J Clin Epidemiol Vol. 51, No. 3, pp. 237–244, 1998 0895-4356/98/$19.00 Copyright  1998 Elsevier Science Inc. All rights reserved. PII S0895-4356(97)00281-3 Agreement between Medical Record Data and Patients’ Accounts of Their Medical History and Treatment for Dyspepsia Johanna I. Westbrook, 1,* Jean H. McIntosh, 1 R. Louise Rushworth, 2 Geoffrey Berry, 3 and John M. Duggan 4 1 School of Health Information Management, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia; 2 Department of Public Health, University of Western Sydney, Sydney, New South Wales, Australia; 3 Department of Public Health and Community Medicine, University of Sydney, Sydney, New South Wales, Australia; and 4 Princeton Medical Centre, Newcastle, New South Wales, Australia ABSTRACT. We examined agreement between data abstracted from medical records and interview data for patients with dyspepsia admitted to hospital for endoscopy, to determine the extent to which health records could be used to validate self-reports of dyspepsia and the management of this condition. Results from the sample of 220 patients showed that there was poor agreement between data sources for information about duration of dyspepsia (k = 0.34) and previous barium meal examination (k = 0.34). Patients reported significantly longer dyspepsia histories (Wilcoxon sign test Z = 4.13, p  0.0001) and significantly more barium meals (sign test Z = 8.43, p  0.0001) than were documented in their records. There was also disagreement between data sources regarding the number of drugs taken before and after endoscopy (k = 0.28 and k = 0.31, respectively). Where there was disagreement for number of drugs there was no significant difference in the direction of the disagree- ment. There was moderate agreement regarding the name of pre-endoscopy medication (k = 0.55) and substan- tial agreement for the name of medication used post-endoscopy (k = 0.62). There was very poor agreement regarding diagnosis. The medical record was the gold standard for this information. Choice of data source, medical records or self-reports, will in many instances provide significantly different results and it is likely that this may also be true for other variables of interest to researchers. Thus in the case where no gold standards are available researchers need to consider carefully the implication of choice of data source on their results. j clin epidemiol 51;3:237–244, 1998.  1998 Elsevier Science Inc. KEY WORDS. Medical records, dyspepsia, interview, recall bias, validity, endoscopy INTRODUCTION (the propensity of cases to recall more complete reports of exposure compared to controls) and problems with memory Investigators of chronic conditions often rely solely upon recall. However there is considerable debate as to the degree self-reports of illness provided by patients either at inter- to which these factors affect data accuracy [1–7]. view or through their responses to questionnaires. One of Some attempts have been made to assess the validity of the reasons that epidemiologists commonly adopt this ap- such self-reports by examining the level of agreement be- proach is that people with chronic conditions often consult tween information documented in hospital and general multiple health care providers over the duration of their practice medical records and information provided by pa- illness and thus have health records held by several health tients during interview or to mailed questionnaires [8–12]. care providers and organizations. Poor linkage between Such studies have demonstrated that these data sources of- these health records and issues of ownership of, and access ten disagree and it is clear that hospital records cannot al- to, privately held records make their accessibility for epide- ways be viewed as the gold standard against which to evalu- miologic studies extremely difficult. Self-reports of health ate self-reported data. Health records have been found to and illness often give rise to concerns relating to recall bias have limitations such as incompleteness and poor quality (including illegibility or inaccuracy) [8,13]. The importance * Address for correspondence: Johanna Westbrook, Faculty of Health Sci- however of such comparative studies is that they provide ences, The University of Sydney, P.O. Box 170, Lidcombe, NSW, Austra- researchers with an indication of which data sources are lia 2141. Accepted for publication on 4 November 1997. most suitable for answering specific research questions.