Form #8 Form #8 CV Checklist Survey

A

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ttachment J

CV Checklist Survey

As you read a question, please tell me out loud any thoughts that go through your mind.

1. To what extent to you agree or disagree that it is appropriate for clinicians to discuss cost-related issues with patients?

Strongly disagree	Disagree	Neutral	Agree	Strongly agree
☐	☐	☐	☐	☐

2. For each of the following items, please indicate if they should or should not be discussed with the patient:

	Should not be discussed	Should be discussed	Don't know
Costs of treatment paid by the patient	☐	☐	☐
Costs paid by 3rd party payer	☐	☐	☐
Consideration of societal resources	☐	☐	☐
Costs billed by the hospital/medical office	☐	☐	☐

3. Who is the most appropriate person to discuss cost-related issues with patients? Is it the physician, the nurse, a social worker, a discharge planner or someone else?

Physician	Nurse	Social worker	Discharge planner	Other
☐	☐	☐	☐	☐

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

4. How comfortable or uncomfortable are you in discussing cost-related issues with patients.

Not at all comfortable	Somewhat uncomfortable	Neither comfortable nor uncomfortable	Somewhat comfortable	Very comfortable
☐	☐	☐	☐	☐

5. How uninformed or informed are you about the cost-related implications of care choices your patients must make

Very uninformed	Not well informed	Somewhat informed	Neutral	Well informed	Very well informed
☐	☐	☐	☐	☐	☐

6. How strongly do you agree or disagree that obtaining cost information is the responsibility of the patient, not their clinicians.

Strongly disagree	Disagree	Neutral	Agree	Strongly agree
☐	☐	☐	☐	☐

For each of the following items, please indicate whether or not it would prevent you from discussing cost-related issues with your patient.

	Would not prevent me from discussing cost-related issues	Would prevent me from discussing cost-related issues
Lack of time to discuss cost-related issues	☐	☐
Reluctance to share values	☐	☐
Lack of a simple tool to assess values	☐	☐
Family members monopolizing the conversation	☐	☐
Other (please specify)	☐	☐

To what extent do you agree or disagree with the following statements:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Clinicians should discuss costs with patients when recommending care that is unlikely to be covered by medical insurance or that have to be paid out of pocket.	☐	☐	☐	☐	☐
Clinicians should discuss the costs of all medications	☐	☐	☐	☐	☐
Clinicians should discuss the costs of medications unlikely to be covered by insurance	☐	☐	☐	☐	☐
Cost considerations should be discussed when advising patients about various medical treatment (excluding medication treatments) options	☐	☐	☐	☐	☐
Clinicians should discuss the location of treatment (nursing home, home, hospital)	☐	☐	☐	☐	☐
Clinicians should discuss the costs of end of life care with patients	☐	☐	☐	☐	☐

To what extent do you agree or disagree with the following statements:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Clinicians should discuss treatment options with patients when prescribing medications	☐	☐	☐	☐	☐
Clinicians should discuss treatment options with patients when recommending care that is unlikely to be covered by medical insurance.	☐	☐	☐	☐	☐
Clinicians should discuss treatment options with patients when discussing options for treating significant health issues	☐	☐	☐	☐	☐
Clinicians should discuss treatment options with patients when prescribing medications	☐	☐	☐	☐	☐
Clinicians should discuss treatment options with patients when discussing where medical treatments should be obtained (i.e. hospital, nursing home, at home, etc.)	☐	☐	☐	☐	☐
Clinicians should discuss quality-related issues with their patients.	☐	☐	☐	☐	☐