Appendix 1

Detailed results from second round of RAND Appropriateness Method exercise.

Identifier	Indicator	Overall panel median Consensus
A: Cardiovascular and respiratory disease

A1(a)^a	Prescription of a beta-blockerto a patient with asthma	5	Equivocal
A1(b)^a	Prescription of a non-cardioselective beta-blocker to a patient with asthma	6	Disagreement
A1(c)^a,^b	Prescription of a beta-blockerto a patient with asthma (excluding patients who also have a cardiac condition)	8	Agreement
A2	Prescription of a nitrate to a patient with aortic stenosis	3	Agreement
A3	Prescription of short-acting nifedipine in an older person (>65 years) (excluding patients with Raynaud's disease)	6	Disagreement
A3X^b,^c	Prescription of short-acting nifedipine (excluding patients with Raynaud's disease)	7	Agreement
A4(a)^a	In an older person (>65 years), prescription of digoxin at a dose of >125 μg daily	7	Equivocal
A4(b)^a,^b	In a patient with renal impairment, prescription of digoxin at a dose > 125 μg daily (for example, CKD 3 or worse)	7	Agreement
A5^b	Prescription of digoxin at a dose of > 125 μg daily for a patient with heart failure who is in sinus rhythm	8	Agreement
A6^b	Prescription of diltiazem orverapamil in a patient with heart failure	8	Agreement
A7^b	In an older patient (>65 years), prescription of aspirin at a dose >75 mg daily	7	Agreement
A7X^b,^c	In an older patient (>65 years), prescription of aspirin at a dose >75 mg daily for ≥1 month	8	Agreement
A8	In a patient with heart failure, the prescription of a high-sodium content drug	3	Equivocal
A9(a)^a	In an older patient (>65 years) with an arrhythmia, the prescription of a tricyclic antidepressant	4	Equivocal
A9(b)^a	In an older patient (>65 years) with a cardiac conductive abnormality, the prescription of a tricyclic antidepressant	4	Equivocal
A10	In a patient with a history of gout, the prescription of a thiazide diuretic	3	Agreement
A11^b	The prescription of a long-acting beta-2 agonist inhaler to a patient with asthma who is not also using an inhaled corticosteroid	8	Agreement

B: Central nervous system (including analgesics)

B1(a)^a,^b	Prescription of aspirin to a child aged ≤16 years	9	Agreement
B1(b)^a,^b	Prescription of aspirin to a child aged ≤16 years, where the child does not have Kawasaki's disease	9	Agreement
B2	In a patient with epilepsy, the prescription of a drug that may lower the seizure threshold	3	Agreement
B3(a)^a,^b	In a patient with Parkinson's disease, the prescription of metoclopramide	8	Agreement
B3(b)^a,^b	In a patient with Parkinson's disease, the prescription of prochlorperazine	8	Agreement
B4(a)^a	In an older person (>65 years) the prescription of a benzodiazepine on a long-term basis (that is, >1 month)	4.5	Equivocal
B4(a)X^a,^c	In an older person (>65 years) the prescription of a benzodiazepine or Z-drug on a long-term basis (that is, >1 month)	4.5	Disagreement
B4(b)^a,^b	In an older person (>65 years) who is not receiving benzodiazepines on a long-term basis, the prescription of a benzodiazepine for >21 days	8	Agreement
B4(b)X^a,^b,^c	In an older person (>65 years) who is not receiving benzodiazepines orZ-drugs on a long-term basis, the prescription of a benzodiazepine or Z-drug for>21 days	8	Agreement
B5(a)^a	In an older person (>65 years) with depression, the prescription of a long-term benzodiazepine (that is, >21 days)	5	Disagreement
B5(a)X^c	In an older person (>65 years) with depression, the prescription of a long-term benzodiazepine or Z-drug (that is, >21 days)	6	Disagreement
B5(b)^a	In an older person (>65 years) with depression initiation of benzodiazepine on a long-term basis (that is, >21 days)	8	Equivocal
B5(b)X^a,^b,^c	In an older person (>65 years) with depression initiation of benzodiazepine orZ-drugs on a long-term basis (that is, >21 days)	8	Agreement
B6	In a patient with COPD, the prescription of a benzodiazepine	4	Agreement
B6X^c	In a patient with COPD, the prescription of a benzodiazepine or Z-drug	4	Agreement
B7(a)^a	In an older patient (>65 years) with a history of falls, the prescription of either a benzodiazepine, an antipsychotic, or a tricyclic antidepressant	3	Agreement
B7(a)X^a,^c	In an older patient (>65 years) with a history of falls, the prescription of a benzodiazepine, a Z-drug, an antipsychotic, or a tricyclic antidepressant	3	Agreement
B7(b)^a	In an older patient (>65 years) with a history of falls, the prescription of a benzodiazepine	4	Equivocal
B7(b)X^a,^c	In an older patient (>65 years) with a history of falls, the prescription of a benzodiazepine or Z-drug	4	Equivocal
B7(c)^a	In an older patient (>65 years) with a history of falls, the prescription of an antipsychotic	3.5	Equivocal
B7(d)^a	In an older patient (>65 years) with a history of falls, the prescription of a tricyclic antidepressant	3.5	Equivocal
B8	In an older patient (>65 years) with hyponatraemia/syndrome of inappropriate antidiuretic hormone secretion, the prescription of a selective serotonin reuptake inhibitor	4	Equivocal
B9	In an older person (>65 years) with cognitive impairment, the prescription of an anti-muscarinic drug	3.5	Equivocal
B10	In a patient with angle closure glaucoma, the prescription of an anti-muscarinic drug	4	Equivocal

C: Anti-infective agents

C1	Prescription of a tetracycline to a child aged >12 years	5	Equivocal
C2(a)^a	Prescription of mefloquine to a patient with a history of psychiatric disorder (including depression)	6	Disagreement
C2(b)^a,^b	Prescription of mefloquine to a patient with a history of convulsions	8	Agreement
C2(b)X^a,^c	Prescription of mefloquine to a patient with a history of epilepsy	3	Equivocal
C3	In an older patient (>65 years) long-term prescription of nitrofurantoin (that is, ≥28-day prescription)	6	Disagreement

D: Women's health and urinary disorders

D1^b	Prescription of a combined hormonal contraceptive to a woman with a history of venous or arterial thromboembolism	9	Agreement
D2(a)^a,^b	Prescription of oral ortransdermal oestrogens to a woman with a history of breast cancer	9	Agreement
D2(b)^a	Prescription of a topical (vaginal) oestrogen to a woman with a history of breast cancer	5	Equivocal
D3^b	Prescription of oral ortransdermal oestrogen without progesterone in a woman with an intact uterus	9	Agreement
D4	Prescription of an anti-muscarinic drug to a patient with bladder outflow obstruction	3	Agreement
D5X^a,^b,^c	Prescription of a combined hormonal contraceptive to a woman aged a35 years who is a current smoker	8.5	Agreement
D6X^b,^c	Prescription of a combined hormonal contraceptive to a woman with body mass index of ≥40	8	Agreement

E: Musculoskeletal

E1(a)^a,^b	Prescription of a non-selective NSAID to a patient with a history of peptic ulceration	8	Agreement
E1(a)X^a,^b,^c	Prescription of an NSAID to a patient with a history of peptic ulceration	9	Agreement
E1(b)^a,^b	Prescription of a non-selective NSAID to an older patient (>65 years) with a history of peptic ulceration	8	Agreement
E1(b)X^a,^b,^c	Prescription of an NSAID to an older patient (>65 years) with a history of peptic ulceration	9	Agreement
E1(c)^a,^b	Prescription of a non-selective NSAID, without co-prescription of an ulcer healing drug, to a patient with a history of peptic ulceration	8	Agreement
E1(c)X^a,^b,^c	Prescription of an NSAID, without co-prescription of an ulcer healing drug, to a patient with a history of peptic ulceration	9	Agreement
E2	Prescription of a selective COX-2 inhibitor NSAID to a patient with cardiovascular disease (for example, CHD, cerebrovascular disease, or peripheral arterial disease)	3	Equivocal
E3	In an older patient (>65 years), prescription of an NSAID without co-prescription of an ulcer healing drug (for example, misoprostol or a proton pump inhibitor)	6	Equivocal
E4	In an older patient (>65 years), prescription of a long-term (a28 days) full-dosage, longer half-life non-COX-2-selective NSAID	4	Equivocal
E5^b	In an older patient (>65 years) with heart failure, the prescription of an NSAID	8	Agreement
E5X^b,^c	In a patient with heart failure, the prescription of an NSAID	8	Agreement
E6^b	In an older patient (>65 years) with chronic renal failure, the prescription of an NSAID (for example, CKD 3 or worse)	8	Agreement
E6X^b,^c	In a patient with chronic renal failure, the prescription of an NSAID (for example, CKD 3 or worse)	8.5	Agreement
E7^b	In an older patient (>65 years) prescription of a long-term (>28 days) NSAID (except for ibuprofen ≤1200 mg daily)	7	Agreement

F: Hazardous co-prescriptions, interactions, and allergy

F1	Prescription of warfarin and aspirin in combination, without co-prescription of an ulcer healing drug	6	Disagreement
F2^b	Prescription of warfarin in combination with an oral NSAID	7.5	Agreement
F3^b	Prescription of a phosphodiesterase type-5 inhibitor (for example, sildenaf il) to a patient who is also receiving a nitrate or nicorandil	8	Agreement
F4(a)^a	Prescription of clarithromycin or erythromycin to a patient who is also receiving simvastatin	4.5	Disagreement
F4(b)^a,^b	Prescription of clarithromycin or erythromycin to a patient who is also receiving simvastatin, with no evidence that the patient has been advised to stop the simvastatin while taking the antibiotic	7	Agreement
F5(b)^a,^b	Prescription of a potassium salt or potassium-sparing diuretic (excluding aldosterone antagonists, such as spironolactone) to a patient who is also receiving an ACE inhibitor or angiotensin II receptor antagonist	8	Agreement
F6^b	Prescription of verapamil to a patient who is also receiving a beta-blocker drug	8	Agreement
F7	Prescription of quinine to a patient who is also receiving a cardiac glycoside, for example, digoxin	5	Equivocal
F8	Prescription of ciprofloxacin or norfloxacin to a patient who is also receiving theophylline	5	Agreement
F9^b	Prescription of a penicillin-containing preparation to a patient with a history of allergy to penicillin	8.5	Agreement
F10	Prescription of warfarin and aspirin in combination	6	Equivocal
G: Laboratory test monitoring
G1^b	Prescription of warfarin to a patient without a record of INR having been measured within the previous 12 weeks	7	Agreement
G1X^b,^c	Prescription of warfarin to a patient without a record of INR having been measured within the previous 12 weeks (excluding patients who self monitor)	8	Agreement
G2	Prescription of amiodarone without a record of liver function being measured in the previous 6 months	7	Equivocal
G2X^b,^c	Prescription of amiodarone without a record of liver function being measured in the previous 9 months	8	Agreement
G3	Prescription of amiodarone without a record of thyroid function being measured within the previous 6 months	7	Equivocal
G3X^b,^c	Prescription of amiodarone without a record of thyroid function being measured within the previous 9 months	8	Agreement
G4^b	Prescription of an ACE inhibitor without a record of renal function and electrolytes being measured prior to starting therapy	7.5	Agreement
G4X^b,^c	Prescription of an ACE inhibitor or angiotensin II receptor antagonist without a record of renal function and electrolytes being measured prior to starting therapy	8	Agreement
G5(a)^a	Prescription of lithium without a record of a lithium level being measured within the previous 3 months	6.5	Equivocal
G5(b)^a,^b	Prescription of lithium without a record of a lithium level being measured within the previous 6 months	8	Agreement
G6^b	Prescription of methotrexate without a record of a full blood count within the previous 3 months	8	Agreement
G6X^c	Prescription of methotrexate without a record of a full blood count within the previous 4 months	7	Equivocal
G7^b	Prescription of methotrexate without a record of liver function having been measured within the previous 3 months	8	Agreement
G7X^c	Prescription of methotrexate without a record of liver function having been measured within the previous 4 months	6.5	Equivocal

↵a Indicators ending in letters ‘(a)’, ‘(b)’, (c), or ‘(d)’ are variations in the wording of indicators used in the first round (and repeated in the second round) of the exercise
↵b Indicators highlighted in bold are those rated appropriate for assessing the safety of prescribing of individual GPs for the purposes of revalidation.
↵c Indicators ending in ‘X’ are variations on indicators (or new indicators) suggested by the panel and assessed in the second round only. ACE = angiotensin-converting enzyme. ARB = angiotensin receptor blocker. CHD = coronary heart disease. CKD = chronic kidney disease. COPD = chronic obstructive pulmonary disease. INR = international normalised ratio. NSAID = nonsteroidal anti-inflammatory drug.