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Baseline - Patient-Reported Form

1 forms  
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Patient ID
Description

Supporting Definition: This number will not be shared with ICHOM. In the case patient-­‐level data is submitted to ICHOM for benchmarking or research purposes, a separate ICHOM Patient Identifier will be created and cross-­‐linking between the ICHOM Patient Identifier and the medical record number will only be known at the treating institution Inclusion Criteria: All patients Timing: On all forms Data Source: Administrative or clinical Type: Numerical Response Options: According to institution

Data type

integer

Alias
UMLS CUI [1]
C2348585
Demographic factors
Description

Demographic factors

Alias
UMLS CUI-1
C1704791
What is your date of birth?
Description

Inclusion Criteria: All patients Timing: Baseline Data Source: Clinical or patient­‐reported Type: Date by DD/MM/YYYY

Data type

date

Measurement units
  • DD/MM/YYYY
Alias
UMLS CUI [1]
C0421451
DD/MM/YYYY
Please indicate your sex at birth
Description

Inclusion Criteria: All patients Timing: Baseline Data Source: Clinical or patient­‐reported Type: Single answer

Data type

integer

Alias
UMLS CUI [1]
C0079399
What is your ethnicity?
Description

In the original form response option is N/A. A codelist is not supplemented because it varies by country and should be determined by country (not for cross country comparison). Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Single answer

Data type

text

Alias
UMLS CUI [1]
C0015031
Please indicate highest level of schooling completed
Description

Supporting Definition: The level of schooling is defined in each country as per ISCED [International Standard Classification] Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Single answer

Data type

integer

Alias
UMLS CUI [1]
C0013658
Baseline Clinical factors
Description

Baseline Clinical factors

Alias
UMLS CUI-1
C0449440
UMLS CUI-2
C1442488
Have you unintentionally lost weight?
Description

Inclusion Criteria: All patients Timing: Baseline Data Source: Patient­‐reported Type: Single answer

Data type

integer

Alias
UMLS CUI [1]
C1262477
Do you have any of the following problems? 0 = I have no other diseases
Description

Supporting Definition: Based upon the Self-­administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0549184
Do you have any of the following problems? 1 = Heart disease (for example: angina, heart attack, or heart failure)
Description

Supporting Definition: Based upon the Self-­administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0018799
Do you have any of the following problems? 2 = High blood pressure
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0020538
Do you have any of the following problems? 3 = Leg pain when walking due to poor circulation
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C1306889
Do you have any of the following problems? 4 = Lung disease (For example, asthma, chronic bronchitis, or emphysema)
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0024115
Do you have any of the following problems? 5 = Diabetes
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0011849
Do you have any of the following problems? 6 = Kidney disease
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0022658
Do you have any of the following problems? 7 = Liver disease
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0023895
Do you have any of the following problems? 8 = Problems caused by stroke
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0038454
Do you have any of the following problems? 9 = Disease of the nervous system (For example, Parkinson’s disease or multiple sclerosis)
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0027765
Do you have any of the following problems? 10 = Other cancer (within the last 5 years)
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C1707251
Do you have any of the following problems? 11 = Depression
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0011581
Do you have any of the following problems? 12 = Arthritis
Description

Supporting Definition: Based upon the Self­‐administered Comorbidity Questionnaire (Sangha et al, 2003) Inclusion Criteria: All patients Timing: Baseline Data Source: Patient-­reported Type: Multiple answer

Data type

boolean

Alias
UMLS CUI [1,1]
C0009488
UMLS CUI [1,2]
C0003864
Please indicate your smoking status at time of your lung cancer diagnosis
Description

Inclusion Criteria: All patients Timing: Baseline Data Source: Patient­‐reported Type: Single answer

Data type

integer

Alias
UMLS CUI [1]
C1519386
Degree of health
Description

Degree of health

Alias
UMLS CUI-1
C0018759
EORTC QLQ-C30 Total Score
Description

As a license is needed for use of this questionnaire, the 30 actual questions are not included in this version of the standard set. ICHOM IDs are EORTCQLQC30_Q01 up to EORTCQLQC30_Q30. Inclusion Criteria: All patients Timing: Baseline 1 year post initiation of treatment Tracked ongoing annually for life (when hospital is able to track this ongoing) Data Source: Clinical Type: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C4055104
UMLS CUI [1,2]
C2964552
EORTC QLQL-C13 Total score
Description

As a license is needed for use of this questionnaire, the 13 actual questions are not included in this version of the standard set. ICHOM IDs are EORTCQLQLC13_Q01 up to EORTCQLQLC30_Q13. EORTCQLQLC30_Q12 and EORTCQLQLC30_Q13 have each an additionally ID: EORTCQLQLC30_Q12SUB and EORTCQLQLC30_Q13SUB. Inclusion Criteria: All patients Inclusion Criteria: All patients Timing: Baseline 1 year post initiation of treatment Tracked ongoing annually for life (when hospital is able to track this ongoing) Data Source: Clinical Type: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C0451149
UMLS CUI [1,2]
C0242379
UMLS CUI [1,3]
C2964552
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Similar models

Baseline - Patient-Reported Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Patient ID
Item
Patient ID
integer
C2348585 (UMLS CUI [1])
Item Group
Demographic factors
C1704791 (UMLS CUI-1)
Date of birth
Item
What is your date of birth?
date
C0421451 (UMLS CUI [1])
Item
Please indicate your sex at birth
integer
C0079399 (UMLS CUI [1])
Sex
Code List
Please indicate your sex at birth
CL Item
Male (1)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
Female (2)
C0086287 (UMLS CUI-1)
(Comment:en)
CL Item
Undisclosed (999)
C0079399 (UMLS CUI-1)
C0439673 (UMLS CUI-2)
(Comment:en)
Ethnicity
Item
What is your ethnicity?
text
C0015031 (UMLS CUI [1])
Item
Please indicate highest level of schooling completed
integer
C0013658 (UMLS CUI [1])
Educational Level
Code List
Please indicate highest level of schooling completed
CL Item
None (0)
C0557286 (UMLS CUI-1)
(Comment:en)
CL Item
Primary (1)
C0013658 (UMLS CUI-1)
C0033145 (UMLS CUI-2)
(Comment:en)
CL Item
Secondary (2)
C0557289 (UMLS CUI-1)
(Comment:en)
CL Item
Tertiary (3)
C0557291 (UMLS CUI-1)
(Comment:en)
Item Group
Baseline Clinical factors
C0449440 (UMLS CUI-1)
C1442488 (UMLS CUI-2)
Item
Have you unintentionally lost weight?
integer
C1262477 (UMLS CUI [1])
Weight loss
Code List
Have you unintentionally lost weight?
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
CL Item
Unknown (999)
C0439673 (UMLS CUI-1)
(Comment:en)
Comorbidities: None
Item
Do you have any of the following problems? 0 = I have no other diseases
boolean
C0009488 (UMLS CUI [1,1])
C0549184 (UMLS CUI [1,2])
Comorbidities: Heart disease
Item
Do you have any of the following problems? 1 = Heart disease (for example: angina, heart attack, or heart failure)
boolean
C0009488 (UMLS CUI [1,1])
C0018799 (UMLS CUI [1,2])
Comorbidities: High Blood Pressure
Item
Do you have any of the following problems? 2 = High blood pressure
boolean
C0009488 (UMLS CUI [1,1])
C0020538 (UMLS CUI [1,2])
Comorbidities: peripheral occlusive arterial disease
Item
Do you have any of the following problems? 3 = Leg pain when walking due to poor circulation
boolean
C0009488 (UMLS CUI [1,1])
C1306889 (UMLS CUI [1,2])
Comorbidities: Lung disease
Item
Do you have any of the following problems? 4 = Lung disease (For example, asthma, chronic bronchitis, or emphysema)
boolean
C0009488 (UMLS CUI [1,1])
C0024115 (UMLS CUI [1,2])
Comorbidities: Diabetes
Item
Do you have any of the following problems? 5 = Diabetes
boolean
C0009488 (UMLS CUI [1,1])
C0011849 (UMLS CUI [1,2])
Comorbidities: Kidney disease
Item
Do you have any of the following problems? 6 = Kidney disease
boolean
C0009488 (UMLS CUI [1,1])
C0022658 (UMLS CUI [1,2])
Comorbidities: Liver disease
Item
Do you have any of the following problems? 7 = Liver disease
boolean
C0009488 (UMLS CUI [1,1])
C0023895 (UMLS CUI [1,2])
Comorbidities: stroke
Item
Do you have any of the following problems? 8 = Problems caused by stroke
boolean
C0009488 (UMLS CUI [1,1])
C0038454 (UMLS CUI [1,2])
Comorbidities: Disease of the nervous system
Item
Do you have any of the following problems? 9 = Disease of the nervous system (For example, Parkinson’s disease or multiple sclerosis)
boolean
C0009488 (UMLS CUI [1,1])
C0027765 (UMLS CUI [1,2])
Comorbidities: Other Cancer
Item
Do you have any of the following problems? 10 = Other cancer (within the last 5 years)
boolean
C0009488 (UMLS CUI [1,1])
C1707251 (UMLS CUI [1,2])
Comorbidities: Depression
Item
Do you have any of the following problems? 11 = Depression
boolean
C0009488 (UMLS CUI [1,1])
C0011581 (UMLS CUI [1,2])
Comorbidities: Arthritis
Item
Do you have any of the following problems? 12 = Arthritis
boolean
C0009488 (UMLS CUI [1,1])
C0003864 (UMLS CUI [1,2])
Item
Please indicate your smoking status at time of your lung cancer diagnosis
integer
C1519386 (UMLS CUI [1])
Smoking status
Code List
Please indicate your smoking status at time of your lung cancer diagnosis
CL Item
Never‐smoker (< 100 cigarettes in your lifetime) (1)
C0337672 (UMLS CUI-1)
(Comment:en)
CL Item
Ex-­smoker (stopped at least 1 year before diagnosis) (2)
C0337671 (UMLS CUI-1)
C1519384 (UMLS CUI-2)
C1277691 (UMLS CUI-3)
(Comment:en)
CL Item
Current smoker (3)
C3241966 (UMLS CUI-1)
(Comment:en)
CL Item
Unknown (999)
C0439673 (UMLS CUI-1)
(Comment:en)
Item Group
Degree of health
C0018759 (UMLS CUI-1)
EORTC QLQ-C30 Total Score
Item
EORTC QLQ-C30 Total Score
integer
C4055104 (UMLS CUI [1,1])
C2964552 (UMLS CUI [1,2])
EORTC QLQL-C13 Total score
Item
EORTC QLQL-C13 Total score
integer
C0451149 (UMLS CUI [1,1])
C0242379 (UMLS CUI [1,2])
C2964552 (UMLS CUI [1,3])
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