BACKGROUND: Health literacy (HL) and numeracy are measured by one of two methods: performance on objective tests or self-report of one's skills. Whether results from these methods differ in their relationship to health outcomes or use of health services is unknown. METHODS: We performed a systematic review to identify and evaluate articles that measured both performancebased and self-reported HL or numeracy and examined their relationship to health outcomes or health service use. To identify studies, we started with an AHRQfunded systematic review of HL and health outcomes. We then looked for newer studies by searching MEDLINE from 1 February 2010 to 9 December 2014. We included English language studies meeting pre-specified criteria. Two reviewers independently assessed abstracts and studies for inclusion and graded study quality. One reviewer abstracted information from included studies while a second checked content for accuracy. RESULTS: We identified four Bfair^quality studies that met inclusion criteria for our review. Two studies measuring HL found no differences between performance-based and self-reported HL for association with self-reported outcomes (including diabetes, stroke, hypertension) or a physician-completed rheumatoid arthritis disease activity score. However, HL measures were differentially related to a patientcompleted health assessment questionnaire and to a patient's ability to interpret their prescription medication name and dose from a medication bottle. Only one study measured numeracy and found no difference between performance-based and self-reported measures of numeracy and colorectal cancer (CRC) screening utilization. However, in a moderator analysis from the same study, performance-based and self-reported numeracy were differentially related to CRC screening utilization when stratified by certain patient-provider communication behaviors (e.g., the chance to always ask questions and get the support that is needed). DISCUSSION: Most studies found no difference in the relationship between results of performance-based and self-reported measures and outcomes. However, we identified few studies using multiple instruments and/or objective outcomes.

Measuring health literacy efficiently yet accurately is of interest both clinically and in research. The authors examined 6 brief health literacy measures and compared their categorization of patient health literacy levels and their comparative associations with patients' health status. The authors assessed 400 emergency department patients with the Short Test of Functional Health Literacy in Adults, the Newest Vital Sign, Single Item Literacy Screen, brief screening questions, Rapid Estimate of Adult Literacy in Medicine-Revised, and the Medical Term Recognition Test. The authors analyzed data using Spearman's correlation coefficients and ran separate logistic regressions for each instrument for patient self-reported health status. Tests differed in the proportion of patients' skills classified as adequate, but all instruments were significantly correlated; instruments targeting similar skills were more strongly correlated. Scoring poorly on any instrument was significantly associated with worse health status after adjusting for age, sex and race, with a score in the combined inadequate/marginal category on the Short Test of Functional Health Literacy in Adults carrying the largest risk (OR = 2.94, 95% CI [1.23, 7.05]). Future research will need to further elaborate instrument differences in predicting different outcomes.

In this cross-sectional ED study, drug allergies and ADRs were both highly prevalent. There were significant discrepancies in documentation of allergies and ADRs between patient self-report and the EMR.

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