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StratX Post-treatment Report Experience Questionnaire

Step 1 of 6

16%

Provider & Hospital:(Required)

Original Procedure Date:(Required)

Original StratX Ref. No.:

Post StratX Request Date:(Required)

Post StratX ID / Ref. No.:(Required)

Additional Procedure Date (if):

Goal of pilot survey: Get preliminary feedback on usefulness and accuracy of the StratX Post-treatment report, assess if the bronchoscopy meet the post report findings. Instruction: Please tick applicable answer for each question

Why did you request a StratX Post-treatment report?

Patient never achieved the expected symptom relief following treatment

Clinical expected outcomes such as FEV1 or change in RV less than MCID

Patient experienced symptom relief following treatment, but the response diminished over time

Complications (hemoptysis, persistent cough, pneumothorax)

Patient has responded to treatment as expected

Other

Please Explain:

What information did you find helpful on the StratX Post-treatment report? (select all that apply)

Amount of TLVR (standard 350 mL)

Valve placement location table

Quantity of valves observed

Airway images

Other

If Other, Please Explain:

Explain why this information was helpful(Required)

Did the StratX Post-treatment report verify the need to perform an additional bronchoscopy?

Yes

No

Please Explain:

What clinical action was taken based on this report?

No action was taken

Re-bronchoscopy without revision procedure

Re-bronchoscopy, with revision procedure and valve(s) placed / replaced

Chartis measurement confirming fissure integrity / no collateral ventilation

Other

Please Explain:

If there was a re-bronchoscopy procedure, did the re-bronchoscopy match the information in the report?

Yes

No

If No, Please Explain:

During the procedure, what action(s) were taken? (select all that apply)

Valve replacement

Partial or complete removal of valves

Cleaning secretion

Chartis assessment

Nothing

Other

If Valve Replacement, please explain (how many/position):

If Partial or Complete Removal of Valves, please explain:

If Other, please explain:

If there was a re-bronchoscopy revision procedure, did the patient feel the benefit from it already?

Yes

No

Not Yet Assessed

For Yes and No, please specify after which time this assessment was done after revision:

Would an additional bronchoscopy have been performed if the StratX Post-treatment report was not used?

Yes

No

If No, Please Explain:

What additional information, if any, do you wish the report provided?

When you consider a re-bronchoscopy is required, would you recommend the usage of Post Treatment StratX report?

1 (strongly disagree)	2	3	4	5	6	7	8	9	10 (strongly agree)

When a re-bronchoscopy is required, I recommend the use of a StratX Post-treatment report? Rank from 1-10 , where 1 = strongly disagree, and 10 = strongly agree

Any additional comments or suggestions:

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こちらのウェブサイトは海外のサイトで医療従事者を対象としたものです。一般の方に対する情報提供を目的としたものではございません。当治療に関する情報を希望される場合は、かかりつけ医までお問合せください。

医療従事者のみなさま：当治療に関する情報提供を希望される場合、以下のお問合せフォームにてお知らせください。弊社の担当者から連絡させていただきます。

お名前*
名 (First) 姓 (Last)
ご施設*
Email*
*この項目は入力必須です。

GLO-JP-1660-v1

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