Given the wide usage of the BSFS but lack of assessment of its reproducibility, we initiated evaluation of the reliability and agreement of the BSFS when used to determine stool form by experts. The BSFS was adopted by the Rome III committee for use in categorizing IBS into one of four subtypes based on the propensity toward constipation, diarrhea or presence of both.( 9) Subsequently, children with IBS have been categorized using the same criteria.( 10, 11), and clinical trials use the BSFS to determine eligibility and evaluate outcomes. Scale reproducibility, which includes both reliability and agreement, is an important measure of any scale, particularly when measuring diagnostic criteria and to determine eligibility for therapeutic trials. It was validated as a measure of intestinal transit but not yet as a reproducible measure of stool form amongst raters.( 1) Despite this, it has been used to assess stool form in several gastrointestinal disorders including irritable bowel syndrome (IBS) and Crohn’s disease.( 2– 8) The Bristol Stool Form Scale (BSFS), a frequently used measure in gastroenterology practice and research, categorizes stools into one of seven stool types ranging from type 1 (hard lumps) to type 7 (watery diarrhea). Inter-rater and intra-rater reliability of the BSFS by Rome III clinical categorization decreased with intraclass correlations of 0.75 (95% CI: 0.69 – 0.81, P<0.001) and 0.65 (95% CI: 0.49 – 0.81, P<0.001) respectively. type 6 stools, representing the boundaries of normal vs. These 13 photographs were rated by the majority of raters as either type 2 vs. However, agreement decreased when using Rome III designations, with 13 (37%) photographs having significantly diverging classifications (semi-interquartile range=0.5).
Inter-rater and intra-rater reliability of the BSFS by individual stool type was excellent with intraclass correlations of 0.88 (95% CI: 0.86–0.90), P<0.001) and 0.89 (95% CI: 0.86–0.91, P<0.001) respectively. Though only 4 photographs had absolute agreement (all Type 1 or Type 7), general agreement was high with 1132 (95.1%) of ratings being within one category type of the modal rating. 1190 individual stool type ratings were completed.
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