Sources of the reviewed prescribing indicators
| Source | Indicators reviewed (n) | Indicators from each source included in round one of consensus processa (n) | Source details | Relevance to prescribing-safety indicators for revalidation |
|---|---|---|---|---|
| Assessing Care of Vulnerable Elders (ACOVE)11,12 | 217 | 2 | This RAND project11 developed a set of evidence-based, quality-of-care indicators relevant to vulnerable older people using systematic literature reviews, expert opinion, and guidance from expert groups and stakeholders. The indicators have been considered for use in the UK12 | Many of these indicators relate to process measures and the care of patients with long-term conditions, ratherthan to prescribing decisions that could easily be attributed to one GP |
| Beers criteria13 | 89 | 20 | A set of criteria from the US for assessing potentially inappropriate medication use in people aged ≥65 years. The original list of criteria were published in the 1990s and updated in 200313 | These provided the greatest number of potentialindicators, but some of the Beers criteria relate either to drugs not commonly used in the UK or issues that were felt not of high clinical importance |
| British National Formulary(BNF)14 | N/A | 4 | Four of the indicators came only from the BNF, which was also used to check the validity of many of the other potential indicators | N/A |
| Draft design specification for NHS IT systems aimed at minimising risk of harm from medications15 | N/A | 2 | This report included a comprehensive literature review on risks of harm from medications in primary care and provides examples of hazardous prescribing | N/A |
| Medication Appropriateness Index9 | N/A | N/A | A method for assessing the appropriateness of medication based on a range of factors such as indication, evidence for effectiveness, and directions and absence of important contraindications. It lends itself best to detailed analysis of prescribing based on clinical judgement, rather than interrogation of electronic medical records | Specific indicators not included |
| National Patient Safety Agency (NPSA) documents16-18 | N/A | N/A | The NPSA16 has produced a number of documents that are relevant to the safety of prescribing in primary care.17 For example, the fourth report from the Patient Safety Observatory18 highlighted medication incidents in the community and at the interface between community and hospital care, as well as suggesting ways in which risks of harm could be reduced. The NPSA has highlighted a number of specific safety issues relevant to primary care, including anticoagulant prescribing, dosing errors with opioid medicines, and the prescribing of methotrexate17 | Information from NPSA documents used to help inform the prescribing-safety indicators project |
| The National Service Framework for Older People(NSF)19 and Medicines for Older People: Implementing Medicines-Related Aspects of the NSF for Older People20 | N/A | N/A | These documents raise important issues regarding medicines used in older people | Specific indicators for assessing the quality and safety of prescribing are not explicitly suggested, although many of the issues raised are covered in the approaches taken by Assessing Care of Vulnerable Elders and Beers criteria |
| PINCER trial indicators21 | 11 | 6 | A cluster randomised trial took place in the UK between 2005 and 2009 to assess a pharmacistled intervention versus simple feedback in correcting clinically important problems in medicines management in general practices in England. The outcome measures for the trial represent important examples of hazardous prescribing, inadequate monitoring, and potentially hazardous dosage instructions21 | Most of these indicators were considered relevant |
| Preventable drug-related morbidity22 indicators | 29 | 4 | Based on identifying preventable morbidity associated with drug use. The University of Manchester has adapted US indicators for use in the UK and, along with the University of Nottingham, has successfully used these indicators of electronic health records in general practices in England22 | These indicators focus on a preventable morbidity associated with drug use, but from this information it would be difficult using electronic searches to identify which doctor(s) were responsible for the prescribing (or monitoring failures) that led to the preventable morbidity |
| Quality and Outcomes Framework (QOF)23 | 8 | 0 | The QOF contains a number of prescribing- related indicators. Most of these relate to the need to prescribe a particular drug for a particular clinical condition. There are also more general indicators of prescribing, including the need to undertake medication reviews | Indicators relate to the need to prescribe a particular drug fora particular clinical condition, which is considered outside the scope of the current exercise. The more general indicators of prescribing, such as the need to undertake medication reviews, cannot easily be applied to the prescribing of an individual GP in a group practice or assessed through interrogation of the electronic health record |
| Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START)24 | 65 | 27 | These sets of indicators have been developed to assess the appropriateness of prescribing for older people. The tools have been developed and validated by a team from Cork, Republic of Ireland | Many of these indicators were considered highly relevant to general practice; variations on 27 of them were put to the consensus panel. STOPP indicators not included were not considered, by the research team, to be of high enough clinical importance forthe purposes of revalidation, or it would be very difficult to extract relevant data from GP computer systems |
↵a As there was some overlap in indicators between the different sources, after removing duplicates, 50 indicators (and a total 68 indicator statements) were included in round one.