Reliability of the recording of hysterectomy in the Saskatchewan health care system

Objective To determine the validity of data pertaining to hysterectomy in the Saskatchewan health care utilisation datafiles. Design Retrospective analysis of routinely collected data covering hospital discharge records and practitioner claims for reimbursement of services, together with a review of clinical charts. Setting Province of Saskatchewan, Canada. Sample All 1905 cases of hysterectomy in one calendar year for analysis of datafiles and a random sample of 227 clinical charts for review. Method Information in the hospitalisation datafile was validated through an external comparison with data extracted from a review of clinical charts, as well as an internal comparison with independent data from the practitioner claims file. Corresponding context data on drug use and performance of related procedures were also analysed. Results Concordance between hospital data and clinical charts was greater than 95% for those items of an administrative nature as well as type of hysterectomy and was around 85% for the diagnoses. When hospitalisation and practitioner claims data were compared, the concordance was 98% for type of hysterectomy but only 56% for diagnoses. Conclusions The agreement between hospital data and clinical charts was excellent. The concordance between hospitalisation and practitioner claims data was almost exact for type of hysterectomy, while discrepancies in diagnoses between these files were mostly explainable on the basis of accepted clinical practice. Saskatchewan health care utilisation datafiles provide a source of valid data for research and evaluation studies.