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PubMed1995

Screening for cardiovascular risk: cost-benefit considerations in a comparison of total cholesterol measurements and two compound blood lipid indices.

BACKGROUND: Serum total cholesterol measurements have been shown to differentiate between patients with angiographically confirmed coronary artery disease and controls less well than compound indices of cardiovascular risk. Details of employees (n = 229) nominated by an occupational health service in a non-manufacturing firm were used as a starting point for calculations to compare the costs and benefits of using compound indices of cardiovascular risk with those of total cholesterol measurements alone. METHODS: Healthy employees were defined as having a low or a high risk of cardiovascular disease according to either total cholesterol level or two compound indices of blood lipid components. The compound indices were the ratio of total to high-density lipoprotein (HDL) cholesterol (the TC: HDLC ratio) and an 'atherogenic index' defined as ([total cholesterol-HDL cholesterol] x [apolipoprotein B])/([HDL cholesterol] x [apolipoprotein A]). If compound indices discriminate better between people at low and high risk, both the number of people given unnecessary advice on lifestyle changes or urged to take cholesterol-reducing medication and the number of people not treated because of their 'normal' cholesterol levels would be reduced. In our calculations, we assumed as 'gains' that (1) the disclosure that a total cholesterol test result is false-positive is equal to treatment costs, consultation fee and consumption foregone (i.e. resources already used on medication, services etc.) (8909 Nkr [US $1 = 7 Nkr]), and (2) the disclosure that a test result is false-negative is equal to consultation fee plus loss of 2 h wages (288 Nkr). RESULTS: The screening of 100,000 men and 100,000 women would incur a cost of 99 and 710 Nkr, respectively, per person assumed to benefit from extended screening using two different compound indices. Net gain would be 438 and 192 million Nkr, respectively, for the two compound indices. However, the lack of prospective data on compound indices suggests the need for cautious interpretation. CONCLUSION: Although prospective studies are needed to confirm our findings, the changes in number of false-positive and false-negative values achievable using different indices suggests a need for greater caution when using single lipid measurements as predictors of risk. The calculations of this non-prospective study indicated an increased benefit-cost ratio in assessing cardiovascular risk by using compound indices of cardiovascular risk compared with total cholesterol measurements alone.

Adult↗
PubMed2005

Satisfaction with pharmacotherapy for approved and off-label indications--a Delphi study.

BACKGROUND: Prescribing for non-approved uses is widespread in the treatment of AIDS, cancer, and pediatric illnesses, but it is by no means limited to these areas. Few studies have been performed evaluating reasons for off-label prescribing. OBJECTIVE: To explore the satisfaction with drug therapy as one of the potential reasons for off-label uses by testing a hypothesis that the satisfaction with drug therapy for off-label indications is lower than for approved indications. METHODS: The study compared the satisfaction with drug therapy for known off-label indications with a control group of approved indications. Twenty-four of the first 50 single-ingredient drugs, according to their share in the drug cost budget of the Slovenian Compulsory Health Insurance, had 86 different off-label indications eligible for inclusion. A control group of 86 approved indications was randomly selected from the list of all possible approved indications for the same 24 drugs. A 2-round Delphi technique, involving an expert panel of physicians who are members of the drug regulatory agency, was used to evaluate the satisfaction with drug therapy for selected indications. RESULTS: After the second round of the Delphi study, the median scores of satisfaction with drug therapy for approved and off-label indications were 7.00 and 6.50, respectively (p = 0.001). CONCLUSIONS: The study shows that the satisfaction with available drug therapy for off-label indications is lower than for approved indications. The statistical association, biologic plausibility, and coherence with existing information, as well as the temporality of the association, provide supporting evidence that low satisfaction with drug therapy is one of the incentives for off-label use.

Databases, Factual↗
PubMedDate not supplied

Preventable drug-related morbidity indicators in the U.S. and U.K.

OBJECTIVE: To qualitatively describe differences between a series of preventable drug-related morbidity (PDRM) indicators in the United States (U.S.) and the United Kingdom (U.K.), after transfer from the U.S. to the U.K. health care setting. METHODS: A preliminary validation was undertaken of the U.S.-derived indicators within the University of Manchester School of Pharmacy, followed by a 2-round Delphi questionnaire of a sample of general practitioners (n=6) and primary care pharmacists (n=10). The main outcome measures were (1) relevance of the U.S. indicators to U.K. primary care prescribing as determined by preliminary validation and (2) the establishment of consensus among the Delphi participants that an indicator represented PDRM. RESULTS: After preliminary validation, 7 of the U.S. indicators and a part of 2 indicators were considered of insufficient relevance to take any further part in the validation process. A further 18 of the U.S.-derived indicators failed to achieve consensus as PDRMs by the U.K. Delphi panel. At the end of the validation process, 19 indicators remained. CONCLUSIONS: Many of the U.S.-derived indicators lacked relevance in the U.K. due to differences in transatlantic clinical practice. In addition, there may be differences in the philosophical viewpoints of health professionals practising in the U.S. and the U.K. In practice, it is therefore inappropriate to transfer quality indicators of this nature directly from the U.S. to the U.K. However, if some form of validation process is undertaken, indicators derived in one health care setting appear to provide a very useful starting point for those developed in another.

Journal Article↗
PubMed2004

A comparison of the sensitivity of stream benthic community indices to effects associated with mines, pulp and paper mills, and urbanization.

This study examined the relative sensitivities of seven commonly used indices of stream benthic community composition and three multivariate indices to effects associated with mines, pulp and paper mills, and urbanization. The indices included total abundance, number of taxa, diversity (H'), evenness, Hilsenhoff's biotic index (HBI), the BioMAP water quality index (WQI), the percent model affinity (PMA), and the first three ordination axes from a correspondence analysis. The second objective of the study was to determine the degree of redundancy among these indices. Six data sets (two from each of the three types of development) were used to address the objectives. In each data set, replicate benthic samples were collected from reference areas as well as one or more downstream areas exposed to a point-source or non-point-source discharge. The PMA approach and the ordination axes indicated significant differences between the reference and downstream communities for all six data sets (p < 0.05). With the exception of H', each of the other metrics revealed significant effects associated with one or two, but not all three, types of development. For example, the HBI and WQI indicated significant effects associated with pulp and paper mills and urbanization, but not mining. In all studies, effect sizes (i.e., the standardized difference between means for the reference and exposed areas expressed in units of standard deviations [SDs]) exceeded 2 SDs. However, effect sizes for the PMA and the first or second ordination axis scores were generally larger than effect sizes for the other metrics, indicating that these indices were often the most sensitive indicators of development. In addition, a high degree of redundancy was found among the various metrics, perhaps because the effects were large (i.e., >2 SDs). The greater sensitivity of the ordination axes and the PMA approach emphasizes their value as indices of benthic community composition. As a result, we recommend that any suite of indices used for assessing benthic communities should include these types of multivariate metrics.

Animals↗
PubMed1997

Comparison of three indices in evaluation of orthodontic treatment outcome.

Three indices measuring outcome of orthodontic treatment were evaluated and compared in 39 specialist-treated individuals (group 1) and in 20 specialist-treated individuals who had undergone orthognathic surgery (group 2). The outcome was evaluated in accordance with the modified Indication Index, the modified ISMHB (Index of the Swedish Medical Health Board), and the PAR (Peer Assessment Rating) Index. Pre- and post-treatment need scores on the basis of the three indices were estimated. The ranking order of the individuals by the different indices was compared in the two groups separately, before and after treatment. Associations between the Indication Index and the ISMHB were consistently stronger than associations between the PAR Index and the two other indices, for which the variations were great. The reasons for the great variations seemed to be the different bases for assessment used and the different constructions of the indices: the PAR Index estimates deviations from an ideal occlusion, and the other indices evaluate treatment need. The outcome describe by the indices differed with regard to the pre- and post-treatment scores and the ranking order of the individuals. Of the three indices, the Indication Index was found to be the one most suitable for estimating treatment outcome in terms of decrease of treatment need, and the PAR Index was unsuitable for estimating treatment need.

Adolescent↗
PubMed2005

Appropriateness of indication and diagnostic yield of colonoscopy: first report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy.

AIM: To assess the appropriateness of referrals and to determine the diagnostic yield of colonoscopy according to the 2000 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: A total of 736 consecutive patients (415 males, 321 females; mean age 43.6+/-16.6 years) undergoing colonoscopy during October 2001-March 2002 were prospectively enrolled in the study. The 2000 ASGE guidelines were used to assess the appropriateness of the indications for the procedure. Diagnostic yield was defined as the ratio between significant findings detected on colonoscopy and the total number of procedures performed for that indication. RESULTS: The large majority (64%) of patients had colonoscopy for an indication that was considered "generally indicated", it was "generally not indicated" for 20%, and it was "not listed" for 16% in the guidelines. The diagnostic yield of colonoscopy was highest for the "generally indicated" (38%) followed by "not listed" (13%) and "generally not indicated" (5%) categories. In the multivariable analysis, the diagnostic yield was independently associated with the appropriateness of indication that was "generally indicated" (odds ratio=12.3) and referrals by gastroenterologist (odds ratio =1.9). CONCLUSION: There is a high likelihood of inappropriate referrals for colonoscopy in an open-access endoscopy system. The diagnostic yield of the procedure is dependent on the appropriateness of indication and referring physician's specialty. Certain indications "not listed" in the guidelines have an intermediate diagnostic yield and further studies are required to evaluate whether they should be included in future revisions of the ASGE guidelines.

Adolescent↗
PubMed2006

Monitoring of mental health systems and services: comparison of four existing indicator schemes.

BACKGROUND: A public mental health indicator scheme may be defined as a systematic collection of brief proxy measures that represent summary information on variables that are potentially influenced by or relevant to mental health systems, programmes and services. Existing public mental health indicator schemes have been developed in or for high-income countries. METHOD: The paper describes and compares four existing high-income country public mental health indicator schemes and highlights key observations. RESULTS: The range of indicators and subclasses of indicators covered by the four existing schemes is large. There was only one item (indicator) that was covered by more than one scheme. CONCLUSIONS: The variety of possibilities in indicators and types of indicators suggests a lack of consensus in the essential contents of an indicator scheme. There is a need for a public mental health indicator scheme that is applicable in resource-poor countries.

Cross-Cultural Comparison↗
PubMed2003

Validity of performance indicators for assessing prescribing quality: the case of asthma.

OBJECTIVES: The aim of this study was to assess the concurrent validity between the identification of sub-optimal treatment based on clinical information and computer generated indicators. Indicators that are associated with sub-optimal treatment in one of the four steps of asthma management were assessed. DESIGN: The ability of each indicator to identify patients with sub-optimal asthma treatment from computerised general practitioner (GP) prescription records was assessed by comparing them with the results of an individual patient assessment using clinical data. SETTING: Chronic asthma patients ( n=146) registered with 16 Dutch GPs. MAIN MEASURES: The sensitivity and positive predictive value (PPV) of each performance indicator was determined. RESULTS: The step-1 indicator, focusing on patients not prescribed a short-acting beta-agonist, had an acceptable sensitivity (0.86), but a low PPV (0.52). The two step-2 indicators, targeting under-prescription of inhaled corticosteroids, had sensitivities of 0.74 and 0.37 and PPVs of 0.46 and 0.71, respectively. The step-3 indicator, which targeted under-dosing of inhaled corticosteroids, had a sensitivity of 0.07 and a PPV of 0.2. The fourth indicator, focusing on under-prescription of long-acting beta-agonists, could not be validated due to inadequate numbers of patients with severe asthma in our study sample. DISCUSSION: None of the indicators investigated was considered valid for assessing prescriber performance, despite having good face and content validity. Performance indicators that have not been validated can only provide a broad-brush approach for assessing prescribing quality and should be used with extreme caution.

Adolescent↗
PubMed2002

[Social inequality and health of the elderly--classical or alternative status indicators?].

This article is focussed on the following two questions: first, whether socio-economic status (SES) differentials in health among the aged vary by the indicators of health and SES applied. Secondly it is investigated how SES differentials in health vary by age. The analyses are based on a telephone survey of 821 older people (> or = 60 years) living in a private household in Germany. In addition to the traditional indicators of SES (education, income and occupational status) two alternative indicators (assets and home ownership) are used in the study. Self-rated health, depression (CES-D) and functional status according to Advanced Activities of Daily Living are introduced as health indicators. Results of multiple regression analyses show that associations between income and the health indicators were comparably strongest. Education, occupational prestige, assets and home ownership were not consistently related to health, especially after controlling for the remainder of the SES indicators. Thus, home ownership and assets do not predict health significantly beyond the effect of the traditional indicators of SES. With regard to age-related variations of the social gradient results were not consistent: In terms of self-rated health associations do not differ between the age groups (60-65, 66-74, 75+), while associations between traditional SES indicators and depression tend to become stronger among those aged 75 years and older. With regard to functional status there were no significant associations with socio-economic status in the multivariate model among those aged 75 years and older. The present study shows that the magnitude of the association between social inequality and health among the aged as well as age related changes in the social gradient depend on the indicators of SES and health applied. Because the analyses are based on cross-sectional data it is not possible to identify causal relationships or to separate age effects from cohort effects. Therefore longitudinal studies are needed in which traditional as well as alternative indicators of SES are used that are appropriate for older adults in general and important for an explanation of differentials in health among the aged in particular.

Activities of Daily Living↗
PubMed1998

Indicators of human health in ecosystems: what do we measure?

Increasingly, scientists are being called upon to assist in the development of indicators for monitoring ecosystem health. For human health indicators, they may draw on environmental exposure, human morbidity/mortality or well-being and sustainability approaches. To improve the rigour of indicators, we propose six scientific criteria for indicator selection: (1) data availability, suitability and representativeness (of populations), (2) indicator validity (face, construct, predictive and convergent) and reliability; (3) indicator responsiveness to change; (4) indicator desegregation capability (across personal and community characteristics); (5) indicator comparability (across populations and jurisdictions); and (6) indicator representativeness (across important dimensions of concern). We comment on our current capacity to adhere to such criteria with examples of measures of environmental exposure, human health and sustainability. We recognize the considerable work still required on documenting environment-human health relationships and on monitoring potential indicators in similar ways over time. Yet we argue that such work is essential in order for science to inform policy decisions which affect the health of ecosystems and human health.

Biomarkers↗
PubMed2002

Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults.

BACKGROUND: Older patients (aged >65 years) may experience drug-related problems that, if unrecognized, can result in drug-related morbidities (DRMs). According to the literature, 49% to 76% of all DRMs may be preventable; however, there is little consensus as to which are preventable and which are not. OBJECTIVE: The aim of this study was to develop consensus-approved clinical indicators of preventable DRM (PDRM) in older adults. Geriatricians, clinical pharmacologists, general practitioners, and clinical pharmacists were included in the consensus-building process. METHODS: In 2001, a survey containing potential indicators of PDRM was prepared based on previous research and the input of 2 clinical pharmacists. The survey was administered concurrently via the Delphi technique to 2 separate specialist panels (6 geriatricians and 6 clinical pharmacologists) to generate clinical indicators of PDRMs in older adults. Subsequently, a focus group of 12 general practitioners (GPs) assessed these PDRM indicators in Nova Scotia, Canada. RESULTS: The specialist panels generated 58 consensus-approved clinical indicators of PDRMs in older adults after 2 rounds of the Delphi technique. The GPs agreed with 52 (90%) of these PDRM indicators. CONCLUSIONS: This study generated consensus-approved indicators of PDRMs in older adults, which could be used by health professionals to identify patients at risk for PDRMs. The indicators could also have a role in quality measurement systems and in epidemiologic research. Furthermore, the indicators could complement existing clinical indicators and establish an important link between patterns of care and clinical outcomes.

Adult↗
PubMed1998

Model indicators for maternal and child health: an overview of process, product, and applications.

OBJECTIVES: Further improvements in the health of mothers and children depend, in part, on collecting, analyzing, and interpreting relevant data correctly. Despite consistent efforts to improve data capacity and use during the past two decades, the need persists for a model set of maternal and child health (MCH) indicators to guide decisions about health conditions to be monitored, elements to be included in data sets, and definitions of measures. This article describes development, key characteristics, and major applications of a set of MCH Model Indicators (MCH MI) created to address these needs. METHODS: A conceptual model with five domains was created to organize and guide development of the indicators. The development process included systematic specification of concepts, formulas, age/gender groups, and data sources, as well as recommendations for frequency of surveillance. Information sources included published reports and expert opinion. RESULTS: There are 217 indicators distributed across domains as follows: 75 health status, 9 contextual characteristics, 16 health systems capacity and adequacy, 49 risk/protective status, and 68 health and related services. Twenty of the indicators, all of them in the health status domain, are recommended for routine surveillance. CONCLUSIONS: The indicators can be used to identify and address MCH problems, to complement and expand other sets of MCH indicators, to serve as standards for consistent definitions, to provide guidance for creation and revision of MCH and related data bases, and to provide a foundation for the development of related sets of indicators. Some of the indicators require further development, but the total MCH MI package constitutes a solid foundation for subsequent work, as well as for ongoing modifications that are essential if the Model Indicators are to remain responsive to MCH needs.

Adolescent↗
PubMed2005

Development of a novel UV indicator and dosimeter film.

A novel UV indicator is described, comprising nanocrystalline particles of titania dispersed in a film of a polymer, hydroxyl ethyl cellulose (HEC), containing: a mild reducing agent, triethanolamine (TEOA) and a redox indicator, methylene blue (MB). The UV indicator film is blue-coloured in the absence of UV light and loses colour upon exposure to UV light, attaining within a few min a steady-state degree of bleaching that can provide a measure of the irradiance of the incident light. The original blue colour of the film returns once the source of UV light is removed. The spectral characteristics of a typical UV indicator film, and its components, are discussed and the UV-absorbing action of the titania particles highlighted. From the measured %bleaching undergone by a typical UV indicator as a function of light irradiance the indicator appears fully bleached, within 7 min, by a UV irradiance of 3 mW cm(-2) or greater. The mechanism by which the UV indicator works is described. The reversible nature of the UV indicator is removed by covering a typical UV indicator with a thin, largely oxygen impermeable, polymer film, such as the regenerated cellulose found in Sellotape. The product is a UV dosimeter, the response of which is related to the intensity and duration of the incident UV light, as well as the amount of titania in the film. A typical UV dosimeter film is fully bleached by 250 mJ cm(-2) of UV light. The possible use of these novel indicators to measure UV exposure levels, irradiance and dose, is discussed.

Film Dosimetry↗
PubMed2001

Quality indicators in postoperative pain management: a validation study.

Quality indicators in postoperative pain management: a validation study. In a previous study, strategic and clinical quality indicators were developed from a tentative model to assess high quality in postoperative pain management. The aim of the present study was to investigate the content validity of these 15 indicators. The indicators were compiled in a questionnaire, and two groups of nurses (n=210, n=321) scored each indicator on a 5-point scale (strongly disagree to strongly agree) from three different standpoints: whether it was essential for achieving high quality, whether it was realistic to carry out, and whether it was possible for nurses to influence management. The respondents were also asked to choose the most crucial indicators for the quality of care. The results showed that both groups of nurses judged the 15 indicators to have content validity from all three standpoints. Both groups also found the same six indicators to be the most crucial. These indicators concerned detecting and acting on signs and symptoms, performing prescriptions, informing and educating, acting on behalf of patients, competence/knowledge, and attitudes. The validated indicators should be useful to consider when implementing a strategy for postoperative pain management and when planning to evaluate the quality of care.

Adult↗
PubMed2003

Fluorescent indicators for Akt/protein kinase B and dynamics of Akt activity visualized in living cells.

Akt/protein kinase B (PKB) is a serine/threonine kinase that regulates a variety of cellular responses. To provide information on the spatial and temporal dynamics of Akt/PKB activity, we have developed genetically encoded fluorescent indicators for Akt/PKB. The indicators contain two green fluorescent protein mutants, an Akt/PKB substrate domain, flexible linker sequence, and phosphorylation recognition domain. A phosphorylation of the substrate domain in the indicators caused change in the emission ratio based on fluorescent resonance energy transfer between the two green fluorescent protein mutants. To let the fluorescent indicators behave as endothelial nitric-oxide synthase and Bad, which are endogenous Akt/PKB substrates, they were fused with the Golgi target domain and mitochondria target domain, respectively. The indicators thus colocalized with the endogenous substrates conferred their susceptibilities to phosphorylation by Akt/PKB. We showed that the Golgi-localized indicator responded to the stimulation with 17beta-estradiol (E2) and insulin in endothelial cells. In addition, E2 elicited the phosphorylation of the mitochondria-localized indicator in the endothelial cells, but no phosphorylation was observed by E2 or by insulin of the diffusible indicator that has no targeting domain. The difference in the results with the three indicators suggests that the activated Akt/PKB is localized to subcellular compartments, including the Golgi apparatus and/or mitochondria, rather than diffusing in the cytosol, thereby efficiently phosphorylating its substrate proteins. E2 triggered the phosphorylation of the mitochondria-localized indicator, whereas insulin did not induce this phosphorylation, which suggests that the localization of the activated Akt/PKB to the mitochondria is directed differently between insulin and E2 via distinct mechanisms.

Amino Acid Sequence↗
PubMed2003

Indicators to improve clinical quality across an integrated health care system.

PURPOSE: To describe key historical and operational elements of change that may assist an organization to develop quality indicators for implementing a strategic plan to improve care, align health care improvement efforts with national directions, and examine the types of medication indicators used to assess these changes. SETTING: The Baylor Health Care System (BHCS) is an integrated health care delivery organization in Dallas-Fort Worth, Texas. It includes 11 hospitals with 83 000 admissions per year and 47 primary care and senior centers with more than 500 000 visits annually. INTERVENTION: Following a charter by the BHCS Board of Trustees to develop a health care quality improvement strategic plan, BHCS undertook a system-wide effort to improve care supported by the use of clinical quality indicators. RESULTS: Consistent with the direction of the US Institute of Medicine, BHCS has implemented a clinical indicator system focused on measures of health care underuse, overuse, and misuse. These indicators demonstrated the accomplishments of specific process of care improvements throughout BHCS. Despite implementing Web-enabled error reporting systems and pilot work with an adverse drug event hospital medical record abstraction tool, BHCS indicators of medication misuse continue to be in a formative stage, much like the national consensus. CONCLUSION: Organizational, compensatory, and cultural commitments may be important for successful implementation of clinical indicator initiatives by health care systems. Using clinical indicators to establish baseline performance and to assess the effectiveness of proposed quality improvements provides quantitative and qualitative means to identify and disseminate best care practices. Although indicators to measure underuse of clinically necessary care are well established, there remains a need to achieve consensus regarding practicable medication quality indicators for overuse, misuse, and adverse drug events.

Benchmarking↗
PubMed2004

Using indicators to quantify the potential to improve the quality of health care.

PURPOSE: Although clinical indicators allow individual providers to monitor and improve their own performance and quality of care, another important role for the indicators is to provide comparative information across all providers. We show that the 'league table' approach is ineffective, and provide an alternative method that uses the comparative rates to quantify the potential for improvement at both the provider and the national level. DATA SOURCES: The methods are applied to English and Australian hospital clinical indicators. METHODS: The key is to regard clinical indicators as screening tools that measure performance in one or more dimensions. All screening processes require explicit tests to determine whether the result should be classified as either positive (requires further investigation) or negative (requires continued monitoring). A clinical indicator will be defined as positive if any of the three following criteria are met: (1) large variation between all areas or hospitals, as defined by the 20th centile gains: requires improvement in the health care system; (2) large variation between strata (rural/urban, teaching/non-teaching, public/private, State): requires action in the relevant stratum; (3) outlier hospitals: requires quality improvement in the individual hospitals. Two techniques are used to determine whether any of the three criteria are positive: (1) empirical Bayesian estimation to calculate 'shrunken' rates; and (2) use of the 20th centile to quantify the potential gains or improvement. RESULTS: For 185 Australian indicators, 55 clinical indicators had system gains involving better outcomes for at least 1000 patients per indicator. Using a set of criteria and subjective judgement, we identified some key areas for quality improvement in Australia. CONCLUSION: Ranking of hospitals does not quantify the potential gains that could be achieved. Indicators that measure health care processes should be reported by quantifying the potential gains, thus encouraging action. Estimating the gains across many indicators allows priorities to be established, such as identifying the areas with the greatest potential for improvement. The main tasks are to then provide the tools and resources to tackle those areas with the most gains.

Australia↗
PubMed2002

Preventing drug-related morbidity--determining valid indicators.

OBJECTIVE: To describe the process that is being undertaken to validate a series of indicators for preventable drug-related morbidity - originally developed in the US - for application in the UK health care system. DESIGN: A two-round Delphi questionnaire survey after a preliminary validation of the indicators within the University of Manchester School of Pharmacy. SETTING: A primary care study set in the UK. STUDY PARTICIPANTS: A purposively selected sample of general practitioners with a specific responsibility for prescribing-related issues (n = 6) and pharmacists actively involved in medication review in primary care (n = 10). MAIN OUTCOME MEASURES: The establishment of consensus among the participants that an indicator reflected preventable drug-related morbidity in primary care. RESULTS: After preliminary validation, 37 of the original 57 US indicators were retained. The Delphi panel generated 16 additional new indicators in the first round. At the end of the second round, the pre-defined level of consensus was reached for 29 indicators (19 of the US generated indicators; 10 generated by the panel in the first round). CONCLUSIONS: The Delphi results highlighted differences in both the clinical perspective and, possibly, philosophical viewpoints of health professionals practising in the UK and US health care systems. Further work, located in both primary and secondary care, is now in progress to operationalize the indicators. This process will form a key part of the refining, and hence further validation, of the indicators. The future development of prospective medical-record-based indicators should facilitate a reduction in the human, clinical, and economic burden of drug-related morbidity.

Attitude of Health Personnel↗