|Year : 2014 | Volume
| Issue : 3 | Page : 252-255
Misinterpretation of the international prostate symptom score questionnaire by Indian patients
Tarun Jindal, Rajan Kumar Sinha, Subhabrata Mukherjee, Soumendra Nath Mandal, Dilip Karmakar
Department of Urology, Calcutta National Medical College, Kolkata, West Bengal, India
|Date of Web Publication||1-Jul-2014|
Department of Urology, 32, Gorachand Road, Calcutta National Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The international prostate symptom score (IPSS) is commonly used in the evaluation of the severity of symptoms of patients with prostatic enlargement. It is a self-administered questionnaire. It has not been validated in any Indian language and an English version is used which can be difficult to interpret by our patients who do not have English as their primary language. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the IPSS questionnaire was self-administered versus when it was administered using the assistance of a clinician.
Materials and Methods: Patients who presented with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, who had passed at least twelfth grade of school and had a reasonable command over English were included in the study. They were allowed to self-administer the IPSS questionnaire following which a clinician, blinded to these scores, assisted the patient in filling the questionnaire. For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the agreement between the two scores.
Results: A total of 87 patients were included in the study. It was found that none of the questions had a perfect agreement of scores in the self-administered and the assisted administration.
Conclusion: Our results show that our patients misinterpret the IPSS questionnaire. This problem can lead to significant errors in interpretation of the symptom severity.
Keywords: Benign prostatic hyperplasia, lower urinary tract symptoms, prostate questionnaires
|How to cite this article:|
Jindal T, Sinha RK, Mukherjee S, Mandal SN, Karmakar D. Misinterpretation of the international prostate symptom score questionnaire by Indian patients. Indian J Urol 2014;30:252-5
|How to cite this URL:|
Jindal T, Sinha RK, Mukherjee S, Mandal SN, Karmakar D. Misinterpretation of the international prostate symptom score questionnaire by Indian patients. Indian J Urol [serial online] 2014 [cited 2019 Nov 15];30:252-5. Available from: http://www.indianjurol.com/text.asp?2014/30/3/252/134246
| Introduction|| |
Benign prostatic hyperplasia (BPH) is a commonly encountered clinical condition in the elderly population. It presents with various obstructive and irritative lower urinary tract symptoms (LUTS) like frequency, urgency, nocturia, intermittency, weak urinary stream etc.  The international prostate symptom score (IPSS) is a tool which is very commonly used in the evaluation of the severity of symptoms of the patients. It is a self-administered questionnaire which scores the symptoms the patient has experienced over of the preceeding 4 weeks.  This questionnaire has been validated by numerous researchers in well-educated patients. , It helps the clinician understand the severity of patient's symptoms and can guide treatment. 
The IPSS questionnaire can be difficult for an average patient to comprehend. Hence the responses can depend upon the level of education and understanding of the patient. This can have a significant bearing on the ultimate score and can lead to improper selection of treatment. , It can lead to significant distress both to the patient and to the treating physician due to the lack of optimum response by the treatment based on the IPSS.
The IPSS questionnaire has been translated and validated in various languages but it has not been validated in any of the Indian languages. ,, We commonly employ the English version of the questionnaire. For a population that does not have English as its primary language, this issue may have a serious impact on the understanding of questions and the scoring. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the questionnaire was self-administered versus when it was administered using the assistance of a clinician.
| Materials and methods|| |
The study was approved by the institutional ethics committee. A total of 87 patients were included over a period of 10 months. Patients who presented with LUTS suggestive of BPH, those who had passed at least twelfth grade school and had a reasonable command over English (assessed by their ability to have a conversation in English with the clinician) were included in the study. A written and informed consent was obtained from all the patients. Those who had previously filled an IPSS questionnaire or those who were < 40 years of age were excluded from the study.
The patients were first given the IPSS questionnaire and were allowed to self-administer it. The score sheet was taken away and then a blinded clinician (2 nd year resident in urology), who was not aware of the score on the self administered questionnaire, assisted the patient in filling the responses (English version) by interpreting and explaining the meaning of the questions in English. The second questionnaire was administered on the same day, 4-5 hours after the administration of the first questionnaire.
The IPSS questionnaire comprises of eight questions, seven regarding the symptoms over a period of the preceedinglast 1 month and one assessing the quality-of-life. The seven questions assessing the symptoms include incomplete emptying, frequency, intermittency, urgency, weak stream, straining and nocturia. Each of these symptoms is assigned a score from 0 to 5 for a maximum 35 points. The scores of these seven questions are added to determine the severity of patient urinary symptoms as follows, mild - 0-7, moderate - 8-19 and severe - 20-35. The eighth question assesses the quality of life is assigned a score of 0-6.
For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the level of agreement between them. By convention, a kappa of 0.0 means that the agreement is no better than a chance event. Kappa scores of 0.01-0.20, 0.21-0.40, 0.41-0.60, 0.61-0.80 and 0.81-0.99 are interpreted as showing poor, fair, moderate, substantial and almost perfect agreement, respectively. 
| Results|| |
The mean age of the patients was 61.4 years. The kappa values of the scores for each question have been shown in [Table 1]. No question had a perfect agreement of scores in the self-administered and the clinician assisted scoring scenarios. Only the scores of questions about weak stream and nocturia showed "moderate" agreement of score while the quality-of-life question revealed a "fair" agreement. The scores for all the other questions had a poor agreement.
|Table 1: The overall mean scores, kappa value and its interpretation for each question of the IPSS questionnaire|
Click here to view
The total scores for each patient were calculated for both the clinical scenarios and they were classified into mild, moderate and severe categories as per the criteria mentioned before. The results have been shown in [Table 2]. It was found that total scores in the self-administered and the clinician assisted scoring agreed "poorly" with each other as the kappa value was 0.19.
|Table 2: The categorization of patient's symptoms as per the IPSS questionnaire when it was self-administered compared to when it was administered by an assessor|
Click here to view
| Discussion|| |
IPSS questionnaire is recommended by the American Urological Association during the work up of a patient with LUTS. Apart from helping the clinician in assessing the severity of the symptoms of a patient, it also acts as a guide in selecting the appropriate mode of treatment which can vary from watchful waiting to surgery. 
Studies in the Western population have pointed out that there can be significant misinterpretation of the IPSS by the patients. ,, Some of these studies have shown that it depends upon the level of education, with patients having a low level of education showing marked misinterpretation. The issue of non-availability of the questionnaire in a local language and its impact on the ability of a patient to self-administer a questionnaire in English has been highlighted by Ogwuche et al.  We also believe that a validated IPSS questionnaire in an Indian language may be helpful in decreasing the error in interpretation, but additional studies will be needed to prove this.
It has also been reported that the error in interpretation of the IPSS questionnaire can lead to miscategorization of the patients' symptoms and selection of a treatment that may not be effective for him. For example, a patient who on self-administered IPSS questionnaire has a score of 6 (mild symptoms) may be offered only watchful waiting while he actually may be having moderate or severe symptoms which becomes evident when the questionnaire is explained to him by a medical assistant. Johnson et al. have pointed out that 25% of patients who self-reported a mild score on IPSS actually had a moderate or severe score.  In our study too, there was a misinterpretation of the IPSS questionnaire by the patients. The scores for each question showed a poor agreement for five out of seven questions. The quality-of-life question too could only show a fair agreement. There was also significant miscategorization of patients' symptoms (mild/moderate/severe) when the scores on self-administered questionnaire were compared to the clinician assisted questionnaire. Thus it is important to realize that although IPSS questionnaire is an important tool in the work up of patients with LUTS, it should not be the sole guide for the treatment offered. Our study shows that there are some questions that are more prone for misinterpretation by the patients hence assistance by a clinician may be desirable.
Our study does have some potential causes of bias. We administered the questionnaire on the same day which might have an effect on the results as the patients might have been able to recall their responses in the first questionnaire. The second issue is that we did not stratify our results according to the level of education of the patients included in the study. It is possible that people with a higher education may have a lesser chance of misinterpretation of the questions.
| Conclusion|| |
Our results show that our patients, who do not have English as their primary language, misinterpret the IPSS questionnaire. There are significant differences in the symptom scores when the IPSS is self-administered as compared to the assisted scoring. This problem can lead to errors in interpretation of the symptom severity of patients by the health care providers; may affect the choice of treatment and ultimately, the clinical outcome.
| References|| |
|1.||Paolone DR. Benign prostatic hyperplasia. Clin Geriatr Med 2010;26:223-39. |
|2.||Barry MJ, Fowler FJ Jr, O'Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992;148:1549-57. |
|3.||Netto Júnior NR, de Lima ML. The influence of patient education level on the International Prostatic Symptom Score. J Urol 1995;154:97-9. |
|4.||MacDiarmid SA, Goodson TC, Holmes TM, Martin PR, Doyle RB. An assessment of the comprehension of the American Urological Association Symptom Index. J Urol 1998;159:873-4. |
|5.||American Urological Association Guideline: Management of Benign Prostatic Hyperplasia Revised, 2010. Available from: http://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf (Last accsessed date on 2014 Oct 01). |
|6.||Johnson TV, Goodman M, Master VA. The efficacy of written screening tools in an inner city hospital: literacy based limitations on patient access to appropriate care. J Urol 2007;178:623-9. |
|7.||Johnson TV, Abbasi A, Ehrlich SS, Kleris RS, Schoenberg ED, Owen-Smith A, et al. Patient misunderstanding of the individual questions of the American Urological Association symptom score. J Urol 2008;179:2291-4. |
|8.||Quek KF, Chua CB, Razack AH, Low WY, Loh CS. Construction of the Mandarin version of the International Prostate Symptom Score inventory in assessing lower urinary tract symptoms in a Malaysian population. Int J Urol. 2005;12:39-45. |
|9.||Sagnier PP, Richard F, Botto H, Teillac P, Dreyfus JP, Boyle P. Adaptation and validation in the French language of the International Score of Symptoms of Benign Prostatic Hypertrophy. Prog Urol 1994;4:532-8. |
|10.||Badía X, García-Losa M, Dal-Ré R. Ten-language translation and harmonization of the International Prostate Symptom Score: developing a methodology for multinational clinical trials. Eur Urol 1997;31:129-40. |
|11.||Viera AJ, Garrett JM. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37:360-3. |
|12.||MacDiarmid SA, Goodson TC, Holmes TM, Martin PR, Doyle RB. An assessment of the comprehension of the American Urological Association Symptom Index. J Urol 1998;159:873-4. |
|13.||Ogwuche EI, Dakum NK, Amu CO, Dung ED, Udeh E, Ramyil VM. Problems with administration of international prostate symptom score in a developing community. Ann Afr Med 2013;12:171-3. |
|14.||Johnson TV, Schoenberg ED, Abbasi A, Ehrlich SS, Kleris R, Owen-Smith A, Gunderson K, Master VA. Assessment of the performance of the American Urological Association symptom score in 2 distinct patient populations. J Urol 2009;181:230-7. |
[Table 1], [Table 2]
|This article has been cited by|
| ||Yasin Ceylan,Bulent Gunlusoy,Zafer Kozacioglu |
| ||Urology. 2015; 85(3): 658 |
|[Pubmed] | [DOI]|