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Importance: In Medicare Advantage (MA), step therapy for physician-administered drugs is an approach to lowering drug spending. The impact of step therapy in MA on prescribing behavior and the magnitude of any changes has not been analyzed., Objective: To evaluate the impact of step therapy on macular degeneration drug prescribing patterns for 3 large MA insurers., Design, Setting, and Participants: This was a retrospective encounter-based analysis using 20% nationally representative MA outpatient and carrier encounter records for 2017 to 2019. Participants were MA beneficiaries who were 65 years or older and had received a macular degeneration drug administration. Macular degeneration drug administrations for beneficiaries of MA Aetna, Humana, and UnitedHealthcare (UHC) insurers were assessed. Humana implemented macular degeneration step therapy in 2019, setting bevacizumab as the plan-preferred drug, and aflibercept and ranibizumab as the plan-nonpreferred drugs. Aetna and UHC, which did not implement macular degeneration step therapy, served as the control group. Data analyses were performed from May 2024 to December 2024., Exposures: A macular degeneration drug administration subject to a step therapy policy., Main Outcome and Measures: A binary indicator of whether the drug administered was bevacizumab. Linear probability models and a difference-in-differences framework were used to quantify changes in prescribing patterns before and after the introduction of step therapy for MA insurers that did and did not implement step therapy. To empirically measure the impact of step therapy, the first administration of a treatment episode was assessed, followed by switching patterns., Results: A total of 18 331 MA beneficiaries, 21 683 treatment episodes, and 171 985 drug administrations were included across the control and treatment groups. The difference-in-differences regressions found a 7.8% (95% CI, 4.9%-10.7%; P < .001) greater probability of being prescribed bevacizumab for the first administration due to step therapy. The predicted probabilities of preferred-drug administration in the treatment group increased from 0.61 to 0.70 between the periods before and after step therapy implementation for the first administration. Step therapy was not significantly associated with an increased rate of medication switching (hazard ratio, 0.86; 95% CI, 0.71-1.06; P = .15)., Conclusions and Relevance: The findings of this retrospective encounter-based analysis indicate that step therapy is associated with a greater probability of prescribing the plan-preferred drug for the first administration. The analysis failed to find a statistically significant greater rate of medication switching within a treatment episode. Step therapy changed macular degeneration prescribing patterns, but step therapy alone did not transition all administrations to the plan-preferred drug.

Purpose: To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population., Design: Retrospective, longitudinal study., Participants: Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery., Methods: Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis., Main Outcome Measures: The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery., Results: There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n = 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3-1.7), 1.1 (95% CI, 1.0-1.2), and 0.8 (95% CI, 0.8-0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P = 0.002) and combined surgery (aOR 1.8, P = 0.047). The other risk factor for both stand-alone (aOR 1.1, P = 0.001) and combined (aOR 1.06, P = 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P = 0.004) and male gender (1.46, P = 0.001) were significant risk factors for combined cataract and glaucoma surgeries., Conclusions: Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: The Consortium of Student-Led Eye Clinics (CSLEC), founded in 2021, administered a comprehensive survey to document the types of services, most common diagnoses, and follow-up care protocols offered by student-led free vision screening programs (SLFVSP) in the United States., Methods: An 81-question institutional review board (IRB)-approved survey was administered to student-led vision screening eye clinics from October 1, 2022 to February 24, 2023., Results: Sixteen SLFVSPs were included in the final analysis, of which 81% (n = 13) conducted variations of fundoscopic examinations and 75% (n = 12) measured intraocular pressure. Cataracts and diabetic retinopathy were reported as the most frequent diagnoses by the majority of SLFVSPs (n = 9, 56%); non-mobile SLFVSPs more commonly reported cataract as a frequent diagnosis (P < 0.05). Most patients screened at participating programs were uninsured or met federal poverty guidelines. Prescription glasses were offered by 56% of the programs (n = 9). SLFVSPs that directly scheduled follow-up appointments reported higher attendance rates (66.5%) than those that only sent referrals (20%). Transportation was the most cited barrier for follow-up appointment attendance., Conclusions: SLFVSPs, one community vision screening initiative subtype, vary significantly in scope and capabilities of identifying vision threatening disease. The follow-up infrastructure is not uniformly robust and represents a key target for improving care delivery to at-risk populations., Translational Relevance: The CSLEC aims to develop a consensus-based standardization for the scope of screening services, offer guidelines for diagnostic criteria, promote real-time data stewardship, and identify means to improve follow-up care mechanisms in member communities.

This document discusses preprocedural planning for transcatheter aortic valve replacement, evaluating the imaging modalities used in initial imaging for preprocedure planning under two variants 1) Preintervention planning for transcatheter aortic valve replacement: assessment of aortic root; and 2) Preintervention planning for transcatheter aortic valve replacement: assessment of supravalvular aorta and vascular access. US echocardiography transesophageal, MRI heart function and morphology without and with IV contrast, MRI heart function and morphology without IV contrast and CT heart function and morphology with IV contrast are usually appropriate for assessment of aortic root. CTA chest with IV contrast, CTA abdomen and pelvis with IV contrast, CTA chest abdomen pelvis with IV contrast are usually appropriate for assessment of supravalvular aorta and vascular access. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Importance: Reported transfers of value (TOV) from pharmaceutical companies have been associated with greater use of branded anti-vascular endothelial growth factor agents by ophthalmologists, but payment under the Medicare Part B buy-and-bill model includes a financial incentive to choose costlier agents, potentially confounding analyses of pharmaceutical TOV and prescribing patterns. How these reported TOV are associated with prescribing patterns for prescription eye drops, not subject to the incentives created by Part B payments, should be considered., Objective: To assess the association between prostaglandin analog (PGA) eye drop prescribing and reported nonresearch TOV by makers of branded PGAs to US vision care professionals., Design, Setting, and Participants: This retrospective cohort analysis used a 20% nationally representative sample of 2018 Medicare Part D claims and industry TOV reported to the Open Payments program. Optometrists and ophthalmologists who had more than 10 claims for PGA drops in the 20% sample were analyzed. Analysis took place from June 2021 to February 2022., Main Outcomes and Measures: Multivariable logistic regression assessing the association between membership in strata of reported TOV and branded PGA prescribing rate, controlling for prescriber demographic factors, local area practices, total PGA prescribing volume, and plan formularies involved., Results: A total of 20 612 ophthalmologists and 5426 optometrists (7449 [29%] female and 18 589 [71%] male) prescribed PGA eye drops. Of these, 9685 (37%) were reported to have received TOV from manufacturers of branded PGAs in 2018, totaling $5 060 346. The median (IQR) reported TOV was $65 ($24-$147). Multivariable logistic regression showed that the predicted probability of primarily prescribing branded PGAs among prescribers who reported receiving no TOV was 12.9% (95% CI, 12.4%-13.4%). This figure increased to 19.6% (95% CI, 18.8%-20.4%) among prescribers receiving TOV, a 50% increase. There was a dose-response association, such that the top 10% of TOV recipients had a 29.2% probability (95% CI, 26.4%-31.9%) of preferential branded use., Conclusions and Relevance: While the median reported TOV to a PGA prescriber was relatively low in this study, there was a positive association between amount of reported nonresearch TOV received from PGA makers and the frequency of branded PGA use. This shows that small reported TOV were associated with differences in prescribing. High rates of branded PGA prescribing may pose a cost burden to patients that affects adherence. Clinicians and policy makers should be aware of these associations.

Prcis: Of 611 individuals seen at referral clinic visits following community screenings, 76% were diagnosed with ≤1 eye condition needing treatment, generating a total of $213,110 in collections for the institution over 2.5 years., Purpose: The purpose of this study was to examine the outcomes and revenue generation of community-based eye screenings., Materials and Methods: Individuals aged 50 years and above screened at community sites in Baltimore, MD, with abnormal ophthalmic findings were referred for one free-of-charge definitive eye examination at the Wilmer Eye Institute. Diagnoses, treatment, and billing information were abstracted from electronic medical records of patients subsequently seen at Wilmer from January 1, 2016, to July 31, 2018., Results: A total of 611 individuals attended 3696 encounters at Wilmer during this time period. Most patients were female (60.3%) and African American (83.7%). At the screening event, 82.9% reported difficulty seeing when not wearing corrective eyewear, although only 49.8% reported having visited an eye doctor within the last 2 years. The majority (60.2%) reported having Medicare/Medicaid coverage, and 8.1% reported being uninsured. At the definitive eye examination after the screening, 75.5% of patients were diagnosed with ≥1 eye condition, most commonly cataract (30.3%), suspicion of glaucoma (24.9%), manifest glaucoma (11.9%), diabetic retinopathy (5.4%), and ocular hypertension (2.6%). Overall, 430 (70.4%) individuals required treatment including surgery (n=106), intravitreal injections (n=14), laser procedures (n=9), and medications (n=48). A total of $213,110 was collected for visits and procedures after the initial referral visit during the study period., Conclusions: A large community-based vision screening program in Baltimore was able to identify ocular conditions requiring treatment in underserved older adults and connect them to eyecare. Our findings also highlight that this model simultaneously generates new revenue streams for the institution organizing the community screenings., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe trends in the glaucoma fellowship match results, glaucoma applicant characteristics, and applicant characteristics associated with matching., Design: Retrospective study., Participants: Ophthalmology fellowship applicants participating in the San Francisco (SF) Match between 2010 and 2017., Methods: De-identified, individual applicant data provided by the San Francisco (SF) Match were used to describe glaucoma fellowship match trends and applicant characteristics between 2010 and 2017. Publicly available, conglomerate SF Match data were used to determine trends in the number of programs participating in the glaucoma fellowship match, as well as the number of positions offered and filled from 2014 to 2019. All trends analyses were performed using linear regression models on log-transformed response variables. Summary statistics for applicants who matched in glaucoma were compared with those who did not match. A multivariable logistic regression model was used to evaluate factors associated with matching in glaucoma fellowship., Main Outcome Measures: Fellowship match status (matched in glaucoma vs. did not match in any ophthalmology subspecialty)., Results: From 2010 to 2019, the number of matched glaucoma fellowship applicants increased from 54 to 77 (mean 3.3% per year, P = 0.001), and the proportion of applicants to any ophthalmology fellowship who matched in glaucoma increased from 13% to 15.5% (mean, 3% per year; P = 0.041). Compared with applicants who did not match in any specialty between 2010 and 2017, matched glaucoma applicants were more likely to have graduated from a top 10 residency program (10.7% vs. 4.5%, P < 0.001), U.S. medical school (93.1% vs. 39.1%, P < 0.001), or U.S. residency program (95.0% vs. 42.2%, P < 0.001), and complete more interviews (9 vs. 1, P < 0.001). After controlling for potential covariates, factors associated with increased odds of matching in glaucoma included graduating from a U.S. residency program (odds ratio [OR], 9.91; 95% confidence interval [CI], 5.45-18.03), applying to fewer programs (OR, 0.91; 95% CI, 0.88-0.93), and completing a greater number of interviews (OR, 1.49; CI, 1.39-1.60). United States Medical Licensing Examination (USMLE) Step scores were not associated with matching in glaucoma., Conclusions: The number of applicants who matched in glaucoma fellowship increased from 2010 to 2019. Factors associated with matching in glaucoma were graduating from a U.S. residency program and completing more interviews., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Coronary atherosclerotic disease is a leading cause of mortality and morbidity due to major cardiovascular events in the United States and abroad. Risk stratification and early preventive measures can reduce major cardiovascular events given the long latent asymptomatic period. Imaging tests can detect subclinical coronary atherosclerosis and aid initiation of targeted preventative efforts based on patient risk. A summary of available imaging tests for low-, intermediate-, and high-risk asymptomatic patients is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2021. Published by Elsevier Inc.)

Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Introduction: Due to the scrotum's multiple layers of different tissues, scrotal cancer can present with several unique histologies. Historically, outcome arising from these different sources has been historically aggregated together. However, it remains unclear whether survival differs by histology of scrotal cancer., Methods: We queried the seventeen registries of the Surveillance, Epidemiology, and End Results database for patients diagnosed with primary scrotal cancer from 1973 to 2006. Patients were initially grouped by the following histologies: basal cell carcinoma, Extramammary Paget's Disease (EMPD), sarcoma, melanoma, squamous cell carcinoma, and adnexal skin tumors. For some analyses, the former three histologies were reclassified as Low-Risk scrotal cancer and the latter three histologies as High-Risk scrotal cancer. Kaplan-Meier survival analyses were conducted to assess the impact of histology on overall survival (OS)., Results: The cohort consisted of 766 patients. Median (95% CI) OSs by histologies were basal cell carcinoma--143 (116-180), EMPD--165 (139-190), sarcoma--180 (141-219), melanoma--136 (70-203), squamous cell carcinoma--115 (97-133), and adnexal skin tumors--114 (55-174). Patients with Low-Risk scrotal cancer experienced a median (95% CI) OS of 166 (145-188) months, while patients with High-Risk scrotal cancer experienced a median (95% CI) OS of 118 (101-135) months., Conclusions: Survival of scrotal cancer depends on tumor histology. Classification of histologies into Low and High Risk can be clinically useful for counseling and clinical decisions.

Objective: A diagnosis of cancer can provoke painful emotional reactions and possibly suicidal thoughts in a patient. Consequently, cancer patients carry a twofold increased lifetime risk of suicide. This risk is much higher within 1 year of diagnosis. However, it remains largely unknown whether suicide frequency remains constant within the first year. Therefore, we sought to characterize the distribution of suicides in order to potentially identify a clinically important window of peak suicide risk., Methods: We queried the Surveillance, Epidemiology, and End Results (SEER) database for cancer patients 20 + years old with diagnosed with a single malignancy from 1973 to 2005 and known cause of death, including whether a patient committed suicide. Initial frequency analysis was performed to identify the period of maximum suicide risk. One-way ANOVA was performed to assess the relationship between year of diagnosis and suicide completions within 1 month of diagnosis., Results: The cohort consisted of 3,678,868 patients. Of the total cohort, 0.2% (5875 patients) committed suicide, 36% (2111 patients) within 1 year of diagnosis. One in three (701 of the patients) who committed suicide in the first year did so within 1 month of diagnosis. No change in this distribution occurred over time., Conclusions: Cancer patients carry an increased risk of suicide. However, this risk peaks with the month following diagnosis. Clinicians should be aware of this increased risk and include assessments of mood state and suicidality at the time of initial diagnosis of the malignancy and be prepared to provide referral to mental health treatment providers., (Copyright © 2011 John Wiley & Sons, Ltd.)

Testis cancer-specific survival (CSS) varies by Hispanic ethnicity. Our goal was to assess whether neighborhood socioeconomic status (SES) accounts for elevated testis CSS among Hispanic patients. We queried the Surveillance, Epidemiology, and End Results (SEER) database for Hispanic (HW) and Non-Hispanic white (NHW) patients. Multivariate Cox regression analyses evaluated Hispanic ethnicity's impact on tCSS while adjusting for neighborhood socioeconomic status (education and income levels). HWs constituted 14.3% of the 26,258 patients in the cohort. Neighborhood SES factors such as county income (P < 0.001) and education level (P < 0.001) were significant predictors of testis cancer-specific survival (tCSS). Controlling for SES and other variables, Hispanic ethnicity remained a significant predictor of tCSS. Compared to NHWs, HWs experienced a 41% greater cancer-specific mortality (HR: 1.406, 95% CI: 1.178-1.678, P < 0.001). The mechanism underlying the increased testis cancer mortality experienced by Hispanic patients remains unknown.

Objectives: To hypothesize that numeracy may also predict patient misunderstanding of the American Urological Association symptom score (AUA-SS). Health literacy consists of document and prose literacy, both considered "traditional" literacy. But, health literacy also comprises quantitative literacy or numeracy. We previously reported that document literacy independently predicts misunderstanding of the AUA-SS. However, the AUA-SS consists of written and numeric information., Methods: Prospective cohort study of male patients who completed a validated, 3-question numeracy test once and the AUA-SS twice, which were self-administered and then interviewer-assisted. These 2 responses were compared with assessed patient understanding of the AUA-SS. Multivariate logistic regression analyses examined the association between patient characteristics and poor understanding of the symptom score, defined as understanding fewer than half of the questions, by calculating the odds ratios and corresponding 95% confidence intervals., Results: A total of 571 patients completed the study, with an average age and education level of 58 and 13.5 years, respectively. On the numeracy test, 16%, 18%, 35%, and 31% correctly answered 3, 2, 1, and 0 questions, respectively. After adjusting for the highest educational level completed, written literacy, and demographics, completely innumerate respondents (score = 0 points) were more than 3 times as likely (odds ratio = 3.55; 95% confidence interval: 1.58-7.99; P = .002) to misrepresent their AUA-SS compared with those who had some numeracy (1-3 points)., Conclusions: Regardless of educational or literacy status, a significant number of patients self-report AUA-SS scores that are different from interviewer-assisted scores, which may severely limit their access to appropriate care., (2010 Elsevier Inc. All rights reserved.)

Purpose: Low health literacy is a significant problem in the United States. At the same time written screening tools such as the American Urological Association symptom score are used more frequently at hospitals and clinics. We previously reported that many patients do not fully understand this tool and often provide inaccurate information. To combat this problem we developed a novel multimedia version of the American Urological Association symptom score., Materials and Methods: In this randomized, controlled trial we divided 232 patients into a control arm that self-administered the traditional written version of the symptom score and an experimental arm that self-administered the new multimedia version. Patients in each arm were later administered the tool a second time by an interviewer for comparison. Using multivariate analysis we measured disagreement between the self-administered and interviewer administered scores, and compared the 2 arms., Results: Patients assigned the written and the multimedia version showed an average error of 3.48 and 1.97, respectively (p <0.001), for a 43% decrease. Improvement was noted regardless of patient literacy. Errors by patients with low and high literacy decreased from 4.55 to 2.24 and 3.10 to 1.86 (p = 0.03 and <0.001, respectively)., Conclusions: As a model, the American Urological Association symptom score multimedia version represents an exciting opportunity to improve many other written screening tools since it increased understanding and decreased scoring errors across all literacy levels, possibly allowing physicians to treat patients more effectively.

Purpose: Recent research suggests that low education and illiteracy may drive misunderstanding of the American Urological Association Symptom Score, a key tool in the American Urological Association benign prostatic hyperplasia guidelines. It is unclear whether misunderstanding is confined to patients of low socioeconomic status. Therefore, we reevaluated the prevalence and impact of this misunderstanding in a county vs university hospital population., Materials and Methods: This prospective study involved 407 patients from a county hospital and a university hospital who completed the American Urological Association Symptom Score as self-administered and then as interviewer administered. Responses were compared by calculating correlation coefficients and weighted kappa statistics to assess patient understanding of the American Urological Association Symptom Score. Multivariate logistic regression analyses were used to examine the association between patient characteristics and poor understanding of the American Urological Association Symptom Score., Results: Of the patients 72% understood all 7 American Urological Association Symptom Score questions. Of the measured demographic variables only education level significantly affected this understanding. Compared to patients with more than 12 years of education county hospital patients with less than 9 years of education were 57.06 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 14.32-329.34) while university hospital patients with less than 9 years of education were 38.27 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 1.69-867.83). Of county hospital patients 31% and of university hospital patients 21% significantly misrepresented their symptom severity according to current guidelines., Conclusions: Patients with low education regardless of location are more likely to misunderstand the American Urological Association Symptom Score, misrepresent their symptoms and, therefore, receive inappropriate treatment.