DFMB Data. Demographics. RedCAP-Assigned Record Number. Project ID

Transcription

1 DFMB Data Drug-Free Moms & Babies - New Sites Page 1 of 24 RedCAP-Assigned Record Number _ Project ID Demographics Is this the first time that the participant has been enrolled in DFMB? What is the project ID for the previous pregnancy? Date of Program Entry Maternal Age at Program Entry Gestational Age at Program Entry If you were not able to note gestational age at program entry was this because: (If this participant has participated in DFMB during a prior pregnancy, select "no". If this is the first pregnancy during which the participant participated, select "yes".) (If the patient's age at intake is not noted in the records from which you are abstracting data, enter "99".) (Enter a two-digit value between 2 and 42. If GA at program entry is not noted in the records from which you are abstracting data, enter "99".) The patient entered the program intending to become pregnant The patient entered the program after a birth outcome (including outcomes such as spontaneous abortion, etc.) The patient entered the program while pregnant, but the age was not recorded

2 Page 2 of 24 Race (Check All That Apply) race Ethnicity White Black Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native Mixed (If race is not noted in the records from which you are abstracting data, check "".) n-hispanic Hispanic (If Hispanic ethnicity is not noted in the records from which you are abstracting data, check "t recorded".)

3 Page 3 of 24 County of Residence Barbour Berkeley Boone Braxton Brooke Cabell Calhoun Clay Doddridge Fayette Gilmer Grant Greenbrier Hampshire Hancock Hardy Harrison Jackson Jefferson Kanawha Lewis Lincoln Logan Marion Marshall Mason McDowell Mercer Mineral Mingo Monongalia Monroe Morgan Nicholas Ohio Pendleton Pleasants Pocahontas Preston Putnam Raleigh Randolph Ritchie Roane Summers Taylor Tucker Tyler Upshur Wayne Webster Wetzel Wirt Wood Wyoming Kentucky Maryland Ohio Pennsylvania Virginia (If the county of residence is not noted in the records from which you are abstracting data, select "".)

4 Page 4 of 24 Housing at time of program entry Number in household Insurance type Living in a permanent residence Living with friends or family Living in temporary housing (e.g., evicted, in process of moving, etc.) Residing in shelter Homeless (If housing at program entry is not noted in the records from which you are abstracting data, check "".) (Enter the number of people with whom the patient lived upon entry into the DFMB program, INCLUDING her. If the number of household residents is not noted in the records from which you are abstracting data, enter "99".) Private Medicaid Self-pay (If insurance type is not noted in the records from which you are abstracting data, check "t recorded".) type of insurance Income level at time of program entry Less than $15,000 (< $15,000), Less than $25,000 ($15,000 < = income < $25,000), Less than $35,000 ($25,000 < = income < $35,000), Less than $50,000 ($35,000 < = income < $50,000), Less than $75,000 ($50,000 < = income < $75,000), More than $75,000 (>= $75,000) (If income is not noted in the records from which you are abstracting data, check "".) Education level at time of program entry Employment at time of program entry Never attended school Some elementary school Some high school High school diploma or GED Technical training after high school Some college College graduate Graduate school (If education level is not noted in the records from which you are abstracting data, check "t recorded".) t currently employed Employed part-time Employed full-time (If employment at program entry is not noted in the records from which you are abstracting data, check "".)

5 Page 5 of 24 Marital status Cohabitation Married Separated Divorced Widowed Never married (If marital status is not noted in the records from which you are abstracting data, check "t recorded".) t cohabitating Cohabitating t reported (Was the patient cohabitating with a partner at the time she entered the DFMB program? The definition of cohabitation is a living arrangement in which an unmarried couple lives together in a long-term relationship that resembles a marriage.) Pregnancy Characteristics Gestational Age when Prenatal Care Initiated Was this a planned pregnancy? Is the participant intending to breastfeed at program entry? (Enter a two-digit value between 2 and 42. If GA at PNC initiation is not noted in the records from which you are abstracting data, enter 99.) Gs & Ps (Gravidity & Parity) Gravidity - G: Number of pregnancies Parity - T: Number of term births Parity - P: Number of preterm births Parity - A: Number of abortions Parity - L: Number of living children (Enter the total number of pregnancies, including the present one.) (Remember to include multiples such as twins as two fetuses/infants when entering parity data.) (Remember to include multiples such as twins as two fetuses/infants when entering parity data.) (Enter total number of spontaneous (miscarriages), therapeutic and elective abortions. Remember to include multiples such as twins as two fetuses/infants when entering parity data.) (Remember to include multiples such as twins as two fetuses/infants when entering parity data.)

6 Page 6 of 24 Pregnancy Complications During PREVIOUS Pregnancies Previous Pre-Term Birth Previous Cesarean Section Previous Pregnancy-Induced Hypertension (PIH) or Preclampsia Previous Abnormal Genetics Screen (unknown) Previous Stillbirth Previous Abdominal Surgery Previous Opioid Abuse Treatment Previous Macrosomia Previous Intrauterine Growth Restriction Gestational Diabetes During Previous Pregnancy Previous Placental Abruption Previous Ectopic Pregnancy Obesity During Previous Pregnancy Hepatitis B + During Previous Pregnancy Hepatitis C + During Previous Pregnancy Group B Strep + During Previous Pregnancy Pyelonephritis During Previous Pregnancy Previous Placental Previa Cervical Incompetence During Previous Pregnancy

7 Page 7 of 24 Pregnancy Complications During THIS Pregnancy Abnormal Genetics Screen Abdominal Surgery Cervical Incompetence Ectopic Pregnancy Gestational Diabetes Group B Strep + Hepatitis B + Hepatitis C + Intrauterine Growth Restriction Macrosomia Obesity Placental Abruption Placental Previa Pregnancy-Induced Hypertension (PIH) or Preclampsia (unknown) Pyelonephritis Was there any other pre-existing medical condition that affected the pregnancy? (e.g., Type II diabetes, hypertension) What pre-existing medical condition? (unknown) Prescription Medications Taken At Time of Pregnancy. In this section, note all of the prescription drugs of which you are aware that the patient was taking AT THE TIME at which she became pregnant (or found out she was pregnant). During pregnancy prescription drugs and non-prescription use are asked later! Selective Serotonin Re-uptake Inhibitors (SSRIs), by prescription Anti-Depressants Benzodiazepines Sleep Aids (Misc Sedatives/Hypnotics)

8 Page 8 of 24 Anti-convulsants Opioids for pain relief Opioids for medication assisted treatment (non-opioid) Pain Relievers Antipsychotic drugs Smoking Cessation Drugs Smoking Cessation Products Prescription Medications Used During THIS Pregnancy. In this section, note all of the drugs of which you are aware that the participant was prescribed DURING her pregnancy. n-prescription use is asked later! Selective Re-uptake Inhibitors (SSRIs), by prescription Anti-Depressants Benzodiazepines Sleep Aids (Misc Sedatives/Hypnotics) Anti-convulsants Opioids for pain relief Opioids for medication assisted treatment (non-opioid) Pain Relievers Antipsychotic drugs Smoking Cessation Drugs Substance Use History PRIOR to this pregnancy 1. Alcohol History of alcohol use? (Select "yes" if the participant has consumed alcohol.)

9 Page 9 of 24 How old was the patient when she first started drinking alcohol? Frequency of alcohol consumption (prior to pregnancy) Typical amount of alcohol consumed (prior to pregnancy) Has the patient ever been treated for alcohol abuse or dependence? Select all types of treatment for alcohol abuse or dependence that the patient has received. (If you are unable to abstract the age of initiation of alcohol use, enter "99".) 1-2 drinks 3-4 drinks 5-6 drinks 7-9 drinks 10 or more drinks (Enter the the number of drinks consumed on a typical day of drinking.) (unknown) In-patient Residential Sober living Intensive out-patient (IOP) Medication-assisted treatment out-patient Counseling Brief intervention (Select each type of treatment that the patient has received for an alcohol-use disorder. The categories may overlap, but still select all that apply.) 2. Tobacco History of tobacco use? How old was the participant when she first started using tobacco? Type used How frequently did the patient use tobacco? (If you are unable to abstract the age at which the participant initiated tobacco use, enter "99".) Cigarettes Smokeless E-cigarettes (such as pipes and cigars) (Check all that apply)

10 Page 10 of 24 How many cigarettes per day did the participant smoke? How many times per day did the patient use tobacco products other than cigarettes? Select the types of smoking cessation treatment that the patient has used prior to pregnancy. (One pack contains 20 cigarettes. If you are unable to abstract the number smoked per day prior to pregnancy, enter "99".) (If you are unable to abstract the number of times per that the participant used a tobacco product prior to pregnancy, enter "99".) Has never attempted to quit using tobacco Prescription (non-nicotine) medication Prescription nicotine replacement (patch, inhaler, nasal spray) Over-the-counter nicotine replacement (patch, gum, lozenge) Behavioral therapy Counseling Brief intervention On their own 3. Cannabis History of cannabis use? How old was the participant when she initiated cannabis use? Frequency of cannabis use (prior to pregnancy) Has the patient ever been in treatment for cannabis abuse? (If you are unable to abstract the age at which the participant initiated cannabis use, enter "99".) (unknown) 4. Stimulants History of stimulant use? How old was the participant when she initiated stimulant use? (Examples - Cocaine, Methamphetamine, Amphetamine (eg, MDMA, ecstasy), Methyphenidate, Synthetic cathinones (eg, bath salts)) (If you are unable to abstract the age at which the participant initiated stimulant use, enter "99".)

11 Page 11 of 24 Frequency of stimulant use (prior to pregnancy) Check all the specific stimulants used. Cocaine Methamphetamine Amphetamine (eg, MDMA, ecstasy) Methyphenidate Synthetic cathinones (eg, bath salts) List any other stimulants. Has the patient ever been in treatment for stimulant abuse? (unknown) 5. Hallucinogens History of hallucinogen use? How old was the participant when she initiated hallucinogen use? Frequency of hallucinogen use (prior to pregnancy) Check all the specific hallucinogens used. (Examples - LSD, PCP, Peyote, Psiloeybin (mushroom), Ketamine) (If you are unable to abstract the age at which the participant initiated hallucinogen use, enter "99".) LSD PCP Peyote Psiloeybin (mushroom) Ketamine DXM (triple C) List any other hallucinogens Has the patient ever been in treatment for hallucinogen abuse? (unknown)

12 Page 12 of Opioids/Narcotics History of opioid or narcotic use (for non-medical purposes defined as using more than prescribed, using more frequently than prescribed, or using that which was prescribed to someone else, i.e. diversion)? How old was the participant when she initiated opioid use? Frequency of opioid use (prior to pregnancy) Check all the specific opiods/narcotics used. (Examples - Heroin, Morphine, Meperidine (Demerol), Oxycodone (Perc, Oxy), Propaxyphene (Darvon), Codeine, Loperamide) (If you are unable to abstract the age at which the participant initiated opioid use, enter "99".) Heroin Morphine Methadone (Dolophone) Meperidine (Demerol) Oxycodone (Perc, Oxy, Roxi, endocet, targiniq) Propaxyphene (Darvon) Codeine and Hydrocodone (hydro, lorcet, lortab, norco, vicodin) Oxymorphone (opana) Anti-diarrheal (eg, Imodium, Lomotil, paregoric) Buprenorphine (Suboxone) synthetic opiods (eg, tramadol) Fentanyl (Hysingla, Zohydro) List any other opiods/narcotics Has the patient ever been in treatment for opioid abuse? (unknown) 7. Depressants History of depressants use (not including alcohol or opiods), for non-medical purposes? Check all the depressants used. (Examples - barbiturats, benzodiazepines) Barbituates Benzodiazepine (xanax, valium, ativan, klonopin) depressants (quaaludes, sleep aids, skeletal muscle relaxants) List the other depressants used

13 Page 13 of 24 How old was the participant when she initiated use of this substance? Frequency of depressant substance use (prior to pregnancy) Has the patient ever been in treatment for abuse of this substance? (If you are unable to abstract the age at which the participant initiated opioid use, enter "99".) (unknown) 8. substance use History of other substance use (for non-medical purposes defined as using more than prescribed, using more frequently than prescribed, or using that which was prescribed to someone else, i.e. diversion)? (Examples - inhalants, steriods) List the other substances used How old was the participant when she initiated use of this substance? Frequency of other substance use (prior to pregnancy) Has the patient ever been in treatment for abuse of this substance? (If you are unable to abstract the age at which the participant initiated opioid use, enter "99".) (unknown) Substance Use During This Pregnancy 1. Alcohol Did the participant drink alcohol during pregnancy? Frequency of alcohol consumption during pregnancy

14 Page 14 of 24 Typical amount of alcohol consumed during pregnancy 1-2 drinks 3-4 drinks 5-6 drinks 7-9 drinks 10 or more drinks (Enter the the number of drinks consumed on a typical day of drinking.) 2. Tobacco Did the participant use tobacco during pregnancy? Type used during pregnancy How many cigarettes per day did the participant smoke during pregnancy? How many times per day did the patient use tobacco products other than cigarettes? (during pregnancy), Cigarettes Smokeless E-cigarettes (such as pipes and cigars) (If you are unable to abstract the number smoked per day prior to pregnancy, enter "99".) (If you are unable to abstract the number of times per that the participant used a tobacco product prior to pregnancy, enter "99".) 3. Cannabis Did the participant use cannabis during pregnancy? Frequency of cannabis use during pregnancy 4. Stimulants Did the participant use stimulants during pregnancy? (Examples - Cocaine, Methamphetamine, Amphetamine (eg, MDMA, ecstasy), Methyphenidate, Synthetic cathinones (eg, bath salts))

15 Page 15 of 24 Frequency of stimulant use during pregnancy Check all the specific stimulants used. Cocaine Methamphetamine Amphetamine (eg, MDMA, ecstasy) Methyphenidate Synthetic cathinones (eg, bath salts) List any other stimulants. 5. Hallucinogens Did the participant use hallucinogens during pregnancy? Frequency of hallucinogen use during pregnancy Check all the specific hallucinogens used. (Examples - LSD, PCP, Peyote, Psiloeybin (mushroom), Ketamine) LSD PCP Peyote Psiloeybin (mushroom) Ketamine DXM (triple C) List the other hallucinogens used. 6. Opioids/Narcotics Did the participant use opioids or narcotics during pregnancy? (for non-medical purposes defined as using more than prescribed, using more frequently than prescribed, or using that which was prescribed to someone else, i.e. diversion)? Frequency of opioid/narcotics use during pregnancy (Examples - Heroin, Morphine, Meperidine (Demerol), Oxycodone (Perc, Oxy), Propaxyphene (Darvon), Codeine, Loperamide)

16 Page 16 of 24 Check all the specific opiods/narcotics used. Heroin Morphine Methadone (Dolophone) Meperidine (Demerol) Oxycodone (Perc, Oxy, Roxi, endocet, targiniq) Propaxyphene (Darvon) Codeine and Hydrocodone (hydro, lorcet, lortab, norco, vicodin) Oxymorphone (opana) Anti-diarrheal (eg, Imodium, Lomotil, paregoric) Buprenorphine (Suboxone) synthetic opiods (eg, tramadol) Fentanyl (Hysingla, Zohydro) List the other opiods used. 7. Depressants Did the participant use depressants (not including alcohol/opiods) during pregnancy? (for non-medical purposes defined as using more than prescribed, using more frequently than prescribed, or using that which was prescribed to someone else, i.e. diversion)? Frequency of depressants use during pregnancy Check all the specific depressants used. (Examples - barbiturats, benzodiazepines) Barbituates Benzodiazepine (xanax, valium, ativan, klonopin) depressants (quaaludes, sleep aids, skeletal muscle relaxants) List the other depressants used. 8. substance use Did the participant use other substances not previously listed during pregnancy? List the specific other substances used during pregnancy (Examples - inhalants, steriods)

17 Page 17 of 24 Frequency of other substances used during pregnancy Substance Abuse Treatment After Program Entry Is the participant enrolled in a substance abuse treatment program? What is the treatment program for? Select all types of treatment that the patient received DURING pregnancy. Currently participating in drug recovery and/or maintenance program? Current substance use self-reported (before testing) Maintenance medication Type of maintenance medication Drug testing method Drugs Alcohol Both In-patient Residential Sober living Intensive out-patient (IOP) Medication-assisted treatment out-patient Counseling Brief intervention (Select each type of treatment that the patient has received for an alcohol-use disorder. The categories may overlap, but still select all that apply.) Alcohol Tobacco Cannabis Stimulant Hallucinogens Opiods/Narcotics Depressants Methadone (Dolophine, Methadose) Buprenorphine (Subutex, Suboxone) Naltrexone (Depade, Revia) /unknown Urine drug screen /

18 Page 18 of 24 Positive drug screens t positive Positive for prescribed drugs only Positive for non-prescribed drugs t tested/ During 1st trimester During 2nd trimester During 3rd trimester At delivery After delivery to 6 weeks postpartum 7 weeks to 6 months postpartum 7 months to 9 months postpartum 10 months to 12 months postpartum 13 months to 24 months postpartum Referred to other treatment Referred to other treatment program? Referred program Inpatient or outpatient? Inpatient Outpatient Both Types of treatment during the program Please check the types of treatment during the program Indiviudal counseling Group counseling Prenatal education Postpartum education Recovering coach session Peer support Individual counseling Number of sessions the participant attended for individual counseling: Typical duration in minutes:

19 Page 19 of 24 Group counseling Number of sessions: Typical duration in minutes: Prenatal Number of prenatal visits Number of prenatal education sessions (These should be considered independent of group or individual counseling) Typical duration in minutes: Postpartum Number of postpartum education sessions: (These should be considered independent of group or individual counseling) Typical duration in minutes: Recovery coach sessions: 1. In Person: Number of in person recovery coach sessions (can include home or clinic visits): Typical duration in minutes: 2. Phone: Number of phone recovery coach sessions: Typical duration in minutes:

20 Page 20 of Text/Messages Number of text/message sessions (ie, about same topic): Typical quality of text/message Low quality (ie, no response from participant) Medium quality (eg, some response) High quality interactions 4. services not listed (eg, transportation) Referrals made to the following programs or services: t made Information given about program but no referral or use of services Referral made, services not used or unknown use Services accessed AA or NA Birth to Three Childcare CHIP or Insurance (e.g., ACA) CPS Criminal Justice or Legal Services Dental or Oral Health Services Domestic Violence Services Educational / Vocational Training Emergency Services (e.g., food, clothing) Family Planning Housing Job Training Mental Health Services (external to DFMB) Postpartum Medical Appointments for the Patient Public Assistance Religious Support Services Respite Care

21 Page 21 of 24 Right From the Start (or other home visitation program) Transportation WIC Services t Already Mentioned Specify Services to Which Patient Was Referred Program and Birth Outcomes Did the patient leave the program prematurely? How long did the patient remained engaged with the Drug-Free Moms & Babies program? How long did the patient remained engaged with the DFMB program? Why didn't the patient complete the program? Why was the patient lost to follow-up? What was the birth outcome for this pregnancy? If twins/multiples, choose all that apply What was the method of delivery for this birth? (completed the program) (Enter whether the patient completed the program.) Until delivery only Two full years postpartum (For patients that completed the program, please select whether they stayed until delivery or the full 2 years postpartum. Multiple answers may be selected for purposes of updating records.) Prior to delivery Until delivery only After delivery but before 6 months postpartum Between 6 months and 1 year post postpartum Between 1 year and 18 months postpartum Between 18 months and 2 years postpartum (For patients that left the program prematurely, please answer the time at which they left) Discharged due to noncompliance Lost to follow-up, i.e. dropped out of the program Referred to a higher level of care Re-entered program, new pregnancy (Enter the reason why the patient did not complete the DFMB program.) Personal preference Moved out of the program area Incarcerated / (Enter the reason why the patient dropped out of the program.) Live, term birth Live, preterm birth Stillborn Termination (Enter "Termination" for pregnancies that ended early due to abortion and "" if the birth outcome is not noted in the record from which you are abstracting these data.) C-section Vaginal

22 Page 22 of 24 What type of termination occurred? At what gestational age did the termination occur? How many weeks gestation was the pregnancy at delivery? Were there twins/multiples for this birth? What was the infant's birthweight in pounds and ounces? What was the infant's birth length in inches? What was the second infant's birthweight in pounds and ounces? What was the second infant's birth length in inches? What was the infant's sex at birth? What was the second infant's sex at birth? What was the infant's APGAR score at five minutes? What was the second infant's APGAR score at five minutes? What were the results of the cord tissue testing? If positive for drug exposure, were ONLY prescribed medications found in the results? Spontaneous abortion (miscarriage) Elective abortion Therapeutic abortion (elective abortion for medical reason) (Enter "99" if the gestational age at which the termination occurred was unknown.) (Enter "99" if unknown) (Enter "99" if unknown) (Enter "99" if unknown) (Enter "99" if unknown) (Enter "99" if unknown) Female Male Female Male (Enter the APGAR score assigned to the infant five minutes after birth. If this information is unknown, enter "99".) (Enter the APGAR score assigned to the infant five minutes after birth. If this information is unknown, enter "99".) t positive for drug exposure Positive for drug exposure or not available, prescribed only, prescribed AND other drugs, other drugs only

23 Page 23 of 24 For which drugs did the cord tissue screen positive? Specify other drugs. Was the infant admitted to a neonatal intensive care unit (NICU)? What was the length of stay in the NICU? After the infant was discharged from the hospital, was he or she readmitted? Was the infant diagnosed with neonatal abstinence syndrome (NAS)? Was the infant treated for NAS? (Check all that apply.) With what was the infant treated (for NAS)? Specify the other treatment. Was the infant breastfed after birth? Was the mother given the opportunity to breastfeed before leaving the hospital? Alcohol Amphetamines (amphetamine, MDA, MDEA, MDMA, methamphetamine) Barbiturates (amobarbital, butalbital, pentobarbital, phenobarbital, secobarbital) Benzodiazepines (alprazolam, diazepam, midazolam, nordiazepam, oxazepam, temazepam) Buprenorphine Cannabinoids (carboxy-thc) Cocaine (benzoylecgonine) Meperidine (meperidine, normeperidine) Methadone (EDDP, methadone) Opiates (6-MAM, meconin, codeine, hydrocodone, hydromorphone, morphine) Oxycodone (oxycodone, oxymorphone) Phencyclidine (phencyclindine) (PCP) Propoxyphene (propoxyphene, norpropoxyphene) Tramadol (tramadol) (Check each drug for which the cord testing results came back positive.) (Enter the number of days that the infant was admitted to the NICU. If these data are not noted in the records from which you are abstracting this information, enter "999".), therapeutic, pharmacologic (Indicate whether the infant received non-pharmacologic and/or pharmacologic treatment for NAS.) Morphine Methadone

24 Page 24 of 24 Was the infant sent home with mother or discharged from hospital to the mother's care?