Patient Misunderstanding Of The Individual Questions Of The American Urological Association Symptom Score

Main Category: Urology / Nephrology
Article Date: 25 Aug 2008 - 0:00 PDT

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UroToday.com - "Listen to the patient, he will tell you the diagnosis." - Sir William Osler

Communication is central to the physician-patient encounter. With decreasing face time in the clinical encounter, possibly because of insurer-driven time constraints, physicians of all specialties rely on written assessment tools. These are potentially useful to track symptom progression/resolution, and particularly for benign prostatic hyperplasia (BPH), to stratify patients for expectant management, drug therapy or more invasive surgical treatments.

The AUA symptom score (AUS-SS), which is often known as the International Prostate Symptom Score (IPSS) (although the IPSS is actually comprised of the identical 7 AUA-SS questions - plus one more question on bother), is the most commonly used tool worldwide to assess BPH. In fact, the symptom score is central to both the American Urological Association and the European Association of Urology BPH treatment guidelines. Previous multiple studies had indicated that it was widely understood. Our anecdotal experience was different, and so we formally studied this question. We had previously studied the ability of patients to understand the AUA-SS in an indigent patient care setting with 300 patients. Strikingly only 16% of our patients fully understood the questionnaire. More ominously, 60% of our patients claimed to fully understand the questionnaire, while they did not.

This current study included nearly 1000 patients at multiple sites of service, including university and public hospital practices. Particular emphasis was placed on figuring out which questions were reproducibly misunderstood, with a future goal of re-wording this questionnaire. We were absolutely sure that the nocturia question would be most subject to patient misunderstanding, but it was not. Actually, the irritative voiding questions, namely question 2 (frequency) and question 4 (urgency) were the most misinterpreted. Low educational level was the strongest driver of misunderstanding, with a two-fold difference between those with greater than 12 years of education versus those with less than 9 years of education. This was true for both the total AUA-SS, as well as the frequency and urgency questions.

It is important to note that the AUA-SS is still an excellent tool for BPH diagnosis and treatment. In these studies, we are only using it as an exemplar. Just like the molecular biologists have used Drosophila to probe genes and development, we are using the AUA-SS to probe how communication occurs and particularly what may improve medical communication. Of note, we have reproduced these findings in other commonly used urology questionnaires.

Written by
Viraj Master, MD, PhD, and Tim Johnson, BA, as part of Beyond the Abstract on UroToday.com.

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