Valuing Reduced Asthma Episodes For Adults And Children -- Focus Groups

Knowledge Networks, Inc. 2233701

UCF

Asthma Survey: Adult Version

[RADIO BUTTONS]

Single Punch Answer

Q1. Has a doctor or health professional ever told you that you have asthma?

Yes A

No B

[IF Q1 = B  TERMINATE SURVEY. ESLE IF Q1 = A, CONTINUE.]

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Single Punch Answer

Q2. About how old were you when a doctor (or health professional) first told you that you had asthma?

5 years old or younger A

6-10 years old B

11-15 years old C

16-20 years old D

21-25 years old E

26-30 years old F

31-35 years old G

36-40 years old H

41-45 years old I

46-50 years old J

51-55 years old K

56-60 years old L

61-65 years old M

65 years old or older N

[DISPLAY]

Some people with asthma are not bothered by asthma symptoms every day. They have some days when no symptoms are present, or days when asthma symptoms are present but don’t really cause discomfort or bother.

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Single Punch Answer

Q3. During the past 12 months, about how often have asthma symptoms caused you discomfort or bother?

Every day A

Most days B

Some days C

Never D

[IF Q3 = “NEVER”  TERMINATE SURVEY.

ELSE  CONTINUE.]

[IF Q3 = “EVERY DAY”  SET “NDAYSYR” = 365.]

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Single Punch Answer

Q3A. On the days that your asthma symptoms cause you discomfort or bother, about how much of the day do your symptoms typically bother you?

All day A

Most of the day B

Some of the day C

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Single Punch Answer

Q4. Compared to one year ago, how well controlled is your asthmas?

Better than one year ago A

About the same as one year ago B

Worse than one year ago C

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Single Punch Answer

Q5. Apart from asthma, has a doctor or health professional ever told you that you have any serious, long term condition that affects your lungs or your breathing – such as chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema?

Yes A

No B

[IF Q5 = A  ASK Q5A. ELSE  SKIP TO Q6.]

[IF Q5 = A]

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Single Punch Answer

Q5A. Does that condition affect the frequency or severity of your asthma symptoms?

Yes A

No B

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Single Punch Answer

Q6. In general, would you say that your health is excellent, very good, good, fair or poors?

Excellent A

Very Good B

Good C

Fair D

Poor E

This screen shows a scale used to rate how healthy you think you are. The scale goes from 0 to 100. On the scale, 100 means “perfect health” and 0 means “death”. In between 0 and 100, higher numbers indicate better health.

[Display like a thermometer, with 101 “steps” ranging from 0 to 100. The “tens” are labeled, e.g., 0, 10, 20, …, 100. At zero, a text box or arrow indicates “Death”. At 100, a text box or arrow indicates “Perfect health.”]

Q7. Please use the scale to rate healthy you think you are. To use the scale, enter a number between 0 and 100 in the box below/next to the scale. After you enter a number in the box, your answer will be shown on the scale. Then, you will have a chance to change your answer if you want.

[Bring up the display. Next to the number box the text reads: Please enter a number between 0 and 100. Respondent enters a number in the box. The thermometer “fills up” to that point on the scale. E.g. if 75 is entered, the thermometer is filled in red up to 75. An indication like an arrow or text box confirms “Your health 75”.

Q7A. You indicated that your overall state of health is about [INSERT ANSWER TO Q7] on a scale of 0 to 100.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q7a = A  LOOP BACK THROUGH Q7 AND Q7A TO GET CORRECT RATING.

ELSE IF Q7A = B  CONTINUE WITH NEXT DISPLAY.]

Q8. Now, try to imagine what your health would be like if asthma did not affect you. Imagine that you were never bothered by asthma symptoms, and did not need to take any asthma medication. On the same scale of 0 to 100, how would you rate your health if you did not have asthma?

[Bring up the thermometer with the previous answer (Q7) still shown. Respondent enters another number in the box.] The thermometer “fills up” to that point on the scale in a different color. E.g. if 95 is entered, the thermometer is filled in red up to the previous answer (Q7) , and in green up to 95. An indication like an arrow or text box confirms “Your health without asthma 95”.

Q8A. You indicated that your overall state of health would be about [INSERT ANSWER TO Q8] on a scale of 0 to 100, if you did not have asthma.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q8A = A  LOOP BACK THROUGH Q8 AND Q8A TO GET CORRECT RATING.

ELSE IF Q8A = B  CONTINUE WITH Q9.]

[RADIO BUTTONS]

Single Punch Answer

Q9. During the past 12 months, about how often have you visited a doctor or health care professional mainly for the purpose of getting treatment or advice for your asthma?

0 times A

1 time B

2 times C

3 times D

4 times E

5 times F

6 times G

7 times H

8 times I

9 times J

10 times K

11 times L

12 times M

More than 12 times N

[DISPLAY]

We would like to find out about the costs of medical care and medications to control your asthma.

People have different ways of paying for medical care and drugs.

• Some people have health insurance, belong to HMOs, or use government plans like Medicare or Medicaid to cover some or all of their health care costs.

• Some people pay all or part of their health care costs out of their own pockets.

• And some people have flexible spending plans through their jobs. In a flexible spending plan, money gets deducted from the paycheck and saved up to reimburse health care expenses that are not covered by insurance.

When we ask about “insurance or other health plan,” we mean things like health insurance, HMOs, PPO plans, Medicare and Medicaid, not flexible spending plans.

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Single Punch Answer

Q10. If you visit a doctor or health care professional for your asthma, does health insurance or other health plan cover at least part of the cost? (Please do not count flexible spending plans.)

Yes A

No B

[IF Q10 = A  ASK Q10A. ELSE  SKIP TO Q10B.]

[IF Q10 = A]

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Single Punch Answer

Q10A. Does insurance or other health plan cover all, or only part, of the cost?

Insurance/health plan covers all of cost A

Insurance/health plan covers part of cost B

[IF Q10A = B  ASK Q10B. IF Q10A=A  SKIP TO Q11.]

[IF Q10A = A OR IF Q10=B]

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Single Punch Answer

Q10B. About how much would you expect to pay, the next time you visit a doctor for your asthma? Please count only your out-of-pocket expense (even if you were reimbursed by a flexible spending plan). Do not include any amount that would be paid or reimbursed by insurance or other health plan.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

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Single Punch Answer

Q11. If you visit a doctor for your asthma, about how much time does it usually take? Please include travel time there and back, time spent waiting to see the doctor, and the time spent with the doctor.

1/2 hour or less A

Between ½ and 1 hour B

Between 1 and 1½ hours C

Between 1½ and 2 hours D

Between 2 and 2½ hours E

Between 2½ and 3 hours F

Between 3 and 3½ hours G

Between 3½ and 4 hours H

4 hours or more I

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Single Punch Answer

Q12. When you visit a doctor for your asthma, do you usually take time off from working at a job or business?

Yes A

No B

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Single Punch Answer

Q13. During the past 12 months, have you taken any prescription medications for your asthma?

Yes A

No B

[IF Q13 = B  SKIP TO DISPLAY BEFORE Q20 .

IF Q13 = A  BEGIN CURRENT DRUG MODULE AT Q14.]

We would like to find out about the medicines you take to control your asthma, and how much these medicines cost.

[RADIO BUTTONS]

Single Punch Answer

Q14. Are you currently covered by any kind of prescription drug plan that pays all or part of the costs of asthma medications? (Again, please do not count flexible spending plans.)

Yes A

No B

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Single Punch Answer

Q15. During the past 12 months, have you taken any inhaled, “rescue” or “quick-relief” bronchodilator medicines for asthma? These medications are meant to be taken as needed to relieve asthma symptoms. Examples include Albuterol, Alupent, Atrovent, Bitolterol, Brethaire, Maxair, Metaproteronol, Tornalate, Terbutaline, Proventil, Ventolin.

Yes A

No B

[IF Q15 = A  ASK Q15A - Q15D. ELSE  SKIP TO Q16.]

[IF Q15 = A]

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Single Punch Answer

Q15A. On average during the past 12 months, about how often have you had this prescription filled?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q15 = A]

[RADIO BUTTONS]

Single Punch Answer

Q15B. When you have had this prescription filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[IF Q15 = A]

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Single Punch Answer

Q15C. During the months of the year that you have asthma symptoms, about how often do you use the rescue inhaler?

Every day A

More than two days per week but not every day B

About two days per week C

About one day per week D

Less than one day per week E

[IF Q15 = A]

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Single Punch Answer

Q15D. During the months of the year that you have asthma symptoms, about how long does one canister of the rescue inhaler last?

Less than 2 weeks A

2 weeks to less than one month B

1-2 months C

2-3 months D

More than 3 months E

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Single Punch Answer

Q16. During the past 12 months, have you taken any inhaled anti-inflammatory medicines for asthma? These are long-term control or “preventer” medications that are meant to be taken every day (e.g., twice daily). Examples include Aerobid, Advair, Azmacort, Beclomethasone dipropionate, Beclovent, Budesonide, Cromolyn, Flovent, Flunisolide, Fluticasone, Intal, Nedocromil, Pulmicort Turbuhaler, Tilade, Triamcinolone acetonide, Vanceril.

Yes A

No B

[IF Q16 = A  ASK Q16A and Q16B. ELSE  SKIP TO Q17.]

[IF Q16 = A]

[RADIO BUTTONS]

Single Punch Answer

Q16A. On average during the past 12 months, about how often have you had this prescription filled?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q16 = A]

[RADIO BUTTONS]

Single Punch Answer

Q16B. When you have had this prescription filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[CONTINUE WITH Q17.]

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Single Punch Answer

Q17. During the past 12 months, have you taken any inhaled, long-acting bronchodilator medicines for asthma? These are also long-term control or “preventer” medications and are meant to be taken every day (e.g., twice daily). Examples include Advair, Salmeterol, Serevent, Serevent Diskus.)

Yes A

No B

[IF Q17 = A  ASK Q17A and Q17B. ELSE  SKIP TO Q18.]

[IF Q17 = A]

[RADIO BUTTONS]

Single Punch Answer

Q17A. On average during the past 12 months, about how often have you had this prescription filled?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q17 = A]

[RADIO BUTTONS]

Single Punch Answer

Q17B. When you have had this prescription filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[CONTINUE WITH Q18.]

[RADIO BUTTONS]

Single Punch Answer

Q18. During the past 12 months, have you taken any pills or tablets for asthma? (Examples: Accolate, Aerolate, Deltasone, Pediapred, Prednisone, Medrol, Singulair, Theophylline, Zafirlukast, Zileuton, Zyflo Filmtab).

Yes A

No B

[IF Q18 = A  ASK Q18A and Q18B. ELSE  SKIP TO Q20.]

[IF Q18 = A]

[RADIO BUTTONS]

Single Punch Answer

Q18A. On average during the past 12 months, about how often have you had this prescription filled?

Every month A

Every 6 weeks B

Every 2 months C

Every 3 months D

Every 4 to 6 months E

Less often than every 6 months F

[IF Q18 = A]

[RADIO BUTTONS]

Single Punch Answer

Q18B. When you have had this prescription filled during the past year, about how much did it cost each time? Please count only your out-of-pocket expense. Do not include any amount that would be paid or reimbursed by a drug plan, insurance, or other health care coverage.

$5 or less A

$6 to $10 B

$11 to $15 C

$16 to $20 D

$21 to $25 E

$26 to $30 F

$31 to $35 G

$36 to $40 H

$41 to $45 I

$46 to $50 J

$51 to $60 K

$61 to $70 L

$71 to $80 M

$81 to $90 N

$91 to $100 O

More than $100 P

[RADIO BUTTONS]

Single Punch Answer

Q19. During the past 12 months, about how often have side effects from your asthma medications caused you discomfort or bother?

Every day A

Most days B

Some days C

Never D

[IF Q19 NOT = D  ASK Q19A. ELSE IF Q19 = D,  SKIP TO Q20.]

[RADIO BUTTONS]

Single Punch Answer

Q19A. On the days that side effects from your asthma medications cause you discomfort or bother, about how severe were the side effects?

Severe A

Moderate B

Mild C

[CONTINUE.]

[IF Q3 = A “every day”  SKIP TO Q22 .]

ELSE  CONTINUE WITH Q20.]

[IF Q3 NOT = A]

[RADIO BUTTONS]

Single Punch Answer

Q20. During the past 12 months, have asthma symptoms caused you discomfort or bother at some time during every month or only during some months?

Every month A

Some months B

[IF Q20 = A  SET “NMTHSYR” = 12, AND SKIP TO Q22.

ELSE  ASK Q20A.]

[IF Q20 NOT = A]

Q20A. The next screen shows a calendar for the past 12 months. Please select all of the months in the past year when your asthma symptoms caused you discomfort or bother on at least one day of the month.

[DISPLAY] 12 boxes, consecutively labeled with months of the year. Each box can be selected as a multi-punch answer.

[SAVE NUMBER OF MONTHS SELECTED IN Q20A AS “NMTHSYR”.

CONTINUE WITH Q21.]

[RADIO BUTTONS]

Single Punch Answer

Q21. During the months of the past year when your asthma symptoms have caused discomfort or bother, have your symptoms bothered you every day of the months, or only some days?

Every day A

Some days B

[IF Q21 = A,  SET “NDAYSYR” = 30*NMTHSYR AND SKIP TO Q22.

(NOTE: NMTHSYR BASED ON Q20 OR Q20A.)

ELSE  ASK Q21A.]

[IF Q21 NOT = A]

[RADIO BUTTONS]

Single Punch Answer

Q21A. Please recall the months during the past 12 when your asthma symptoms have caused discomfort or bother. On the average, about how many days per month did your symptoms cause discomfort or bother? (Assume 30 days in a month.)

Answer options are 1,2,…,30.

[SET “NDAYSYR” = (NUMBER OF DAYS IN Q216) * NMTHSYR.

NOTE: NMTHSYR BASED ON Q20 OR Q20A.]

[RADIO BUTTONS]

Single Punch Answer

Q22. Based on your answers to previous questions, it appears that asthma symptoms caused you discomfort or bother on about [INSERT NDAYSYR] days during the past 12 months. Is that about the right number of days?

Yes A

No B

[IF Q22 = A  SKIP TO DISPLAY.

ELSE IF Q22 = B  ASK Q22B.]

Number Box Answer

[Number Box]

Range 0 – 365

Q22B. About how many days during the past 12 months did asthma symptoms cause you discomfort or bother?

Please enter a number from 0 through 365 in the box below:

[SET “NDAYSYR” = ANSWER TO Q22B, AND CONTINUE WITH Q22C.]

Q22C. You indicated that asthma symptoms caused you discomfort or bother on [INSERT NDAYSYR (=ANSWER TO Q22B)] days during the past year.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q22C = A  LOOP BACK THROUGH Q22B AND Q22C TO GET CORRECT NUMBER OF DAYS.

ELSE IF Q22C = B  CONTINUE WITH DISPLAY.]

[DISPLAY]

This display shows the number of days during the past year when asthma symptoms caused you discomfort or bother. In the rest of the survey, we’ll refer to these [INSERT NDAYSYR] as “asthma symptom days.”

[DISPLAY] A bar chart with one vertical bar in one color, e.g., green.

Height of bar = NDAYSYR.

Next we would like to find out how much your asthma symptoms interfered with your activities on these [INSERT NDAYSYR] asthma symptom days.

[RADIO BUTTONS]

Single Punch Answer

Q23. Thinking about your [INSERT NDAYSYR] asthma symptom days during the past year, were there any days when your asthma symptoms caused you to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital?

Yes A

No B

[IF Q23 = A  ASK Q23A.

IF Q23 = B  SET “NSEVERE” = 0 AND SKIP TO Q24.]

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23A. About how many days during the past 12 months did your asthma symptoms cause you to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital?

Please enter a number from 1 through [INSERT NDAYSYR] in the box below:

[SAVE NUMBER OF DAYS IN Q23A “NSEVERE”.]

[IF Q23 = A]

[RADIO BUTTONS]

Single Punch Answer

Q23B. You indicated that your asthma symptoms caused you to visit an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital, on [INSERT NSEVERE (=ANSWER TO Q23A)] days during the past year.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q23B=A  LOOP BACK THROUGH Q23A & Q23B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH DISPLAY BEFORE Q24.]

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23C. About how many nights, if any, did you stay overnight in a hospital because of your asthma?

Please enter a number from 0 through [INSERT NSEVERE] in the box below:

[IF Q23 = A]

[Number Box]

Range 1 – ndaysyr

Q23D. About how many days, if any, did you visit an emergency room for urgent treatment of your asthma symptoms?

Please enter a number from 0 through [INSERT NSEVERE] in the box below:

[IF Q23 = A  INSERT BEFORE Q24:]

Please do not count those [INSERT NSEVERE] days when you answer the next question. Please think only about your remaining [INSERT NDAYSYR - NSEVERE] asthma symptom days.

[RADIO BUTTONS]

Single Punch Answer

Q24. Thinking about your [INSERT NDAYSYR – NSEVERE] asthma symptom days during the past year, were there any days when your asthma symptoms…

interfered with most of your activities, or awakened you at night or significantly disturbed your sleep, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse?

Yes A

No B

[IF Q24 = A  ASK Q24A.

IF Q24 = B  SET “NBAD” = 0 AND SKIP TO Q25.]

[IF Q24 = A  INSERT BEFORE Q24A:]

Again, please do not count the [INSERT NSEVERE] days when you were in the hospital for asthma, or when your symptoms caused you to seek urgent medical attention when answering the next question.

[IF Q24 = A]

[Number Box]

Range 1 – (ndaysyr minus nsevere)

Q24A. On about how many of the [INSERT NDAYSYR - NSEVERE] days did your symptoms interfere with most of your activities, awaken you at night or significantly disturb your sleep, or cause you to leave work or school, or to stay home, or to telephone a doctor or nurse?

Please enter a number from 1 through [INSERT NDAYSYR - NSEVERE] in the box below:

[SAVE NUMBER OF DAYS IN Q24A “NBAD”.]

[IF Q24 = A]

[RADIO BUTTONS]

Single Punch Answer

Q24B. You indicated that there were [INSERT NBAD (=ANSWER TO Q24A)] days during the past year when your asthma symptoms interfered with most of your activities, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24B=A  LOOP BACK THROUGH Q24A & Q24B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH Q24C.]

[RADIO BUTTONS]

Single Punch Answer

Q24C. Did your asthma symptoms cause you to miss work on any of those [INSERT NBAD] days?

Yes A

No B

[IF Q24C = A  ASK Q24D.

IF Q24C = B  SKIP TO Q24F.]

[IF Q24C = A]

[Number Box]

Range 1 – nbad

Q24D. On about how many of those [INSERT NBAD] days did your asthma symptoms cause you to miss work?

Please enter a number from 1 through [INSERT NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q24D “NWLD”.]

[IF Q24C = A]

[RADIO BUTTONS]

Single Punch Answer

Q24E. You indicated that your asthma symptoms caused you to miss work on [INSERT NWLD (=ANSWER TO Q24D)] days.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24E=A  LOOP BACK THROUGH Q24D & Q24E TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH Q24F.]

[RADIO BUTTONS]

Single Punch Answer

Q24F. Thinking about those [INSERT NBAD] days during the past year, were there any times when your asthma symptoms awakened you at night or significantly disturbed your sleep?

Yes A

No B

[IF Q24F = A  ASK Q24G.

IF Q24F = B  SKIP TO Q25.]

[IF Q24F = A]

[Number Box]

Range 1 – ndaysyr

Q24G. About how many nights did your asthma symptoms awaken you at night or significantly disturbed your sleep?

Please enter a number from 1 through [INSERT NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q24G “NAWAKE”.]

[IF Q24F = A]

[RADIO BUTTONS]

Single Punch Answer

Q24H. You indicated that your asthma symptoms awakened you at night or significantly disturbed your sleep [INSERT NAWAKE (=ANSWER TO Q24G)] days during the past year.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q24H=A  LOOP BACK THROUGH Q24G & Q24H TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE.]

[IF Q23 = A  INSERT BEFORE Q25:]

Please do not count the [INSERT NSEVERE] days when you were in the hospital for asthma, or when your symptoms caused you to seek medical attention, when you answer the next question.

[IF Q24 = A  INSERT BEFORE Q25:]

Please do not count the [INSERT NBAD] days when your asthma symptoms interfered with most of your activities, or awakened you at night or significantly disturbed your sleep, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse, when you answer the next question.

[RADIO BUTTONS]

Single Punch Answer

Q25. Thinking about the [INSERT NDAYSYR - NSEVERE - NBAD] asthma symptom days, were there any days when your asthma symptoms interfered somewhat with your activities or sleep?

Yes A

No B

[IF Q25 = A  ASK Q25A.

IF Q25 = B  SET “NMOD” = 0 AND SKIP TO DISPLAY BEFORE Q26.]

[IF Q18 = A  INSERT BEFORE Q25A:]

Again, please do not count the [INSERT NSEVERE] days when you were in the hospital for asthma, or when your symptoms caused you to seek medical attention, when you answer the next question.

[IF Q24 = A  INSERT BEFORE Q25A:]

Again, please do not count the [INSERT NBAD] days when your asthma symptoms interfered with most of your activities, or awakened you at night or significantly disturbed your sleep, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse, when you answer the next question.

[IF Q25 = A]

Number Box Answer

[Number Box]

Range 1 – (ndaysyr minus nsevere minus nbad)

Q25A. Thinking about the [INSERT NDAYSYR - NSEVERE - NBAD] asthma symptom days, about how many days did your symptoms interfere somewhat with your activities or sleep?

Please enter a number from 1 through [INSERT NDAYSYR – NSEVERE - NBAD] in the box below:

[SAVE NUMBER OF DAYS IN Q25A “NMOD”.]

[IF Q25 = A]

[RADIO BUTTONS]

Single Punch Answer

Q25B. You indicated that there were [INSERT NMOD (=ANSWER TO Q25A)] days during the past year when your asthma symptoms interfered somewhat with your activities or sleep.

Would you like to change your answer or are you satisfied with your answer?

I would like to change my answer, please go back. A

I am satisfied with my answer, please continue. B

[IF Q25B=A  LOOP BACK THROUGH Q25A & Q25B TO GET CORRECT NUMBER OF DAYS.

ELSE CONTINUE WITH DISPLAY BEFORE Q26.]

[DISPLAY]

Based on your answers, this display shows your asthma symptom days during the past year. The green bar shows the [INSERT NDAYSYR – NSEVERE – NBAD - NMOD] days when your asthma symptoms caused you discomfort or bother, but didn’t really interfere with your activities.

If you said that asthma symptoms interfered with your activities on any days during the past year, these days are shown in a different color.

[IF NMOD > 0:] The [INSERT NMOD] days when you said your asthma symptoms interfered somewhat with your activities or sleep are shown in yellow.

[IF NBAD > 0:] The [INSERT NBAD] days when you said your asthma symptoms interfered with most of your activities, or awakened you at night/significantly disturbed your sleep, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse, are shown in orange.

[IF NSEVERE > 0:] The [INSERT NSEVERE] days when you said stayed overnight in a hospital, or when you visited an emergency room, hospital, health clinic or doctor’s office for urgent treatment of your asthma symptoms, are shown in red.

The overall height of the bar shows your total number of [INSERT NDAYSYR] asthma symptom days during the past year.

[DISPLAY] A bar chart with one vertical bar.

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – NSEVERE – NBAD – NMOD].

• Next segment = YELLOW: Height = NMOD, IF NMOD > 0.

• Next segment = ORANGE: Height = NBAD, IF NBAD > 0.

• Next segment = RED: Height = NSEVERE, IF NSEVERE > 0.

[NOTE: The next section gets descriptions of asthma symptom days.

For Respondents who reported interference with activities in q23, Q24, or Q25, pick a day in the most severe category, and characterize the day.

If worst day = medical attention, go to q26A-q29A.

If worst day = interfere most activities, go to q26B-q29B.

if worst day = interfere somewhat, go to q26C-q29C.

Then, for ALL respondents, characterize a day when asthma symptoms cause discomfort or bother, but do not interfere with activities. This is the loop Q30-Q33.]

[DISPLAY]

Next we would to find out the kinds of symptoms you have when your asthma symptoms cause you discomfort or bother.

[IF Q23=A  ASK Q26A through Q29A.

ELSE IF Q23=B AND Q24=A  ASK Q26B through Q29B.

ELSE IF Q23=B AND Q24=B AND Q25=A  ASK Q26C through Q29C.

ELSE IF Q23=B AND Q24=B AND Q25=B  SKIP TO Q30.]

[IF Q23=A]

Q26A. Please recall a day when your asthma symptoms caused you to make an urgent or unscheduled visit to an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital. Which of the following symptoms did you experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q27A. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q28A. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=A]

[RADIO BUTTONS]

Single Punch Answer

Q29A. During episodes like this, did you use a rescue inhaler more than you would on days when your symptoms were less bothersome?

Yes A

No B

[SKIP TO Q30.]

[IF Q23=B AND Q24=A]

Q26B. Please recall a day when your asthma symptoms interfered with most of your activities, or awakened you at night/significantly disturbed yours sleep, or caused you to leave work or school, or to stay home, or to telephone a doctor or nurse. Which of the following symptoms did you experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q27B. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q28B. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=B AND Q24=A]

[RADIO BUTTONS]

Single Punch Answer

Q29B. During episodes like this, did you use a rescue inhaler more than you would on days when your symptoms were less bothersome?

Yes A

No B

[SKIP TO Q30.]

[IF Q23=B AND Q24=B AND Q25=A]

Q26C. Please recall a day when your asthma symptoms interfered somewhat with your activities or sleep. Which of the following symptoms did you experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q27C. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q28C. About how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[IF Q23=B AND Q24=B AND Q25=A]

[RADIO BUTTONS]

Single Punch Answer

Q29C. During episodes like this, did you use a rescue inhaler more than you would on days when your symptoms were less bothersome?

Yes A

No B

[CONTINUE WITH Q30.]

Q30. Please recall a day when your asthma symptoms caused you discomfort or bother, but did not really interfere with your activities or sleep. On a typical day like that during the past year, which of the following symptoms did you experience? (Please select all that apply.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Other symptoms F

[RADIO BUTTONS]

Single Punch Answer

Q31. Which of those symptoms was the most bothersome? (Please choose one answer.)

Cough A

Phlegm/Sputum B

Chest tightness C

Wheeze D

Shortness of breath E

Some other symptom F

No single symptom was most bothersome G

[RADIO BUTTONS]

Single Punch Answer

Q32. When your symptoms caused discomfort or bother, but did not interfere with your activities or sleep, about how long did these episodes last on average?

Less than an hour A

One to a few hours B

All day or night C

Continuing for the next 1 or 2 days D

Continuing for the next 3 days or longer E

[RADIO BUTTONS]

Single Punch Answer

Q33. During episodes like this, did you use a rescue inhaler more than you would on days when your symptoms were less bothersome?

Yes A

No B

[All respondents get Q34.]

Suppose that the doctor who treats your asthma told you about a new asthma medication. The new drug would be taken daily by inhaler, and would help reduce the total number of days when your asthma symptoms cause you discomfort or bother.

These two paragraphs for those currently taking daily medication: [Yes to Q16 OR Q17]

The new medication would be similar to any inhaled “preventer” medications you now take daily for long-term control of asthma. It would provide the same benefits as these drugs, but it would be more effective at reducing the number of days when your asthma symptoms bother you.

The taste and smell of the new drug would be similar to inhaled medications you currently use. It would be taken on the same time schedule. The new drug would be as safe as the asthma medications you now take, and would have similar side effects. Any side effects you experience from current drugs would probably occur with the new drug as well. If you have no side effects from current drugs, you should expect not to have any with the new drug.

These two paragraphs for those not taking daily medications [No Q16 AND Q17]

The new medication would be similar to inhaled “preventer” medications that some people with asthma now take daily for long-term control of asthma. It would provide the same benefits as these drugs, but it would be more effective at reducing the number of days when your asthma symptoms bother you.

Also, the new drug would be safer with fewer side effects than the daily medications that some people with asthma currently use. Only a very small fraction of patients would experience any side effects at all, and these effects would be very minor. It would require only about a minute to take the new drug as directed once daily.

And everyone gets the rest…

In clinical trials, the new drug has proven safe and effective in reducing the number of days that asthma symptoms cause discomfort or bother. If you used the new drug, you should expect to have X fewer days per year when your asthma symptoms caused you discomfort or bother.

[Compute X = a * ndaysyr. If this formula does not produce an integer, round UP to the nearest integer. Assign a from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

The new drug would only reduce the total number of days that asthma symptoms bothered you. It would not affect the severity of any symptoms that cause discomfort or bother.

The display shows the number of asthma symptom days you had during the past year, and the reduction in days that you would experience from using the new drug.

[DISPLAY] A bar chart with one vertical bar.

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – X].

• Top segment = BLACK: Height = X.

The new drug is designed to replace any inhaled medications you now take daily for long-term control of asthma. However, this drug would be covered differently by insurance and health plans. Based on your answers about health insurance and drug costs, the new drug would cost you $Y more per year than you currently spend on inhaled medications for long-term control of asthma. This would be your out-of-pocket expense. So if you bought the new drug you would have $Y less per year to spend for buying other things.

[RADIO BUTTONS]

Single Punch Answer

Q34. Would you be willing to pay $Y per year for this drug, to reduce the number of days that asthma symptoms cause you discomfort or bother by X per year?

Yes A

No B

[IF Q34 = A  ASK Q34A.

ELSE IF Q34 = B  ASK Q34B.]

[IF Q34=A]

[RADIO BUTTONS]

Single Punch Answer

Q34A. Would you be willing to pay $YUP per year for this drug, to reduce the number of days that asthma symptoms cause you discomfort or bother by X per year?

Yes A

No B

[IF Q34=B]

[RADIO BUTTONS]

Single Punch Answer

Q34B. Would you be willing to pay $YDOWN per year for this drug, to reduce the number of days that asthma symptoms cause you discomfort or bother by X per year?

Yes A

No B

Assign Y, YUP and YDOWN from:

Y (Q34)	YUP (Q34A)	YDOWN (Q34B)

[IF Q34B = B  ASK Q34C.

ELSE ASK Q34D.]

[IF Q34B=B]

Q34C. Which of the following best describes why you would not buy the new medication? (Please select all that apply.)

The new drug does is not effective enough A

The new drug is too expensive B

I should not have to pay for medicine C

I am concerned about possible side effects from the new drug D

The new drug is not much better than current drugs E

The new drug would not really work as claimed F

I need more information about the new drug G

I do not need the new drug H

I’m not that worried about reducing days when asthma symptoms bother me I

I already do enough to control my asthma J

Other reasons K

Q34D. Which of the following best describes why you would buy the new medication? (Please select all that apply.)

The new drug does is more effective than current drugs A

The new drug is worth the cost B

When it comes to my asthma, I don’t care about cost C

It’s important to me to reduce the number of days when asthma symptoms bother me D

Other reasons E

Earlier in the survey, you rated your overall health with asthma as [insert answer to Q7] on a scale of 0 to 100. Also, you indicated that your health without asthma would be [insert answer to Q8] on a scale of 0 to 100. Recall that on this scale, 0 means death and 100 means perfect health. Please think about how you would rate your health if you used the new drug and reduced your asthma symptom days by X per year.

Q34E. Suppose that you did use the new drug, and it reduced the number of days that asthma symptoms cause you discomfort or bother by X per year. How would you rate your health on the 0 to 100 scale?

[Bring up the display with the previous answers still shown. Again the respondent enters a number in the box. “Your health with your asthma” is indicated next to the first answer [Q7]. “Your health without asthma” is indicated next to the second answer [Q8]. The respondent now enters a new number in the box.

Now suppose that instead of the drug just described, your doctor told you about a different new drug.

[IF Q23 = B AND Q24 = B AND Q25 = B  ASK Q35.

ELSE IF Q23 = A OR Q24 = A OR Q25 = A  SKIP TO Q36.]

(Note: Respondents get Q36 IF: Q23=B AND Q24=B AND Q25=B.)

Insert second WTP question for those without any bad days.

(Note: Respondents get Q36 IF: Q23=A or Q24=A or Q25=a.)

Unlike the drug just described, this medication would not reduce the number of days when your asthma symptoms cause discomfort or bother. But it would help relieve your symptoms on the days when your symptoms are the most bothersome.

The new medication would be similar to the “rescue” inhaler you currently use to relieve asthma symptoms. It would provide all of the same benefits as your current quick-relief medication. But the new drug would be more effective at relieving asthma symptoms when they are the most bothersome.

The taste and smell of the new drug would be similar to inhaled medications currently used. It would be taken in the same way. The new drug would be as safe as the asthma medications you now take, and would have similar side effects. Any side effects you experience from current drugs would probably occur with the new drug as well. If you have no side effects from current drugs, you should expect not to have any with the new drug.

In clinical trials, the new drug has proven as safe and effective as current “rescue” medications. But the new drug has proven more effective at relieving asthma symptoms when they are the most bothersome

[IF Q23 = A:]

If you used the new drug, you should expect to have W fewer days per year when your asthma symptoms cause you to visit an emergency room, hospital, health clinic or doctor’s office, or to stay overnight in a hospital.

[Compute W = b * nsevere. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[ELSE IF Q23 = B and Q24 = A:]

If you used the new drug, you should expect to have W fewer days per year when your asthma symptoms interfere with most of your activities, or awaken you at night or significantly disturb your sleep, or cause you to leave work or school, or to stay home, or to telephone a doctor or nurse.

[Compute W = b * nbad. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[ELSE IF Q23 = B and Q24 = B and Q25 = A:]

If you used the new drug, you should expect to have W fewer day per year when your asthma symptoms interfere somewhat with your activities or sleep.

[Compute W = b * nmod. If this formula does not produce an integer, round UP to the nearest integer. Assign b from {.05, .10, .20, .40, .50, .60, .70, .80, .90, .95}.]

[END IF]

On the W days your asthma symptoms would still be present and bothersome, but would not interfere with your activities. The total number of days that your asthma symptoms cause discomfort or bother would not be affected by switching from your current rescue inhaler to the new drug.

The display shows the number of asthma symptom days you had during the past year, and the number that would occur if you used the new drug.

[DISPLAY] A bar chart with one vertical bar.

Starting point for chart is as follows:

• Total height of bar = NDAYSYR.

• Bottom segment = GREEN: Height = Residual of [NDAYSYR – NSEVERE – NBAD – NMOD].

• Next segment = YELLOW: Height = NMOD, IF NMOD > 0.

• Next segment = ORANGE: Height = NBAD, IF NBAD > 0.

• Next segment = RED: Height = NSEVERE, IF NSEVERE > 0.

Then, take the top segment and the top W units BLACK, to show the reduction.

The new drug is designed to replace any rescue inhaler you now use. However, this drug would be covered differently by insurance and health plans. Based on your answers about health insurance and drug costs, the new drug would cost you $Z more per year than you currently spend on any rescue inhaler you currently use. This would be your out-of-pocket expense. So if you bought the new drug you would have $Z less per year to spend for buying other things.

[RADIO BUTTONS]

Single Punch Answer

Q36. Would you be willing to pay $Z per year for this drug, to reduce the number of days when your asthma symptoms are most bothersome by W per year?

Yes A

No B

[IF Q36 = A  ASK Q36A.

ELSE IF Q36 = B  ASK Q36B.]

[IF Q36=A]

[RADIO BUTTONS]

Single Punch Answer

Q36A. Would you be willing to pay $ZUP per year for this drug, to reduce the number of days when your asthma symptoms are most bothersome by W per year?

Yes A

No B

[IF Q36=B]

[RADIO BUTTONS]

Single Punch Answer

Q36B. Would you be willing to pay $ZDOWN per year for this drug, to reduce the number of days when your asthma symptoms are most bothersome by W per year?

Yes A

No B

Assign Z, ZUP and ZDOWN from:

Z (Q36)	ZUP (Q36A)	ZDOWN (Q36B)

[IF Q36B = B  ASK Q36C.

ELSE ASK Q36D.]

[IF Q36B=B]

Q36C. Which of the following best describes why you would not buy the new medication? (Please select all that apply.)

The new drug does is not effective enough A

The new drug is too expensive B

I should not have to pay for medicine C

I am concerned about possible side effects from the new drug D

The new drug is not much better than current drugs E

The new drug would not really work as claimed F

I need more information about the new drug G

I do not need the new drug H

I’m not that worried about reducing days when asthma symptoms bother me I

I already do enough to control my asthma J

Other reasons K

Q36D. Which of the following best describes why you would buy the new medication? (Please select all that apply.)

The new drug does is more effective than current drugs A

The new drug is worth the cost B

When it comes to my asthma, I don’t care about cost C

It’s important to me to reduce the days when my asthma symptoms are most bothersome D

Other reasons E

Earlier in the survey, you rated your overall health with asthma as [insert answer to Q7] on a scale of 0 to 100. Also, you indicated that your health without asthma would be [insert answer to Q8] on a scale of 0 to 100. Recall that on this scale, 0 means death and 100 means perfect health. Please think about how you would rate your health if you used the new drug and reduced the number of days that your asthma symptoms are most bothersome by W per year.

Q36E. Suppose that you did use the new drug, and it reduced the number of days that your asthma symptoms are most bothersome by W per year. How would you rate your health on the 0 to 100 scale?

[Bring up the display with the original two answers still shown. Again the respondent enters a number in the box. “Your health with your asthma” is indicated next to the first answer [Q7]. “Your health without asthma” is indicated next to the second answer [Q8]. The respondent now enters a new number in the box.

We have just a few final questions about your asthma…

[RADIO BUTTONS]

Single Punch Answer

Q40. Does your asthma limit the amount or kind of work you could do in a job or business?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q41. Does your asthma limit your ability to do household chores?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q42. Has a doctor or health professional ever given you written instructions for monitoring and controlling your asthma?

Yes A

No B

[RADIO BUTTONS]

Single Punch Answer

Q43. Do you have a peak flow meter (a device that measures how much air you can blow out of your lungs)?

Yes A

No B

[IF Q43 = A]

[RADIO BUTTONS]

Single Punch Answer

Q43A. How often do you use it?

(Answer options are…)

[RADIO BUTTONS]

Single Punch Answer

Q44. Besides using a peak flow meter and monitoring your asthma symptoms, do you do anything else to give you advance warning of when your asthma might be getting worse?

Yes A

No B

Q45. The following questions are about some activities and items in the home that may affect the symptoms some people with asthma experience. Please answer each question.

	No	Yes	Don’t Know
Do you use a mattress cover that is made especially for controlling dust mites?
Do you use a pillow cover that is made especially for controlling dust mites?
Are your bed sheets and pillowcases washed in hot water?
Do you have carpeting or rugs in your bedroom?
Are any pets, like dogs, cats, hamsters, birds or other furry or feathered pets allowed in your bedroom?
Are any furry or feathered pets that are allowed inside your home?
During the past 12 months, has anyone seen cockroaches inside your home?
Is an air cleaner or purifier used regularly inside your home?
Is a dehumidifier regularly used to reduce moisture inside your home?
During the past 12 months, has anyone smoked inside your home?
Is a fireplace or wood-burning stove used in your home?
Is gas used for cooking in your home?
During the past 12 months, has anyone seen or smelled mold or a musty odor in your home?
Do you ever work or play hard outdoors when pollen or air pollution levels are high?
Do you ever work or play hard outdoors during cold and windy weather?

[IF SAMVAR HEAL1700 IS NULL]

[RADIO BUTTONS]

Single Punch Answer

Q46. Do you smoke cigarettes?

Yes ................................................................... 1

No..................................................................... 2

End of survey: Thank you for completing this survey.

Page 30 Last saved: 2/23/2007 1:26 PM