Table 2 Origination, panel rating and wording of final agreed indicators
Indicator group | Original indicator wording | Source | Method of development | Revised wording suggested in stage two | Median score | Final revised wording agreed with panel |
|---|---|---|---|---|---|---|
Adherence | Does the patient adhere to his/her medication schedule? | Drenth-van Maanen, 2009 [24] | - Literature based - Research team - Developed by the research team on basis of literature review | Â | 8.5 | The patient adheres to the drug schedule |
Adverse effect | If a [type A/B] drug reaction occurs, there are details given of the reaction and recommended future monitoring in the patient medical record | Tully, 2005 [30] | - Literature based - Nominal Group Technique (NGT) - Domains of appropriate prescribing established using NGT - Indicators based on this and previously published indicators; refined through cyclical operationalisation in UK hospital setting | Â | 9 | If an adverse drug reaction occurs, there are details given of the reaction and recommended future monitoring in the medical record |
Alternatives to current therapy | Non-pharmacological | Lenaerts, 2013 [25] | - Not stated - No details in source of how indicators were developed | Are there non-pharmacological alternatives? | 8.5 | There are no effective non-pharmacological alternatives available |
Clinical response | Is the drug effective for this indication? | Lara, 2012 [26] | - Literature based - Expert panel - Developed from literature review and a two-stage consensus process with panel of 11 multidisciplinary experts | Â | 8.5 | The drug is effective in this patient for this indication |
Interaction | Are there clinically significant drug–drug interactions? | Hanlon, 1992 [14] | - Literature based - Expert review - Developed from literature review; clinical pharmacist and internist-geriatrician identified key elements to derive criteria |  | 9 | There are no clinically significant drug–drug interactions (including duplication of therapy) |
Complexity of medication | Could the drug regimen be simplified? | Newton, 1994 [31] | - Expert panel - Two geriatric internists discussed medications of four elderly patients; further internist recorded implicit rules used - Initial algorithm developed and reviewed by panel of 5 internists; final algorithm tested in a hospital outpatient clinic | Â | 9 | The drug regimen cannot be simplified |
Compliance with guidance | Medication selections are consistent with established clinical practice guidelines | Bergman-Evans, 2006 [27] | - Literature based - Research team - Developed by the research team on basis of literature review/evidence synthesis of previously published indicators | Â | 8 | Drug selection is consistent with established clinical practice |
Adequate directions | Is the patient/caregiver unclear about the medication regimen? | Newton, 1994 [31] | - Expert panel - Two geriatric internists discussed medications of four elderly patients; further internist recorded implicit rules used - Initial algorithm developed and reviewed by panel of five internists; final algorithm tested in a hospital outpatient clinic | Is the patient/caregiver clear about the medication regimen? | 9 | The patient/caregiver is clear about the medication regimen |
Contraindication | If the drug is contraindicated, the prescriber gives a valid reason | Cantrill, 1998 [28] | - Nominal group technique - Delphi survey - NGT (panel of nine multidisciplinary experts) convened to derive potential indicators - Two-round Delphi (100 GPs and 100 community pharmacists) used to assess face validity and content validity and develop consensus | Â | 8 | If the drug is contraindicated, the prescriber gives a valid reason |
Indication available | The indication for the drug is recorded in the discharge summary | Tully, 2005 [30] | - Literature based - NGT - Domains of appropriate prescribing established using NGT - Indicators based on this and previously published indicators; refined through cyclical operationalisation in UK hospital setting | Â | 8.5 | The indication for the drug is recorded in the medical record |
Review | The drug treatment is reviewed by an appropriate clinician at least once per year in accordance with best clinical practice | NEW | - Expert panel - Proposed by expert panel during stage 2 discussions | Â | 9 | The drug treatment is reviewed by an appropriate clinician at least once per year, or more frequently if in accordance with best clinical practice |
Dose/route/formulation/frequency | Is the drug as currently given likely to be sub-therapeutic or toxic, based on the dose, route and dosing interval for the age and renal status of the patient? | Hamdy, 1995 [29] | - Research team - Developed by the research team, based on guidelines from drug-regimen review criteria used by consultant pharmacists | Â | 8 | The drug as currently prescribed is not likely to be sub-therapeutic or toxic, based on the dose, route and dosing interval for the age, renal and hepatic status of the patient |