The efficacy of written screening tools in an inner city hospital: Literacy based limitations on patient access to appropriate care

Purpose: Appropriate patient treatment necessitates patient literacy due to the increasing use of written screening tools in medicine. We evaluated the frequency, predictors and impact of poor understanding of the American Urological Association symptom index on patient care. Materials and Methods: This prospective cohort study included 300 male patients older than 40 years who completed the American Urological Association symptom index twice, as self-administered and then as interviewer administered. These 2 responses were compared by calculating correlation coefficients and weighted kappa statistics to assess patient understanding of the American Urological Association symptom index. Multivariate logistic regression analyses examined the association between patient characteristics and poor understanding of the symptom index, defined as understanding fewer than 4 questions, by calculating the OR and corresponding 95% CI. Results: Of the 7 symptom index questions 16% of patients understood all, 38% understood more than half, 18% understood fewer than half and 28% understood none. The agreement between self-administered and interviewer administered responses decreased with decreasing education level. Compared to patients with at least some college education those with fewer than 9 years of education were more likely to have a poor understanding of the American Urological Association symptom index (OR 102.16, 95% CI 23.93-436.10), resulting in a 2-fold increase in the risk of symptom misclassification (P trend < 0.01). After controlling for education associations for age, income, employment and race were not significantly different from null. Conclusions: A significant number of patients with lower education and literacy levels incorrectly self-administer the American Urological Association symptom index, resulting in the misclassification of their symptoms, which may severely limit their access to appropriate care.