Of the 140 invited physicians, 57 responded positively and completed the first round, 50 participated in the second, and 47 (33.5 %) completed all three rounds. This article is based on data from the 47 panellists participating in all three rounds: 14 clinical pharmacologists, 17 geriatricians, and 16 GPs.
The panel agreed that 36 of 37 suggested criteria for pharmacological inappropriateness were clinically relevant for patients ≥70 years in general practice. Twenty-one explicit criteria (ECs) concerned single drugs and dosages ( and ), and 15 ECs concerned drug combinations to be avoided ( and ). Only one of the suggested recommendations, namely to avoid the combination of erythromycin or clarithromycin and digitoxin, did not meet the conditions for being included on the list (median score of 65.3 and IQR 20.0).
Norwegian General Practice (NORGEP) explicit criteria (EC) for single drugs and drug dosages considered potentially pharmacological inappropriate for patients ≥70 years in general practice.
Table III. Norwegian General Practice (NORGEP) explicit criteria (EC) for single drugs and drug dosages considered potentially pharmacologically inappropriate for patients >70 years in general practice. Validating the clinical relevance of the criteria by (more ...)
Norwegian General Practice (NORGEP) explicit criteria (EC) for drug combinations considered potentially pharmacologically inappropriate for patients >70 years in general practice.
Table IV. Norwegian General Practice (NORGEP) explicit criteria (EC) for drug combinations considered potentially pharmacologically inappropriate for patients >70 years in general practice. Validating the clinical relevance of the criteria by a specialist (more ...)
During the three rounds of the Delphi process, the panel held a stable opinion for 33 of the remaining 36 criteria whereas their mean rating increased significantly during the process for three (ECs 12, 31, and 32) of them (see and ). From first to third round, increasing agreement was seen for 30 of the criteria (i.e. all criteria except ECs 1, 3, 14, 22, 25, and 29). The mean standard deviation, as a measure of disagreement, decreased from 22.3 in Round 1 to 15.6 in Round 2 and 14.9 in Round 3. Concurrent prescription of a non-steroid anti-inflammatory drug (NSAID) and a selective serotonin reuptake inhibitor (SSRI) (EC 29) achieved the lowest relevance rating score, while the panellists gave the highest score for concurrent prescription of three or more psychotropic drugs (EC 36). Highest agreement was seen for ECs 11 (flunitrazepam), 14 (carisoprodol), and 36 (simultaneous use of three or more psychotropic drugs). The lowest agreement concerned concurrent use of an NSAID and a glucocorticoid, and the combination of an NSAID and an SSRI (see ).
Over the three Delphi process rounds, the geriatrician group showed highest internal agreement, while most disagreement was seen among the GPs. The consequences of not using the benzodiazepine hypnotic flunitrazepam (EC 11) in the elderly was judged (mean score in last round with 95% confidence interval) differently by clinical pharmacologists, 88.6 (82.4 to 94.8), and GPs 97.8 (95.3 to 100.0).
The tendency towards more agreement within the panel during the three rounds is illustrated by the increasing average relevance scores for all 36 criteria (78.0, 81.0, and 82.3, respectively), and the decrease in corresponding SDs (22.3, 15.6, and 14.9, respectively).
Only for five of the criteria (ECs 1, 3, 22, 24, and 26) did the agreement decrease slightly from Round 2 to Round 3 as illustrated by an SD increase by an average of 6.1. But here also the panellists’ agreement increased from the first to the third round.