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Table 2 Origination, panel rating and wording of final agreed indicators

From: Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study

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
  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
  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
  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
  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
  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
  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
  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
  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
  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