Table 7.

Indicators used to monitor inappropriate use of medicines in different settings

	Setting	Example indicator*	Data source	Pharmaceutical	Longitudinal	Geographical	Organisational	Sociodemographic	Clinical	Financial
Unnecessary medicines use (overuse)
Antibiotic use330, 331, 332	Primary care	Percentage encounters with an antibiotic prescribed	Sample of paper prescriptions	Yes	Yes	No	No	No	No	No
Medication safety333	Hospital	Number of patients prescribed warfarin or clopidogrel concomitantly with a NSAID	Prescription charts or prescription database	Yes	Yes	No	No	No	No	No
Inequality330, 331, 332, 333	Primary care	Percentage encounters with an injection prescribed	Sample of paper prescriptions	Yes	Yes	NA	Yes	No	No	No
Failure to use needed medicines (underuse)
Cardiovascular disease334	Residential care	Number of patients who were given angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for hypertension or congestive heart failure	Audit of patient notes or electronic patient record	Yes	Yes	No	Yes	No	Yes	NA
Asthma335	Primary care	>1 defined daily dose beta agonist and <1 defined daily dose of inhaled steroids and beta agonists in patients aged 15–44 years	Prescribing database	Yes	Yes	No	No	Yes	No	NA
Chronic kidney disease336	Primary care	Percentage of patients aged 18–80 years with chronic kidney disease stages 4–5 and hypertension in the absence of low diastolic blood pressure	Electronic medical record	Yes	Yes	No	No	Yes	Yes	NA
Medication safety337	Primary care	Number of patients with history of peptic ulceration or gastrointestinal bleed, not prescribed gastroprotection and prescribed NSAID	Electronic medical record	Yes	Yes	No	No	Yes	Yes	NA
Incorrect medicines use (misuse)
Drug abuse338	General	Volume of psychotropic drug volume in one area exceeds average by factor of two or more	Electronic prescription database	Yes	No	Yes	No	No	No	No
Cardiovascular disease334, 339	Residential care	Number of patients at risk of falling or with a history of falls given a medicine to avoid falling (eg, sedating antihistamines, tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, benzodiazepines, and antipsychotics)	Administrative and prescribing databases	Yes	Yes	No	Yes	NA	Yes	NA
Chronic kidney disease336	Primary care	Percentage of patients ≥18 years of age with estimated glomerular filtration rate of <30 mL/min/1·73 m2 and diabetes who are prescribed metformin	Electronic medical record	Yes	Yes	No	No	Yes	Yes	NA
Unnecessary use of highly priced medicines
Low cost prescribing330	General	Percentage of drugs prescribed by generic name; percentage of drugs prescribed from National Essential Medicines List or Formulary	Sample of paper prescriptions	Yes	NA	No	No	No	No	No
Budget impact340, 341, 342	General	Relative expenditure per year survived of different treatment regimens for lung cancer	Health insurance claims database	Yes	Yes	No	Yes	Yes	Yes	Yes

NSAID=non-steroidal anti-inflammatory drug. NA=not applicable.

^*These indicators are sometimes constructed as the volume of a product (or products) sold per head of population. Examples include: total volumes of antibiotic or antidiabetic medicines, or patterns of use of critical antibiotics. Appendix 4.2 gives a suggestion of the range of indicators that have been used to monitor inappropriate use of medicines across several countries, settings, and therapeutic areas. The indicators listed in appendix 4.2 have generally been shown to have face and content validity; however, experts caution that there could be justifiable reasons for outlying prescribing patterns.328, 340