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BMC Health Serv Res. 2013 Jan 3;13:1. doi: 10.1186/1472-6963-13-1.

Official statistics and claims data records indicate non-response and recall bias within survey-based estimates of health care utilization in the older population.

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Helmholtz Zentrum M├╝nchen, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Ingolst├Ądter Landstr, 1, Neuherberg, 85764, Germany.



The validity of survey-based health care utilization estimates in the older population has been poorly researched. Owing to data protection legislation and a great number of different health care insurance providers, the assessment of recall and non-response bias is challenging to impossible in many countries. The objective of our study was to compare estimates from a population-based study in older German adults with external secondary data.


We used data from the German KORA-Age study, which included 4,127 people aged 65-94 years. Self-report questions covered the utilization of long-term care services, inpatient services, outpatient services, and pharmaceuticals. We calculated age- and sex-standardized mean utilization rates in each domain and compared them with the corresponding estimates derived from official statistics and independent statutory health insurance data.


The KORA-Age study underestimated the use of long-term care services (-52%), in-hospital days (-21%) and physician visits (-70%). In contrast, the assessment of drug consumption by postal self-report questionnaires yielded similar estimates to the analysis of insurance claims data (-9%).


Survey estimates based on self-report tend to underestimate true health care utilization in the older population. Direct validation studies are needed to disentangle the impact of recall and non-response bias.

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