Many Patients Misunderstand Written Screening Tests

Time constraints frequently limit the amount of face time doctors and patients share together. To optimize their office visit, patients often answer written questions while awaiting their turn to see their doctors. In two separate studies presented at the 2008 Clinical Congress of the American College of Surgeons, Viraj A. Master, MD, PhD, assistant professor of urology at Emory University School of Medicine, Atlanta, pointed out a profound gap in the understanding of physicians about the literacy levels of their patients as it relates to the efficacy of screening tools.

“In our particular 300-patient cohort of men with an average age of 61, the average reading level in our inner-city hospital was 4th grade. In the seven questions that we asked from the International Prostate Symptom Score (IPSS), for example, only 16 % of patients understood all seven questions. Possibly the most worrisome, was the number of patients who thought they understood this test…but did not,” Master said in a press release.

Evaluation of responses to the IPSS test, which asks such questions as: “During the last month or so, how often have you had to push or strain to urinate?” further showed that only 38% of patients understood more than half the questions, 18% understood fewer than half, and 28% understood none. After controlling for education, age, income, employment status, race, homelessness and English as a second language, the only independent predictor of understanding of this instrument that emerged was the number of years of schooling.

According to Master, the most frightening aspect of these poor results is that communication and understanding is not as simple as being able to read a sentence.

“We also expect people to be reasonably numerate and capable of discussing numbers and quantities. Doctors, in particular, want patients to be able to answer, on a scale of one to 10, ‘How are you?’ and be able to communicate whether symptoms occur ‘half the time,’ or ‘a third of the time.’” Master said.

In the second study, 266 patients with an average age of 58, completed a validated, three-question Woloshin-Schwartz numeracy quiz. The quiz asked questions such as “Imagine that we flip a coin 1,000 times. What is your best guess about how many times the coin will come up heads in 1,000 flips?” (Answer: 500 times).

Results showed that only 16% of respondents answered all three questions correctly and 15 % answered two correctly. Therefore, only 31% fell into the ‘numerate’ category. Most respondents were innumerate, with 33% having one correct answer and 35% having no correct answers.

“Even after controlling for age, race, homelessness, English as a second language, income and a host of other variables, including educational level, numeracy was shown to be an independent predictor of misunderstanding,” Master said. “Being innumerate, in addition to being illiterate, results in high levels of misunderstanding that severely limit access to appropriate health care for millions of patients.”

Having established that both words and numbers are drivers of illiteracy in America, Master and his colleagues suspected that adding carefully designed pictures to their screening tests to help depict the concept being discussed would improve patient understanding. To test this hypothesis, they designed a robust randomized prospective trial, which has been completed, and is to be published as a letter to the editor in the October 2008 issue of the Journal of Urology. However, the results show that pictures did not improve understanding.

During a shopping trip with his family, Master was struck by the number of people pleasantly immersed in video games, rapidly absorbing an incredible amount of information. Suddenly an idea was born.

“I thought, how do we translate that into the health care arena?” he said.

Master and his colleagues designed another randomized clinical trial–this one a computer program. The program allowed patients to look at a figure that was speaking to them and asking the very same questions that were on the Symptoms Score questionnaire.

This third study, presented at the American Urology Association meeting in May 2008, was highly significant and quite successful.

“The computer program improved understanding for all patients at all educational levels. Importantly, it even improved understanding for individuals who had no familiarity with computers,” Master said.

The lesson in all of this research is that “there is a true epidemic of health illiteracy in this country. Do not assume that your patients are literate with either prose or numeracy,” Master said.

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