Accurately ascertaining risk for subarachnoid hemorrhage (SAH) is critical to making appropriate diagnostic decisions. Risk is often based on response to the question “Is this the worst headache of your life?” We sought to determine whether the manner and order in which historical questions are asked significantly alter the response.
Methods Adult patients complaining of headache in the ER were presented with one of two questionnaires each containing a series of five questions, two pertinent and three distracters. The two pertinent questions were “Is this the worst headache of your life?” and “When was the last time you had a headache this bad?” The two versions varied in regards to the order in which the questions were asked. Version 1 first asked “Is this the worst headache of you life?” while version 2 reversed the order by first asking “When was the last time you had headache this bad?” A population of 120 was determined to be adequate to achieve 80% power and detect a difference of 20 to 25%. Data were analyzed to determine (1) what percentage of patients answer these questions concordantly and (2) whether the order in which the questions are asked influences the outcome, in this case the rate of concordance. To correct for the element of chance responsible for a certain degree of concordance we utilized a kappa (K) statistic.
Results For research question 1 the percentages of patients who answered the questions concordantly were 60% and 75% respectively for version 1 and version 2. For research question 2 the agreement corrected for chance for version 2, _ = 0.51, is higher than the agreement corrected for chance for version 1, _ = 0.28, a difference of 0.23 with a 95% CI (-0.03, 0.49; p = .08; SE = 0.13). Comparing percentages, 75% vs 60%, produces a difference of 15% with a 95% CI of (-2%, 32%; p = .08).
Conclusion Asking patients “Is this the worst headache of your life?” does not provide the clinical information most clinicians assume it does and is not sufficient justification to do a work-up for SAH. Knowing the patient has had a similar headache in the past could be an essential component of the history and aid in preventing invasive and costly procedures. Our study indicates that up 38% answer these two very similar questions discordantly. Also, there appears to be a higher degree of concordance (15%) when patients are first asked “When was the last time you had a headache this bad?” These data raise the question of whether the wording of these two questions plays a statistically significant role, in addition to order in which they are asked.
Supported by University of New Mexico (UNM) School of Medicine.
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