................................................ | |
| DPILLS | 1 - Active 2 - Former 3 - Never |
| 8. History of Lung Disease: | |
| LUNGDIS | Chronic obstructive pulmonary disease (COPD) ................ |
| 1 - Yes 2 - Suspected 3 - No | |
| 9. Neoplasms (other than skin): ........................................... | |
| NEOPLASM | 1 - Yes 2 - Suspected 3 - No |
| If item 9 is "no," skip to item 10. | |
| a. Primary sites (up to 2) .... | |
| NEO_TYPE | 10 - Lung 11 - Stomach/Esophagus 12 - Breast 13 -- Pancreas 14 - Prostate 15 -- Liver 16 - Colon/Rectal 17 -- Myeloma 18 - Lymphoma/Leukemia 19 -- Brain 20 - Ovary/Uterus 21 - Melanoma of skin 22 - Bladder 23 - Oral/Larynx 24 - Kidney 25 - Other, Unknown |
| NEO_YEAR | b. Year of first dx: ............ ......... ... 19__ |
| HIV | 10. HIV Status: ...................................................................... |
| 1 - Positive 2 - Negative 3 - Unknown 4 - Can't disclose | |
| AIDS | 11. AIDS Diagnosis: ............................................................... |
| 1 - Positive 2 - Negative 3 - Unknown 4 - Can't disclose | |
DW2M C: Information at Study Start Date (Date A7)
| You may use information from the period between 30 days prior to date at A7 to 30 days after date at A7 | ||
| 1. Height (at any time): (REQUIRED) ft. in. OR cm. | ||
| If bilateral amputee give original height and check this box | ||
| AFT_WTLB | 2. Dry weight as ordered nearest study start date: wt: lbs. OR . kgs. | |
| AFT_WTKG | 3. Undernourished or cachectic (malnourished) at study start date (A7) | |
| UNDNOUR | 1 - Yes 2 - No 3 - Suspected | |
| 4. Blood pressure and weight (most recent 3 readings before date (A7); please right justify entry): | ||
| a. Predialysis BP (sitting preferred) for HD (any readings for PD patients): | ||
| weight (rounded) | ||
| SBP DBP | ||
| SBP DBP | ||
| SBP DBP | ||
| Required: | ||
| weight in pounds (lbs) or in kg. rounded (check one) | ||
| b. Postdialysis BP (sitting preferred) for HD (skip for PD patients): 1-Yes 2-No | ||
| weight (rounded) | ||
| SBP DBP | ||
| SBP DBP | ||
| SBP DBP | ||
| HEMODIALYSIS (if used on date A7) | ||
| If patient is using peritoneal dialysis, skip to PD section | ||
| 5. Hemodialysis prescription at date A7: | ||
| DIALYSAT | a. Dialysate:..................................................................... | |
| 1 - Bicarbonate 2 - Acetate | ||
| HEMO_HRS HEMO_MIN | b. Prescribed hours per treatment: : hr. min. | |
| c. Prescribed # of dialysis sessions per week:.................. | ||
| SESSIONS | d. Blood flow rate (BFR):.................... ml/min | |
| BFR | If BFR varies please enter the prescribed or the most common "high" rate. | |
| e. Patient usually reusing dialyzer:............................... .. | ||
| 1 - Yes 2 - No | ||
| f. If reuse does not occur, please indicate reason:............. | ||
| 1 - Unit does not reuse 2 - Patient refuses 3 - Hepatitis 4 - Other Medical | ||
| g. Dialyzer type (see codes on back of page 5): | ||
| Only if you have entered code 9999, please specify below the manufacturer and dialyzer model: | ||
| Manufacturer dialyzer model at date A6 at date A7 | ||
| h. Vascular access in use: .................................................... | ||
| 1 - AV Fistula | ||
| ACCESS1 | 2 - PTFE graft e.g. Gortex, Impra, Teflon | |
| ACCESS2 | 3 - Bovine graft | |
| 4 - Permanent catheter e.g. Permcath (any site) | ||
| 5 - Temporary internal jugular (IJ) catheter | ||
| 6 - Temporary subclavian catheter | ||
| 7 - Temporary femoral catheter | ||
| 8 - Other | ||
| at date A6 at date A7 | ||
| i. Side of THIS access: .......................................................... | ||
| 1 - Right 2 - Left | ||
| AC1_SIDE | j. First permanent vascular access created or attempted on or before date A7: | |
| AC2_SIDE | Type (use codes 1-4 from item 5h above):........................ | |
| ACCTYPE | Date of surgery: | |
| SURGMTH | Date of first use of THIS access before A7: (leave blank if never used before date A7) | |
| SURGYR | Did this access require revision or did it fail? (Be sure to answer both boxes) | |
| FACCMTH | 1 - No, not before date A7 | |
| FACCYR | 2 - Yes, before date A6 | |
| ACCREVIS | 3 - Yes, between date A6 and date A7 | |
| ACCFAIL | Did this access fail to mature before date A7?............. . | |
| ACCMATUR | 1 - Yes 2 - No | |
| k. Temporary access in central vein anytime before date A7............................................... . | ||
| 1 - Yes 2 -No | ||
| ACCTEMP | If item 5k is "no,"skip to item 5l. | |
| Any Subclavian (SC)............................. | ||
| SUBCLAV | Any Internal jugular (IJ)......................... | |
| INTJUG | 1 - Right 2 - Left 3 - Right and Left 4 - Neither | |
| l. Number of HD treatments skipped by patient during 30 days prior to A7 (do not include time in the hospital) | ||
| SKIPDIAL | m. Number of prescribed HD treatments shortened by more than 10 minutes by the patient during the 30 days prior to A7 (do not include skipped treatments): | |
| SHRTDIAL | n. Did this patient have any peritoneal dialysis before date A7 (study start date)? | |
| PD_BSSD | 1 - Yes 2 -No | |
| If item 5n is "no," skip to item 8 (Psychosocial Evaluation) | ||
| o. Date of placement for PD catheter: | ||
| If patient is on hemodialysis on date A7, skip to Psychosocial Evaluation, item C8 | ||
| PERITONEAL DIALYSIS (if used on date A7) | ||
| 6. Peritoneal dialysis prescription at study start date (Date A7): | ||
| a. Dialysis location:............................................................ | ||
| PDLOCAT | 1 - Home 2 - Home Training 3 - In-center | |
| b. Type:............................................................................... | ||
| PDIALTYP | 1 - CAPD 2 - Cycler(full only when off cycler) 3 - Cycler (empty when off cycler) 4 - Combined | |
| c. Peritoneal Dialysis Prescription: | ||
| Cycler Manual? | ||
| EXCYDAY | # of exchanges/day: | |
| LT_EXCY | Liters/exchange (most common): | |
| HRS_CYC | Total hours/day on cycler: | |
| DAYS_CYC | Days/week cycler: | |
| DAYS_MAN | Days/week manual: | |
| DIALY_VM | Total dialysate volume per 24 hrs: | |
| PDCATH | d. Type of PD catheter in use at date A7: .......................... | |
| CATHMTH | 1 - single cuff 2 - double cuff 3 - no cuff | |
| CATHYR | e. Date of placement for THIS catheter: | |
| FSTPDC | f. Was this the first peritoneal catheter for this patient?............................................................. | |
| 1 - Yes 2 - No | ||
| HEMO_BPD | g. Was this patient treated with hemodialysis before date A7 (study start date)?............................... | |
| 1 - Yes 2 - No | ||
| PERMVA_B | h. Did this patient have a permanent vascular access before date A7 (study start date)?............................... | |
| 1 - Yes 2 - No | ||
| If item 6h is "yes," go back to item 5j (go left) and complete 5j. | ||
| 7. Please give, on a voluntary basis, 24 hour dialysate urea N and creatinine in period of A6 to A7 + 30 days. | ||
| VOLDRAIN | Total volume (drained) ................................................. | |
| DIALUREA | Dialysate Urea N - .mg/dl ......................................... | |
| DIALCRET | Dialysate Creatinine .- mg/dl ....................................... | |
| BUN_SD | BUN (same day) .- mg/dl..................................... | |
| SERCRET | Serum creatinine .- mg/dl............................................... | |
| PSYCHOSOCIAL EVALUATION | ||
| Complete this section for both PD and HD patients | ||
| Complete the following with information from the psycho-social evaluation most recent before the STUDY START DATE (or up to 30 days after A7). Use social worker's evaluation supplemented by the nurse's, and/or dietitian's records. You may want to consult with the social worker, dietitian, or ask the patient. | ||
| 8. Activities of daily living (currently or recently): 1 - Yes 2 - No | ||
| IND_EAT | a. Able to eat independently :............................................... | |
| IND_XFER | b. Able to transfer independently:......................................... | |
| IND_AMBU | c. Able to ambulate independently (includes ambulating with an assistance device).............................. | |
| MAR_STAT | 9. Marital status:..................................................................... | |
| 1 - Single 2 - Married 3 - Widowed 4 - Divorced 5 - Separated | ||
| ALONE | 10. Living alone:................................................................... | |
| 1 - Yes 2 - No 3 - Nursing home, institution 4 - Homeless | ||
| EDUCAT | 11. Education:........................................................................... | |
| 1 - Less than 12 Yrs. 2 - High School Grad 3 - Some College 4 - College Grad | ||
| OCCUPAT | 12. Primary occupation before ESRD:.................................. | |
| [codes changed by ECRI] | 1 - Professional | |
| 2 - Clerical | ||
| 3 - Student | ||
| 4 - Tradeperson | ||
| 5 - Manual Labor | ||
| 6 - Other | ||
| 7 - Not Employed Outside of Home | ||
| 8 - Homemaker | ||
| 9 - Disabled | ||
| 13. Employment Level: | ||
| a. Please indicate the one most appropriate employment category for the patient during the periods of time indicated. Please enter one number only in each box from the list below. | ||
| EMP_2YR | 24 mo. prior to ESRD -- | |
| EMP_NDT | 6 mo. Near prior to ESRD | |
| date at A7 | ||
| 1 - Employed full time or full time student............................. | ||
| 2 - Employed part time or part time student | ||
| 3 - Homemaker | ||
| 4 - Retired | ||
| 5 - Never Employed | ||
| 6 - Unemployed | ||
| 7 - Disabled | ||
| 8 - Other (specify) | ||
| b. If unemployed, is patient looking for employment:......... | ||
| LOOKEMP | 1 - Yes 2 - No | |
DW2M D: Laboratory Data
| Complete with information closest to study start date (A7) from a period of up to3 months before study start date (A7) and one month after study start date (A7+ 30 days). | |
| XRAY | 1. Cardiomegaly by X-ray:........................................................ |
| 1 - Yes 2 - No | |
| 2. Left ventricular hypertrophy: | |
| 1 - Yes 2 - No | |
| EKG | a. by EKG ? |
| ECHOCARD | b. by echocardiography? |
| SER_CAL | 3. Total serum calcium, predialysis:............. . mg/dl |
| PHOSPH | 4. Serum phosphate or phosphorus, predialysis:.............................................. . mg/dl |
| SER_BIC | 5. Serum bicarbonate or CO2, predialysis: ____mEq/l |
| HEMATO | 6. Hematocrit information (from the lab report) |
| a. Hematocrit (If transfused, give value before blood transfusion):........ . % | |
| HEMOGLOB | b. Hemoglobin (If transfused, give value before transfusion.................. . g/dl |
| TRANS | c. Transfused in first 60 days of dialysis?................ |
| 1 - Yes 2 -- No | |
| If item 6c is "no," skip to item 7. | |
| NUMTRANS | d. If transfused, number of transfusions in first 30 days of dialysis:.................................... |
| EPO1 | 7. Was the patient taking EPO (Erythropoietin)? |
| 1 - Yes 2 -- No | |
| EPO_FS | a. During first 60 days of dialysis (between A6 and A7):....................... .... |
| EPOTYPE | If yes: IV = 1, subcutaneous = 2 ................................ ......... |
| EPO_LAST | b. During last month before ESRD (30 days prior to A6)? |
| CREAT2 | 8. Serum Creatinine: |
| CREAT1 | a. Before first regular dialysis.. ........... . mg/dl |
| (on day of first regular dialysis or on the closest day prior to date A6) | |
| b. Nearest day 60 (A7):........................ . mg/dl | |
| 9. BUN or urea values: Check here if urea:.............. | |
| BUN_BFST | a. Before first regular dialysis: ............. mg/dl |
| PREBUN_1 | (on day of 1 st regular dialysis or on the closest day prior to date A6) |
| PSTBUN_1 | b. Nearest day 60 (measurements must be from same date): |
| BUNWT_LK | Predialysis:........................... mg/dl required |
| Postdialysis:.......................... mg/dl required | |
| c. Weights pre and post dialysis (must be on same day as 9b): weight in lb. or kg. rounded (check one) | |
| PREWT | Predialysis (required) |
| PSTWT | Postdialysis (required) |
| Dates for pre and post BUN values and pre and post weights MUST match. | |
| SER_ALB | 10. Predialysis or random Serum Albumin: ____g/dl |
| Complete with information closest to study start date (A7) from a period of up to 3 months before study start date (A7) to 1 month after study start date (A7+30) | |
| 11. Lipids: | |
| CHOLEST | a. Cholesterol Total:....................... mg/dl |
| CHOL_HDL | b. HDL cholesterol:.......................... mg/dl |
| CHOL_LDL | c. LDL cholesterol:......................... mg/dl |
| TRIGLY | d. Triglycerides:.................... mg/dl |
| SER_PTH | 12. Serum intact PTH:......................... pg/ml |
| SER_ALUM | 13. Serum Aluminum: ........................ mg/l |
| (Random or if DFO, please use base line measurement) | |
| 14. Residual Renal Function: | |
| [This section is important but is not an official requirement. Please give all available information and/or obtain the measurements within period of date A6 to date A7 + 30 days, ( i.e.days 0 -90 days ESRD) on a voluntary basis if at all possible:] | |
| UCSTDT_M | a. Urine collection time: |
| UCSTTMDY | start............. : mm dd hr min AM=1 PM=2 |
| UCEDDT_M | end............... . : mm dd hr min AM=1 PM=2 |
| UCEDTMDY | Total hours of urine collection (Verification)_______ |
| THRS_UC | b. Lab Values |
| Value Units | |
| URINE_VM | Urine Volume ____ ml or cc |
| URINE_CR | Urine Creatinine________(indicate units mg/vol) |
| UUNITROG | Urine Urea Nitrogen _______ mg/24 hrs. (mg/dl=mg%) |
| PRECREAT | Pre Creatinine* _________. mg/dl |
| PREBUN_2 | Pre BUN* ________mg/dl |
| PSTCREAT | Post Creatinine* _______. mg/dl |
| PSTBUN_2 | Post BUN* ________ mg/dl |
| U_UNITS | * For the pre and post blood creatinine and BUN, please provide values taken ideally at the beginning (pre) and end (post) of URINE collection If this is not possible: |
| For hemo patients, enter values from measurements taken pre and post dialysis on a date as close as possible to the dates of urine collection. | |
| For PD patients, enter blood creatinine and BUN values taken on a date as close as possible to the date of urine collection available. | |
| 15. Medications at time of A7, please copy the list of all medications as generic or trade name. (The dosage is not required) | |
| VITAMN_D | 16. Was patient receiving at time of A7 injectable vitamin D (Calcijex) |
| 1 - Yes 2 -- No | |
DMMS Wave 2 Patient Questionnaire
D2Q A. General Health
| HELGEN | 1. In general, would you say your health is: | |||||||
| (Circle One Number) | ||||||||
| Excellent..........................................................................1 | ||||||||
| Very good........................................................................2 | ||||||||
| Good.................................................................................3 | ||||||||
| Fair....................................................................................4 | ||||||||
| Poor...................................................................................5 | ||||||||
| HELPRE | 2. Compared to one year ago, how would you rate your health in general now? | |||||||
| (Circle One Number) | ||||||||
| Much better now than one year ago..................................1 | ||||||||
| Somewhat better now than one year ago........................2 | ||||||||
| About the same as one year ago..........................................3 | ||||||||
| Somewhat worse now than one year ago.......................4 | ||||||||
| Much worse now than one year ago.................................5 | ||||||||
| The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? | ||||||||
| (Circle One Number on each line) | ||||||||
| 1 Yes, limited a lot 2 Yes, limited a little 3 No, not limited at all | ||||||||
| VIGACT | 3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports 1 2 3 | |||||||
| MODACT | 4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3 | |||||||
| LIFT | 5. Lifting or carrying groceries 1 2 3 | |||||||
| CLIMBMLT | 6. Climbing several flights of stairs 1 2 3 | |||||||
| CLIMBONE | 7. Climbing one flight of stairs 1 2 3 | |||||||
| BEND | 8. Bending, kneeling, or stooping 1 2 3 | |||||||
| WALKMLT | 9. Walking more than a mile 1 2 3 | |||||||
| WALKSEV | 10. Walking several blocks 1 2 3 | |||||||
| WALKBLK | 11. Walking one block 1 2 3 | |||||||
| BATHING | 12. Bathing or dressing yourself 1 2 3 | |||||||
| During the last 30 days, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? | ||||||||
| (Circle One Number on Each Line) Yes No | ||||||||
| REDTIM | 13. Cut down the amount of time you spent on work or other activities? 1 2 | |||||||
| ACCLESS | 14. Accomplished less than you would have liked? 1 2 | |||||||
| LIMWRK | 15. Were limited in the kind of work or other activities? 1 2 | |||||||
| DIFFPER | 16. Had difficulty performing work or other activities (for example, it took extra effort)? 1 2 | |||||||
| During the last 30 days, have you had any of the following problems with your work or other regular daily activities as a result of emotional problems such as anxiety or depression? | ||||||||
| (Circle One Number on Each Line) Yes No | ||||||||
| REDWRK | 17. Cut down the amount of time you spent on work or other activities? 1 2 | |||||||
| ACMPLS | 18. Accomplished less than you would have liked? 1 2 | |||||||
| WRKCAR | 19. Didn't do work or other activities as carefully as usual? 1 2 | |||||||
| SOCINT | 20. During the last 30 days, to what extent have your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (Circle One Number) | |||||||
| Not at all ...1 Slightly ...2 Moderately ... 3 Quite a bit ...4 Extremely ...5 | ||||||||
| BODPAIN | 21. How much bodily pain have you had during the last 30 days? (Circle One Number) | |||||||
| 1 None 2 Very mild 3 Mild 4 Moderate 5 Severe 6 Very severe | ||||||||
| PAININT | 22. During the last 30 days, how much did pain interfere with your normal work (including work both outside the home and housework)? (Circle One Number) | |||||||
| ||||||||
| These questions are about how you feel and how things have been with you during the last 30 days. For each question, please give the one answer that comes closest to the way you have been feeling. | ||||||||
| How much of the time during the last 30 days....(Circle One Number on Each Line) | ||||||||
| ||||||||
| PEP | 23. Did you feel full of pep? 1 2 3 4 5 6 | |||||||
| NERVPER | 24. Have you been a very nervous person? 1 2 3 4 5 6 | |||||||
| DOWNDUMP | 25. Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 6 | |||||||
| CALM | 26. Have you felt calm and peaceful? 1 2 3 4 5 6 | |||||||
| ENERGY | 27. Did you have a lot of energy? 1 2 3 4 5 6 | |||||||
| DOWNBLU | 28. Have you felt downhearted and blue? 1 2 3 4 5 6 | |||||||
| WORNOUT | 29. Did you feel worn out? 1 2 3 4 5 6 | |||||||
| HAPPYPER | 30. Have you been a happy person? 1 2 3 4 5 6 | |||||||
| TIRED | 31. Did you feel tired? 1 2 3 4 5 6 | |||||||
| INTSOC | 32. During the last 30 days, how much of the time have your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? (Circle One Number) | |||||||
| All of the time...........................................................................1 | ||||||||
| Most of the time........................................................................2 | ||||||||
| Some of the time.....................................................................3 | ||||||||
| A little of the time...................................................................4 | ||||||||
| None of the time......................................................................5 | ||||||||
| How TRUE or FALSE is each of the following statements for you? | ||||||||
| (Circle One Number on Each Line) | ||||||||
| ||||||||
| SICK | 33. I seem to get sick a little easier than other people. 1 2 3 4 5 | |||||||
| HLTHEXP | 34. I am as healthy as anybody I know. 1 2 3 4 5 | |||||||
| HLTWRS | 35. I expect my health to get worse. 1 2 3 4 5 | |||||||
| EXLHLTH | 36. My health is excellent. 1 2 3 4 5 | |||||||
| YOUR KIDNEY DISEASE | ||||||||
| How TRUE or FALSE is each of the following statements for you? (Circle One Number on Each Line) | ||||||||
| ||||||||
| INTLIFE | 37. My kidney disease interferes too much with my life 1 2 3 4 5 | |||||||
| TIME | 38. Too much of my time is spent dealing with my kidney disease 1 2 3 4 5 | |||||||
| FRUST | 39. I feel frustrated dealing with my kidney disease 1 2 3 4 5 | |||||||
| BURDEN | 40. I feel like a burden on my family 1 2 3 4 5 | |||||||
| These questions are about how you feel and how things have been with you during the last 30 days. For each question, please give the one answer that comes closest to the way you have been feeling. | ||||||||
| How much of the time during the last 30 days... | ||||||||
| (Circle One Number on Each Line) | ||||||||
| ||||||||
| ISOLATE | 41. Did you isolate yourself from people around you? 1 2 3 4 5 6 | |||||||
| RCTSLOW | 42. Did you react slowly to things that were said or done? 1 2 3 4 5 6 | |||||||
| IRRIT | 43. Did you act irritable toward those around you? 1 2 3 4 5 6 | |||||||
| DIFFCON | 44. Did you have difficulty doing activities involving concentration and thinking? 1 2 3 4 5 6 | |||||||
| GETALNG | 45. Did you get along well with other people? 1 2 3 4 5 6 | |||||||
| CONFUSE | 46. Did you become confused and start several activities at a time? 1 2 3 4 5 6 | |||||||
| During the last 30 days, to what extent were you bothered by each of the following? | ||||||||
| (Circle One Number on Each Line) | ||||||||
| ||||||||
| MUSSOR | 47. Soreness in your muscles? 1 2 3 4 5 | |||||||
| CHESTPN | 48. Chest Pain? 1 2 3 4 5 | |||||||
| CRAMPS | 49. Cramps? 1 2 3 4 5 | |||||||
| ITCHSKN | 50. Itchy skin? 1 2 3 4 5 | |||||||
| DRYSKN | 51. Dry skin? 1 2 3 4 5 | |||||||
| BREATH | 52. Shortness of breath? 1 2 3 4 5 | |||||||
| FAINT | 53. Faintness or dizziness? 1 2 3 4 5 | |||||||
| APPET | 54. Lack of appetite? 1 2 3 4 5 | |||||||
| DRAIN | 55. Washed out or drained? 1 2 3 4 5 | |||||||
| NUMB | 56. Numbness in hands or feet? 1 2 3 4 5 | |||||||
| NAUSEA | 57. Nausea or upset stomach? 1 2 3 4 5 | |||||||
| ACSPROB | 58. Problems with your access or catheter site? 1 2 3 4 5 | |||||||
| EFFECTS OF KIDNEY DISEASE ON YOUR LIFE | ||||||||
| Some people are bothered by the effects of kidney disease on their daily life, while others are not. How much does kidney disease bother you in each of the following areas? | ||||||||
| (Circle One Number on Each Line) | ||||||||
| ||||||||
| FLDRST | 59. Fluid restrictions? 1 2 3 4 5 | |||||||
| DITRST | 60. Dietary restrictions? 1 2 3 4 5 | |||||||
| WRKABL | 61. Your ability to work around the house? 1 2 3 4 5 | |||||||
| TRVABL | 62. Your ability to travel? 1 2 3 4 5 | |||||||
| DEPEND | 63. Being dependent on doctors and other medical staff? 1 2 3 4 5 | |||||||
| STRESS | 64. Stress or worry caused by kidney disease? 1 2 3 4 5 | |||||||
| SEXLF | 65. Your sex life? 1 2 3 4 5 | |||||||
| The next two questions are personal, but your answers are important in understanding how kidney disease impacts people's lives. | ||||||||
| How much of a problem was each of the following during the last 30 days? | ||||||||
| (Circle One Number on Each Line) | ||||||||
| ||||||||
| ENJSEX | 66. Inability to relax and enjoy sex 1 2 3 4 5 | |||||||
| AROUSABL | 67. Difficulty in becoming sexually aroused 1 2 3 4 5 | |||||||
| For each of the following statements, please indicate whether these describe you today and are related to your state of health. (Circle One Number on Each Line) | ||||||||
| Yes No | ||||||||
| REST | 68. I lie down more often during the day in order to rest 1 2 | |||||||
| NAP | 69. I sleep or nap more during the day 1 2 | |||||||
| SLEEPLS | 70. I sleep less at night; for example, wake up too early, don't fall asleep for a long time, awaken frequently 1 2 | |||||||
| 71.On a scale from 0 to 10, how would you rate the quality of your sleep during the last 30 days?(Circle One Number) | ||||||||
| SLEEPQLT | ||||||||
| In terms of your satisfaction with family and social life, circle one number to rate each of the following: | ||||||||
| (Circle One Number on Each Line) | ||||||||
| 1 Poor 2 Fair 3 Good 4 Very good 5 Excellent | ||||||||
| TOGETH | 72. The amount of togetherness you have with your family and friends 1 2 3 4 5 | |||||||
| SUPPORT | 73. The support and understanding your family and friends give you 1 2 3 4 5 | |||||||
| 74. Are you now able to work? (Circle One Number on Each Line) | ||||||||
| Yes No | ||||||||
| WRKPT | a. Part time? 1 2 | |||||||
| WRKFT | b. Full time? 1 2 | |||||||
| EMPLST | 75. During the last 30 days, were you: (Circle One Number) | |||||||
| Working full time.................................................................1 | ||||||||
| Working part time................................................................2 | ||||||||
| In school ..................................................................................3 | ||||||||
| Keeping house ......................................................................4 | ||||||||
| Retired .....................................................................................5 | ||||||||
| Unemployed, laid off, or looking for work ...............6 | ||||||||
| Disabled.................................................................................7 | ||||||||
| None of the above.................................................................8 | ||||||||
| FRIENDLY | 76. Think about the care you receive at this facility for kidney dialysis. In terms of your satisfaction, how would you rate the friendliness and interest shown in you as a person? (Circle One Number) | |||||||
| ||||||||
| How TRUE or FALSE is each of the following statements? (Circle One Number on Each Line) | ||||||||
| ||||||||
| ENCOURGD | 77. Dialysis staff encourage patients to lead as normal a life as possible 1 2 3 4 5 | |||||||
| COUNSLD | 78. Dialysis staff here counsel me on achieving full potential for rehabilitation 1 2 3 4 5 | |||||||
D2Q B. Medical Care Before Regular Dialysis
| For the next series of questions, think back to the time prior to starting regular dialysis. | |
| WHNTLD | 1. When were you first told that your kidney function was abnormal? |
| |
| BLDTST | 2. Within the two years prior to starting regular dialysis, did you first receive a blood test from a physician (internist, family physician, general practitioner, etc.) other than a kidney specialist (nephrologist)? |
| |
| WHNSAW | 3. Prior to starting regular dialysis, when did you first receive medical attention from a kidney specialist (nephrologist)? |
| |
| NEPHVST | 4. In the year prior to starting dialysis, about how many visits did you make to a kidney specialist (nephrologist)? |
| |
| DIETVST | 5. Prior to starting dialysis, were you ever seen by or did you talk to a dietitian about your kidney problem? |
| |
| APPLOSS | 6. About how long before your first dialysis did you lose your appetite? (Circle one) |
| |
| VOMIT | 7. About how long before your first dialysis did you experience nausea or vomiting from your kidney failure? (Circle one) |
| |
| 8. Prior to starting dialysis were you treated with any of the following medications? | |
| BICARB | a. Bicarbonate? 1. Yes 2. No 3. Not sure (Sodium bicarbonate, citrate, baking soda) |
| EPO | b. Erythropoietin? 1. Yes 2. No 3. Not sure (Procrit, Epogen, EPO) |
| AVOIDBLD | 9. Were you told to avoid blood draws or intravenous lines in either arm in order to protect the veins for a permanent hemodialysis access? (Circle one) |
| NUMMONTH |
|
D2Q C. Choosing the Treatment for Your Kidney Failure
| For the next set of questions, think back to the time when the type of treatment for your kidney failure was being decided. | |||||||||||||
| 1. What options were described and discussed for your initial treatment of your kidney failure? | |||||||||||||
| (Please circle all that apply) | |||||||||||||
| ODDIALUN | 1. Hemodialysis in a dialysis unit | ||||||||||||
| ODDIALHM | 2. Hemodialysis at home | ||||||||||||
| ODCAPDHM | 3. Continuous ambulatory peritoneal dialysis (CAPD) at home | ||||||||||||
| ODPERCYC | 4. Peritoneal dialysis using a cycling machine | ||||||||||||
| ODPERCEN | 5. Peritoneal dialysis at a center or nursing home | ||||||||||||
| ODTRANS | 6. Transplantation | ||||||||||||
| ODOTHER | 7. Other [specify _______________________________________] | ||||||||||||
| 2. Which of the following best describes the process of choosing your method of treatment ? | |||||||||||||
| CHOSMTD | 1. I took the lead in selecting my treatment. | ||||||||||||
| 2. The medical team (physician, nurse, social worker) took the lead in selecting my treatment. | |||||||||||||
| 3. The medical team and I contributed equally to selecting my treatment. | |||||||||||||
| 3. How did you learn about your options for dialysis treatment? (Please circle all that apply.) | |||||||||||||
| HLDISCPH | 1. Individual discussion with physician | ||||||||||||
| HLDISCSW | 2. Individual discussion with social worker or nurse | ||||||||||||
| HLGRPDIS | 3. Group discussion or class to explain treatment options | ||||||||||||
| HLFAMDIS | 4. Discussion with family, friends or other patients | ||||||||||||
| HLVIDEO | 5. Videotape materials | ||||||||||||
| HLWRITEN | 6. Written materials | ||||||||||||
| HLOTHER | 7. None of the above [specify ______________________________] | ||||||||||||
| TRANSDIS | 4. Has your doctor or medical team discussed the option of kidney transplantation with you? (Circle one) | ||||||||||||
| 1. Yes | |||||||||||||
| 2. No | |||||||||||||
| 3. Not sure | |||||||||||||
| TRANSEVL | 5. Have you been or are you currently being evaluated for a kidney transplant? (Circle one) | ||||||||||||
| 1. Yes | |||||||||||||
| 2. No | |||||||||||||
| 3. Not sure | |||||||||||||
| WAITLIST | 6. Are you currently on a transplant waiting list? (Circle one) | ||||||||||||
| 1. Yes | |||||||||||||
| 2. No | |||||||||||||
| 3. Not sure | |||||||||||||
| 7. For the following factors, indicate how important they were in your decision to be treated at this dialysis facility rather than at another facility: (Circle one per line) | |||||||||||||
| |||||||||||||
| CLOSENS | Travel time/convenience of location 1 2 3 4 5 6 | ||||||||||||
| TRTSCHED | Convenience of treatment schedule 1 2 3 4 5 6 | ||||||||||||
| DIALTYP | Type of dialysis offered (hemo, CAPD) 1 2 3 4 5 6 | ||||||||||||
| DIALREUS | Dialyzer reuse policy 1 2 3 4 5 6 | ||||||||||||
| PHYSREC | Recommended by physician or other health professional 1 2 3 4 5 6 | ||||||||||||
| FACCOM | Comfort of facility (TV, etc.) 1 2 3 4 5 6 | ||||||||||||
| 8. For the following series of statements please indicate to what extent you believe the statement to be true: | |||||||||||||
| I BELIEVE THIS STATEMENT IS TRUE : | |||||||||||||
| |||||||||||||
| PERITCOM | a) Peritonitis (infection) is a common complication of peritoneal dialysis. 1 2 3 4 5 6 | ||||||||||||
| LONGER | b) Hemodialysis takes up more of my available time than peritoneal dialysis. 1 2 3 4 5 6 | ||||||||||||
| FLEXIBLE | c) Peritoneal dialysis allows me more flexibility than hemodialysis. 1 2 3 4 5 6 | ||||||||||||
| NOTSTRCT | d) My diet is less strict on hemodialysis. 1 2 3 4 5 6 | ||||||||||||
| FLDSTRCT | e) Fluid restriction is less on peritoneal dialysis. 1 2 3 4 5 6 | ||||||||||||
| NEEDLES | f) I do not like needles/injections. 1 2 3 4 5 6 | ||||||||||||
| MORESTRS | g) Peritoneal dialysis is more stressful for me than hemodialysis. 1 2 3 4 5 6 | ||||||||||||
| DIFWRK | h) Hemodialysis makes it difficult for me to continue work or school. 1 2 3 4 5 6 | ||||||||||||
| BURDFAM | i) Hemodialysis is a burden to my family. 1 2 3 4 5 6 | ||||||||||||
| SOCIALZE | j) I like to socialize with other dialysis patients and staff. 1 2 3 4 5 6 | ||||||||||||
| LIVEFAR | k) I live far away from a hemodialysis unit. 1 2 3 4 5 6 | ||||||||||||
| MEDPROB | l) Medical problems did not allow me the choice of other treatment types. 1 2 3 4 5 6 | ||||||||||||
| 9. Which of the previous reasons (a-l) was the MOST IMPORTANT reason in selecting your type of treatment? Write the question letter from 8. in here:___________________ | |||||||||||||
| BESTQLTY | 10. When comparing hemodialysis and peritoneal dialysis, do you believe that quality-of-life (Circle one best answer): | ||||||||||||
| ____1. is better for patients treated with hemodialysis | |||||||||||||
| ____2. is better for patients treated with peritoneal dialysis | |||||||||||||
| ____3. is equal for both peritoneal and hemodialysis | |||||||||||||
| ____4. don't know | |||||||||||||
| LONGLIFE | 11. Comparing hemodialysis and peritoneal dialysis, which treatment do you believe helps patients live longer? | ||||||||||||
| ____1. Hemodialysis | |||||||||||||
| ____2. Peritoneal dialysis | |||||||||||||
| ____3. Peritoneal and hemodialysis are about the same | |||||||||||||
| ____4. Don't know | |||||||||||||
| The next questions are for patients on peritoneal dialysis. If you are not on peritoneal dialysis, skip to Part 4 (Transportation) below. | |||||||||||||
| MISSXCHG | 12. If you are on CAPD, how many times have you missed an exchange during the last 7 days? (Circle one best answer) | ||||||||||||
| ___ 7 or more times | |||||||||||||
| ___ 4 to 6 times | |||||||||||||
| ___ 2 to 3 times | |||||||||||||
| ___ once | |||||||||||||
| ___ not at all | |||||||||||||
| ___ I am not on CAPD | |||||||||||||
| MISSTRMT | 13. If you use a cycler for peritoneal dialysis, how many days did you miss a treatment in the last 2 weeks? (Circle one best answer) | ||||||||||||
| ___ four times or more | |||||||||||||
| ___ three times | |||||||||||||
| ___ twice | |||||||||||||
| ___ once | |||||||||||||
| ___ not at all | |||||||||||||
| ___ I am not on a cycler | |||||||||||||
| SHRTRMT | 14. If you use a cycler for peritoneal dialysis, how many times have you shortened the treatment (or not using all the dialysis fluid) during the last 2 weeks? (Circle one best answer) | ||||||||||||
| ___ four times or more | |||||||||||||
| ___ three times | |||||||||||||
| ___ twice | |||||||||||||
| ___ once | |||||||||||||
| ___ not at all | |||||||||||||
| ___ I am not on a cycler | |||||||||||||
D2Q D. Transportation
| For the next questions, please think about the first month after starting dialysis. Unless otherwise noted, please circle one best answer. | |
| MINFAC | 1. How long does it usually take you to get to your dialysis unit or center (one way)? |
| |
| Questions 2-6 below are for patients who are on hemodialysis. If you are not on hemodialysis, skip to E. (Employment) | |
| METRANS | 2. How do you usually get to dialysis? |
| |
| 3. Why do you not drive yourself? (Please circle all that apply.) | |
| NOCAR | 1. I do not own or have access to a car, vehicle. |
| NODRIVE | 2. I do not know how to drive. |
| NOTABLE | 3. I am no longer able to drive a car. |
| NEEDHELP | 4. I require assistance with walking or climbing stairs. |
| TOOWEAK | 5. I am too weak or sick to drive after dialysis. |
| GURNEY | 6. I must be transported on a stretcher or gurney. |
| DRVOTHER | 7. Other |
| PERHLP | 4. If someone helps you get to your dialysis treatment, is that person: |
| |
| 5. Who bears the cost (pays for) your transportation to your dialysis unit? Circle all that apply. | |
| MYSELF | 1. Myself and/or my family |
| DIALUNIT | 2. Dialysis Unit |
| PUBAGEN | 3. Public agency or charity organization |
| WPOTHER | 4. Other |
| 6. During your first month of dialysis, have transportation problems caused you to | |
| TRANPRB1 | a. shorten a hemodialysis treatment? 1. Yes 2. No |
| TRANPRB2 | b. skip or miss a hemodialysis treatment? 1. Yes 2. No |
D2Q E. Employment
| 1. If you are employed, what is your present hourly rate (before taxes)? | |
| WAGERATE | $_____________ dollars per hour |
| (Skip to #3 if you are currently working and have answered this question.) | |
| _____________ I am not currently employed. (Check if this applies) | |
| 2. If not currently employed and you were to take a job now, what do you think would be your approximate hourly rate? | |
| WAGEST | $_____________dollars per hour |
| WRKLMT1 | 3. Are you limited in the kind of work for pay you can do because of your health? |
| 1. Yes | |
| 2. No | |
| WRKLMT2 | 4. Are you limited in the amount of work for pay you can do because of your health? |
| 1. Yes | |
| 2. No | |
D2Q F. Rehabilitation
| EXFREQ | 1. How often do you exercise (do physical activity during your leisure time)? |
| (Circle One) | |
| Daily or almost daily 1 | |
| 4-5 times a week 2 | |
| 2-3 times a week 3 | |
| About once a week 4 | |
| Less than once a week 5 | |
| Almost never or never 6 | |
| QUALCAR | 2. How good a job do you feel you are doing in taking care of your health? (Please circle one) |
| 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor | |
| 3. If not currently employed and you worked in the past, why did you stop working?(Please circle all that apply) | |
| NWTOOSK | 1. I am too sick/had too much time off |
| NWTRD | 2. My job is physically too tiring |
| NWRTRD | 3. I am retired |
| NWOTHDT | 4. I am needed for other duties |
| NWTRTDM | 5. My dialysis treatment is too demanding |
| NWNOJB | 6. My employer had no other job, hours, etc |
| NWNOND | 7. I didn't want/need to work any more |
| NWNOFLX | 8. My dialysis facility schedule is not flexible |
| NWLSBNFT | 9. I would lose benefits which are close to what I could earn |
| DESWRK | 4. Given the opportunity, would you like to return to work? |
| (please circle one best answer) | |
| 1. Full time 2. Part time 3. Not at all 4. Not sure | |
| If you are retired or a homemaker or are on CAPD you may skip to question 6. | |
| 5. Which statement reflects the impact of your dialysis treatment sessions on your work schedule? | |
| extremely - quite a bit - moderately - slightly - not at all) | |
| I AGREE WITH THIS STATEMENT: (Circle one per line) | |
| 1 Extremely 2 Quite a bit 3 Moderately 4 Slightly 5 Not at all | |
| SCHEDINT | a) My current dialysis schedule does not/would not interfere with a work schedule. 1 2 3 4 5 |
| SCHEDCHG | b) If it was necessary, my dialysis schedule could probably be changed to allow me to work. 1 2 3 4 5 |
| SCHEDNOT | c) There is not a shift available that would allow me to work1 2 3 4 5 |
| 6. Were you assisted in completing this form? | |
| ASSTGVN | Yes No |
| 1 2 | |
| WHOGAVE | 7. If Yes, who helped? |
| 1 Family member 2 Unit personnel 3 Other | |
D2Q PFUP: Patient Followup Questionnaire
This questionnaire replicates the first patient questionnaire, but without the questions on medical attention prior to dialysis initiation.
Medical Update Questionnaire
DW2. MFUP A. Patient Status Since Day 60 of ESRD (Date A.7)
| DW2. MFUP A. Patient Status Since Day 60 of ESRD (Date A.7) | |
|---|---|
| SPANQ2 | |
| NET_FU | 1. We need to know the first change in patient status or modality since _________________ (Day 60 of ESRD). The date of this FIRST change in patient status or modality since Day 60 of ESRD was: |
| DATE_MTH DATE_YR | Please enter date of FIRST change |
| (Please enter Today's Date if there was no change in the patient's status or modality. If unavailable, give month and year or year only.) | |
| SSMTH_FU | For the date you just entered, give the code for patient status: |
| SSYR_FU | Codes for Change in Status or Modality |
| SSTMOD | 1=had no change in status or modality |
| CHNG_MTH | 2=changed to PD (for at least 2 weeks) |
| CHNG_YR | 3=changed to hemodialysis (for at least 2 weeks) |
| CHNG_TYP | 4=changed to home hemodialysis (for at least 2 weeks) |
| 5=had return of renal function | |
| 6=transferred to another facility | |
| 7=received a kidney transplant | |
| 8=died | |
| 9=was lost to followup | |
| 10=withdrew from dialysis | |
| PTSTATUS | 2. The patient's current status is (please enter code): |
| 1-alive 2-died 3-lost to followup | |
| DEATHMTH DEATHYR | If the patient died, please enter the date of death. If the patient is living or lost to followup, please enter the date that the patient was last know to be alive. |
D2W MFUP B. BUN and Residual Renal Function
| D2W MFUP B. BUN and Residual Renal Function | |
|---|---|
| Complete this section only for patients from your unit who are currently on in-center hemodialysis or peritoneal dialysis. Use information as close as possible to today's date, that is not more than 60 days from today's date. | |
| MOD_NOW | 1. The patient's current modality of treatment is: |
| 1-HD 2-PD (CAPD or CCPD) | |
| URINE | 2. The approximate urine output of the patient is currently: |
| 1 -- greater than 200 ml/day | |
| 2 -- less than 200 ml/day (200 ml is about 1 cup) | |
| 3. BUN and weight: | |
| All values for a. and b. must be from same date | |
| PREBN_FU | a. Pre-dialysis BUN mg/dl (most recent if PD) |
| PREWT_FU | Pre-dialysis Weight lbs or . kg |
| PRE_KGLB | b. Post-dialysis BUN mg/dl (Hemo Patients Only) |
| PSTBN_FU | Post-dialysis Weight lbs or . kg |
| PSTWT_FU | Question #4 is Voluntary. |
| PST_KGLB | 4. Residual Renal Function (Do not complete this item if urine volume is less than 200 ml/day.) |
| URNSTMTH | a. Urine collection time: |
| URNSTYR | mm dd yy hr min AM=1 PM=2 |
| URNEDMTH | End: (Usually next pre-dialysis treatment for hemo patients) |
| URNEDYR | mm dd yy hr min AM=1 PM=2 |
| Total hours of urine collection (Verification).......... | |
| b. Lab Values | |
| Urine Volume ___ml or cc | |
| URNCR_FU | Urine Creatinine____mg/vol |
| URNNT_FU | Urine UreaNitrogen ____mg/24 hrs. (mg/dl=mg%) |
| SCRST_FU | Start SerumCreatinine* . mg/dl |
| BUNST_FU | Start BUN* mg/dl |
| UNIT_TYP | End SerumCreatinine* . mg/dl |
| VAPRM_FU | End BUN* mg/dl |
| CORR_PVA | ** For PD patients, enter only one set of serum creatinine and BUN values (START) taken on a date as close as possible to the date of urine collection. Start and End refer to the same point in time as in 4a above. |
| Start: (Post dialysis for hemo patients) | |
DW2 MFUP C. Vascular Access Update (Patients who were on Hemo on Day 60 of ESRD)
| DW2 MFUP C. Vascular Access Update (Patients who were on Hemo on Day 60 of ESRD) | |
|---|---|
| ECRI's Added Variables (Calculated from existing variables) | |
| Complete this section only if patient was on hemo at Day 60 of ESRD. We need to know the status of this patient's FIRST PERMANENT VASCULAR ACCESS. Please complete the following items with information from the patient's medical record. Please complete this section even if the patient has died or changed modality. Codes to be used for type of vascular access | |
| VA1PM_FU | 1-AV fistula |
| ASIDE_FU | 2-PTFE graft |
| 3-Bovine graft | |
| 4-Permcath | |
| 5-Other | |
| 1. Has a permanent vascular access ever been created or attempted in this patient? 1-Yes 2-No | |
| If NO, please do not complete the rest of this section on Vascular Access (Items 2-6) | |
| 2. This patient's Medical Questionnaire indicated that on or before _______________________(Date 60 of ESRD), the patient had the following type of first permanent access: _______________________. If this is incorrect, please provide the correct answer using codes 1-4 from above. | |
| (If C.2 is correct, please leave this box blank) | |
| If C.2 above is blank, what was the first permanent vascular access created or attempted? | |
| (Use one of codes 1-5 from above.) | |
| What SIDE was this first permanent access placed on? 1-Right 2-Left | |
| SGMTH_FU SGDAY_FU SGYR_FU | 3. The patient's Medical Questionnaire indicated that the date of surgery for creation of first permanent vascular access was: |
| If incorrect or blank, please provide the date of the surgery for creation of the first permanent vascular access: | |
| WAS1VAP | 4. Was this first permanent access ever used for dialysis? 1-Yes 2-No |
| VAMTH_FU VAYR_FU | If YES, what was the first date that this permanent access was used for dialysis? |
| AFAIL_F1 | If NO, did this first permanent access fail to mature adequately for dialysis? 1-Yes 2-No |
| 5. Did this first permanent access fail after being used for dialysis? | |
| AFAIL_F2 | 1-Yes 2-No 3-Unknown |
| FAILMTH FAILDAY FAILYR | If YES, please provide the date of first failure. |
| LAST_MTH LAST_DAY LAST_YR | If NO or UNKNOWN, please provide the last known date the access was used for dialysis. |
| 6. Were there any revisions or procedures made to this first permanent access? | |
| VA_REVIS | 1-Yes 2-No 3-Unknown |
| REV1_MTH REV1_YR | If YES, please give the FIRST two dates and type of revisions (or procedures) that were made subsequent to the date provided in C.3. Please use the codes provided. |
| REV1_TYP | 1-Thrombolysis |
| 2-Balloon angioplasty with or without thrombolysis | |
| 3-Surgical repair or declotting | |
| 4-creation of a new AV fistula | |
| 5-creation of a new PTFE graft (e.g. Goretex) | |
| 6-creation of another permanent access (e.g. Permcath) | |
| 7-other | |
| First Revision or Procedure: | |
| Type: (use codes 1-7 above) | |
| LAST_FDT | Second Revision or Procedure: Was there a second revision or procedure within two weeks of the first one? If yes, please indicate the type using codes 1-7 from above and the date: |
| REV1_FDT | Type: (use codes 1-7 above) |
| USRDS_ID | |
| TOTMOS | Total # months between first questionnaire and followup questionnaire |
| AGE | Age in years |
| TOTHT_IN | Height in inches |
| MDPRESBP | Median pre-dialysis systolic blood pressure |
| MDPREDBP | Median pre-dialysis diastolic blood pressure |
| MEDPREWT | Median pre-dialysis weight (in lbs) |
| MDPSTSBP | Median post-dialysis systolic blood pressure |
| MDPSTDBP | Median post-dialysis diastolic blood pressure |
| MDPSTWT | Median post-dialysis weight (in lbs) |
| DRY_BMI | Dry body-mass index |
| PRE_BMI | Pre-dialysis body mass index |
| POST_BMI | Post-dialysis body mass index |
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