Table 2.
Changes made to original criteria according to agreement, disagreement and panel discussion
| Criteria number | Original prescribing appropriateness criteria for older (≥65 years) Australians published in 200825 | Rating by median method41 (median value, A, agreement; D, disagreement), n=15 | Rating by IPRAS1 method41 (IPR value, IPRAS value, A, agreement; D=disagreement), n=15 |
Validated prescribing appropriateness criteria for older (≥65 years) Australians as a result of this study | Rating by median method41 (median value, A, agreement, D, disagreement), n=12 |
Rating by IPRAS1 method41 (IPR value, IPRAS value, A, agreement, D, disagreement), n=12 |
Amendment/reason | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Patient taking an antihypertensive is at their target blood pressure | 7 | A | 1.00, 6.10 | A | Patient taking an antihypertensive is at the target blood pressure appropriate for them | 8 | A | 1.10, 7.52 | A | ‘Appropriate for them’ added. Current blood pressure guidelines may not be appropriate for all older patients47–49. For example, in the oldest old50; in palliative care; and for those who are/become hypotensive and/or fall51 52 |
| 2 | Patient at high risk of a cardiovascular event is taking a statin | 7 | A | 1.00, 6.10 | A | Patient at high risk of a recurrent cardiovascular event is taking a statin | 8 | A | 1.00, 6.10 | A | ‘Recurrent’ added to ensure use in secondary prevention of cardiovascular events rather than primary prevention, where evidence is less clear, especially in the oldest old33 53–57 |
| 3 | Patient with IHD or a history of MI is taking a β-blocker | 8 | A | 2.00, 6.85 | A | Patient with CHD or a history of MI is taking a β-blocker | 7 | A | 1.00, 6.10 | A | ‘CHD’ replaced ‘IHD’. The term ‘coronary heart disease’ is preferred over ‘ischaemic heart disease’ |
| 4 | Patient with IHD or a history of MI is taking an antiplatelet agent unless on an oral anticoagulant | 8 | A | 1.00, 7.60 | A | Patient with CHD or a history of MI is taking an antiplatelet agent unless on an oral anticoagulant | 8 | A | 1.00, 7.60 | A | ‘CHD’ replaced ‘IHD’. The term ‘coronary heart disease’ is preferred over ‘ischaemic heart disease’ |
| 5 | Patient with heart failure is taking a β-blocker | 7 | A | 1.00, 6.10 | A | Patient with stable HF-LVSD is taking a β-blocker | 8 | A | 0.10, 6.78 | A | Description of heart failure amended. The use of β-blockers is contraindicated in unstable heart failure. The optimal treatment of HFPEF is uncertain at this time58 59 |
| 6 | Patient with heart failure is taking an ACEI or A2A | 8 | A | 2.00, 6.85 | A | Patient with stable HF-LVSD is taking an ACEI or A2A | 9 | A | 1.00, 7.60 | A | Description of heart failure amended. The optimal treatment of HFPEF is uncertain at this time58 59 |
| 7 | Patient with heart failure is NOT taking medications which may exacerbate heart failure | 9 | A | 1.00, 7.60 | A | Patient with HF-LVSD or HFPEF is NOT taking medications which may exacerbate heart failure | 9 | A | 0.10, 8.27 | A | Description of heart failure amended. The types of medicines contraindicated in HF-LVSD and HFPEF may not be identical60 61 |
| 8 | Patient with heart failure or hypertension is NOT taking high sodium medications | 8 | D | 2.20, 5.50 | A | Deleted | – | – | – | High sodium medicines (among others) in heart failure are addressed by indicator 7. In hypertension, they are addressed as lifestyle modifications62 63 | |
| 9 | Patient with AF is taking an oral anticoagulant | 7 | D | 2.0, 5.35 | A | Patient with AF is taking an oral anticoagulant or an antiplatelet agent, depending upon stroke risk and bleeding risk | 8 | A | 0.10, 6.93 | A | An antiplatelet agent may be appropriate for patients at low risk of stroke. Bleeding risk may determine choice of antithrombotic agent49 64 65 |
| 10 | Patient with AF taking an anticoagulant has an INR between 2 and 3 | 8 | A | 2.20, 6.70 | A | Patient taking warfarin for AF has an INR between 2 and 3 | 9 | A | 1.00, 7.60 | A | New anticoagulants like rivaroxaban and dabigatran do not require INR monitoring |
| 11 | Patient with a history of non-haemorrhagic stroke or TIA is taking an antiplatelet agent unless on an anticoagulant | 8 | A | 1.00, 7.60 | A | Patient with a history of non-haemorrhagic stroke or TIA is taking an antiplatelet agent unless on an anticoagulant | 9 | A | 1.00, 7.60 | A | No change |
| 12 | Patient with risk factors for myopathy is NOT taking 40 mg or more per day of simvastatin or atorvastatin | 7 | D | 3.00, 4.60 | A | Patient with risk factors for statin-induced myopathy is not taking a high dose of a high-potency statin | 8 | A | 1.10, 7.52 | A | The use of all high dose of high-potency statins together with risk factors may increase the likelihood of myopathy49 66 67 |
| 13 | Patient with cardiovascular disease is NOT taking an NSAID | 7 | A | 1.20, 5.95 | A | Patient with cardiovascular disease is NOT taking an NSAID | 8 | A | 1.10, 6.18 | A | No change |
| 14 | Patient with cardiovascular, respiratory disease or diabetes who smokes has been offered smoking cessation therapy | 9 | A | 0.00, 8.35 | A | Patient with cardiovascular, respiratory disease or diabetes who smokes has been offered smoking cessation options | 9 | A | 0.00, 8.35 | A | ‘Therapy’ implies pharmacotherapy, whereas repeated counselling/psychotherapy may be preferred to avoid the risks associated with polypharmacy |
| 15 | Patient with type 2 diabetes and hypertension and albuminuria is taking an ACEI or A2A | 8 | A | 2.00, 6.85 | A | Patient with type 2 diabetes and hypertension and albuminuria is taking an ACEI or A2A | 9 | A | 1.00, 7.60 | A | No change |
| 16 | Patient with diabetes at high risk of a cardiovascular event is taking an antiplatelet agent unless on an anticoagulant | 7 | D | 2.20, 5.50 | A | Patient with diabetes at high risk of a cardiovascular event is taking an antiplatelet agent unless on an anticoagulant | 9 | A | 1.00, 7.60 | A | No change |
| 17 | Patient with diabetes is NOT taking a medication which may increase or decrease blood glucose concentrations | 5 | D | 2.20, 3.70 | A | Patient with diabetes receiving medications that may affect glycaemic control is having regular monitoring of blood glucose concentrations | 9 | A | 1.00, 7.60 | A | Increased awareness and monitoring may require adjustment of hypoglycaemic medication doses, depending on the need to continue interacting medicines. For example, the start of oral corticosteroids may worsen diabetes control39 |
| 18 | Patient with diabetes has had an HbA1c measurement within the previous 6 months | 8 | A | 1.20, 7.45 | A | Patient with diabetes has had an HbA1c measurement within the previous 6 months | 8 | A | 1.00, 7.60 | A | No change |
| 19 | Patient taking metformin for diabetes has had the dose adjusted for creatinine clearance | 8 | A | 1.20, 7.45 | A | Patient taking metformin for diabetes has had the dose adjusted for renal function | 9 | A | 1.00, 7.60 | A | Creatinine clearance may represent only one of the methods used to determine renal function |
| 20 | Patient taking metformin for diabetes is NOT concurrently taking glibenclamide | 6 | D | 2.40, 3.85 | A | Deleted | – | – | – | Glibenclamide is an uncommonly used hypoglycaemic | |
| 21 | Patient with OA pain interfering with daily activities has been trialled on paracetamol 2–4 g/day | 8 | A | 2.00, 6.85 | A | Patient with OA pain interfering with daily activities has been trialled on regular paracetamol 2–4 g/day | 9 | A | 0.40, 8.05 | A | ‘Regular’ paracetamol added to improve quality of indicator |
| 22 | Patient taking analgesic(s) does NOT have pain that interferes with daily activities | 7 | D | 3.2, 4.75 | A | Patient taking analgesic(s) has had the dose(s) titrated in order to avoid pain that interferes with daily activities | 8 | A | 2.00, 6.85 | A | Indicator rephrased to improve clarity |
| 23 | Patient taking an opioid is on prophylactic treatment for constipation | 8 | A | 2.00, 6.85 | A | Patient taking a regular opioid is on prophylactic treatment for constipation | 9 | A | 1.00, 7.60 | A | ‘Regular’ use added as ‘when required’ use may not always require prophylactic treatment |
| 24 | Patient with risk factors for impaired renal function is NOT taking an NSAID | 8 | A | 1.00, 7.60 | A | Patient with risk factors for impaired renal function is NOT taking an NSAID | 8 | A | 1.00, 7.60 | A | No change |
| 25 | Patient is NOT concurrently taking an ACEI or A2A, diuretic and NSAID (excluding low-dose aspirin) | 9 | A | 1.00, 7.60 | A | Patient is NOT concurrently taking an ACEI or A2A, diuretic and NSAID (excluding low-dose aspirin) | 9 | A | 1.00, 7.60 | A | No change |
| 26 | Patient with sleep disturbance or anxiety has NOT been taking benzodiazepines for >4 weeks | 8 | A | 1.20, 7.45 | A | Patient has NOT been taking benzodiazepines for >4 weeks | 9 | A | 1.00, 7.60 | A | ‘Sleep disturbance or anxiety’ deleted. Benzodiazepines increase the risk of oversedation, ataxia, confusion, falls, respiratory depression and short-term memory impairment, and are recommended for short-term use only39 |
| 27 | Patient with depression is NOT taking anticholinergic-type antidepressants | 7 | D | 1.00, 4.60 | A | Deleted | – | – | – | The issue of anticholinergic burden is addressed by indicator 32 | |
| 28 | Patient with a history of falls is NOT taking psychotropic medications | 8 | A | 1.00, 6.10 | A | Patient with a history of falls is NOT taking psychotropic medications | 8 | A | 1.40, 6.40 | A | No change |
| 29 | Patient taking an SSRI is NOT concurrently taking medications known to increase the risk of GI bleeding | 7 | D | 2.20, 5.20 | A | Deleted | – | – | – | Redundant indicator. This issue would be identified by indicator 47 | |
| 30 | Patient taking an SSRI is NOT concurrently taking other medications that may contribute to serotonin toxicity | 8 | A | 2.20, 6.70 | A | Patient taking an SSRI is NOT concurrently taking other medications that may contribute to serotonin toxicity | 8 | A | 1.40, 6.40 | A | No change. Retained by panel due to its potential significance, despite the use of indicator 47 |
| 31 | Patient with dementia is NOT receiving anticholinergic medication | 8 | A | 1.20, 7.45 | A | Patient with dementia is NOT receiving anticholinergic medication | 8 | A | 1.00, 7.60 | A | No change |
| 32 | Patient is NOT taking more than one medication with anticholinergic activity | 8 | A | 0.2, 6.70 | A | Patient is not taking medication with SIGNIFICANT anticholinergic activity | 8 | A | 0.40, 7.15 | A | Rewording focuses on the issue of anticholinergic burden |
| 33 | Patient taking a PPI is NOT taking a medication that may cause dyspepsia | 7 | D | 3.20, 4.45 | A | Patient taking a PPI is NOT taking a medication that may cause dyspepsia unless prescribed for gastroprotection | 8 | A | 0.40, 7.15 | A | ‘Unless prescribed for gastroprotection’ added to improve the accuracy of the indicator |
| 34 | Patient with COPD is NOT taking benzodiazepines | 7 | D | 3.00, 6.10 | A | Patient with COPD is NOT taking benzodiazepines | 8 | A | 1.00, 6.10 | A | No change |
| 35 | Patient with asthma using an inhaled LABA is also using an inhaled corticosteroid | 9 | A | 0.20, 8.20 | A | Patient with asthma using an inhaled LABA is also using an inhaled corticosteroid | 9 | A | 1.00, 7.60 | A | No change |
| 36 | Patient using salbutamol or terbutaline inhaler more than three times per week for reversible airways disease has been prescribed an ICS | 9 | A | 1.00, 7.60 | A | Patient using salbutamol or terbutaline inhaler more than three times per week for reversible airways disease has been prescribed an ICS (except for exercise-induced asthma) | 9 | A | 0.40, 8.05 | A | ‘Except for exercise-induced asthma’ added to improve the accuracy of the indicator |
| 37 | Patient with asthma is NOT taking a medication that may worsen asthma | 7 | A | 1.20, 6.25 | A | Patient with asthma is NOT taking a medication that may worsen asthma | 8 | A | 1.00, 7.60 | A | No change |
| 38 | Female patient with recurrent UTIs has been prescribed intravaginal oestrogen | 5 | D | 2.00, 3.85 | A | Deleted | – | – | – | Evidence for this indicator was judged to be poor68 | |
| 39 | Patient with a creatinine clearance <60 ml/min is NOT receiving nitrofurantoin for UTI | 8 | A | 2.00, 6.85 | A | Patient with a UTI is not receiving nitrofurantoin or hexamine for prophylaxis or acute treatment | 8 | A | 1.00, 7.60 | A | Hexamine and nitrofurantoin are not recommended for the prophylactic or acute treatment of UTI in older patients39 49 |
| 40 | Patient with a creatinine clearance <50 ml/min is NOT receiving hexamine for UTI prophylaxis | 8 | A | 1.20, 6.25 | A | Deleted | – | – | – | – | Hexamine and nitrofurantoin are not recommended for the prophylactic treatment of UTI in older patients39 49 |
| 41 | Patient with an URTI is NOT receiving antibiotics | 7 | D | 3.00, 4.60 | A | Patient with a non-specific URTI is NOT receiving antibiotics | 8 | A | 1.00, 7.60 | A | ‘Non-specific’ added to improve the accuracy of the indicator |
| 42 | Patient with osteoporosis who is not receiving at least 600 IU vitamin D daily from dietary sources is receiving supplementation with vitamin D | 8 | D | 3.20, 4.75 | A | Deleted | – | – | – | This indicator is covered by indicator 44 and an expanded footnote | |
| 43 | Patient with osteoporosis who is not receiving at least 1200 mg of calcium daily from dietary sources is receiving calcium supplementation | 8 | A | 1.60, 5.95 | A | Deleted | – | – | – | This indicator is covered by indicator 44 and an expanded footnote | |
| 44 | Patient with osteoporosis is receiving antiosteoporotic medication | 7 | A | 1.00, 6.10 | A | Patient with osteoporosis is receiving appropriate antiosteoporotic medication | 8 | A | 0.40, 7.15 | A | ‘Appropriate’ added and an expanded footnote to include calcium and vitamin D |
| 45 | Patient using topical corticosteroids does NOT have itch or discomfort that interferes with daily activities | 6 | D | 2.00, 5.35 | A | Patient using topical corticosteroids for contact or allergic dermatitis does not have itch or discomfort that interferes with daily activities | – | – | – | This indicator was deleted by the panel because there was no identification of the diagnosis/condition being treated. However, contact and allergic dermatitis is one of the top 40 most frequently managed problems by general practitioners in patients ≥65 years old in Australia,36 so this indicator was re-worded by the authors | |
| 46 | Patient has received influenza and pneumococcal vaccination | 9 | A | 1.00, 7.60 | A | Patient has received influenza and pneumococcal vaccination | 9 | A | 0.00, 8.35 | A | No change |
| 47 | Patient has no significant medication interactions (agreement between two medication interaction databases) | 8 | D | 3.00, 6.10 | A | Patient has no clinically significant medication interactions (agreement between two medication interaction databases) | 8 | A | 0.40, 7.15 | A | ‘Clinically’ added to improve the accuracy of the indicator |
| 48 | Patient has had no significant change in medications in the previous 90 days | 5 | D | 1.20, 3.25 | A | Deleted | – | – | It was preferred to transfer this information to the explanatory text of the article | ||
| New | Patient taking thyroid hormone replacement therapy has had a serum TSH measurement within the previous 12 months | Thyroid disease is a common medical condition managed by GPs in older Australians36 69 | |||||||||
| New | Patient with coronary heart disease is taking an ACEI or A2A | ACEIs or A2As reduce the risk of cardiovascular events70 71. However, a high incidence of comorbid disease in CHD (commonly arthritis or respiratory disease) or other clinical factors (eg, dizziness or falls, cognitive impairment, use of >5 medicines, patient preference) may be more important in determining medication priorities72 | |||||||||
ACEI, ACE inhibitor; AF, atrial fibrillation; A2A, angiotensin 2 receptor antagonist; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; HbA1c, glycosylated haemoglobin; HF-LVSD, heart failure with left ventricular systolic dysfunction; HFPEF, heart failure with preserved ejection fraction; GI, gastrointestinal; GP, general physician; ICS, inhaled corticosteroid; IHD, ischaemic heart disease; INR, international normalized ration; IPR, interpercentile range; IPRAS, interpercentile range adjusted for symmetry; LABA, long-acting β agonist; MI, myocardial infarct; NSAID, non-steroidal anti-inflammatory drug; OA, osteoarthritis; PPI, proton pump inhibitor; SSRI, selective serotonin reuptake inhibitor; Statin, HMG-coenzyme A reductase inhibitor; TIA, transient ischaemic attack; TSH, thyroid stimulating hormone; UTI, urinary tract infection; URTI, upper respiratory tract infection.