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Teria. Although the remaining criteria could be applied using solely pharmacy data, we perceived them as potentially insensitive measurement instruments, which do not always reflect inappropriate prescribing. For example, the use of multiple antipsychotic drugs that was inappropriate according to these criteria, may be clinically beneficial. Also, the fact that a prescribing indication is not documented, another indication of suboptimal prescribing according to this study, does not necessarily mean that the drug is being prescribed inappropriately. The fact that in the Swedish studies more than a quarter of the residents received prescriptions that were classified as potentially inappropriate suggests these criteria may have been too unspecific. The Medication Appropriateness Index MAI ; , developed by Hanlon in 1992 [13], was found to be the closest to a reliable, standardised and valid instrument for assessing medication appropriateness in elderly outpatients [1]. To our knowledge, the MAI has not been used to assess medication appropriateness in nursing homes. In view of the differences in drug use and living circumstances between elderly outpatients and nursing home residents, criteria for medication appropriateness are not necessarily the same for both populations. The MAI consists of 10 questions assessing the appropriateness of a prescribed medication. For 4 questions, information on diagnoses is necessary. The other 6 questions might be suitable for use with pharmacy prescription data only, such as `are there clinically significant drug-drug interactions' and `is there unnecessary duplication with other drug s ; '. However, we considered aspects concerning directions of use, such as patient leaflets, not to be as relevant to the appropriateness of nursing home prescribing, as nurses ensure adequate administration of the drugs. Recently, Knight and Avorn [5] published a list of 12 quality indicators, based on literature review and expert panel consideration. For 5 quality indicators, clinical information such as drug indication, response to therapy or renal function was needed. One indicator concerned a drug not available on the Dutch market. Another indicator concerned patient education, an item that could be relevant in view of monitoring side effects by caregivers. The quality indicators that could be used with pharmacy prescription data only included the availability of a medication list, periodic drug regimen review, avoidance of drugs with strong anticholinergic properties and avoidance of barbiturates, although we consider the latter a less clinically relevant problem in view of the limited use of barbiturates in the Netherlands. To assess medication appropriateness in nursing homes, indicators that reflect deviations from national pharmacotherapy guidelines and drug formularies should be used [14]. The development of pharmacotherapy guidelines specifically for the elderly is limited so far. In the Netherlands, initiatives for Dutch nursing home patients are currently being developed [15]. Our aim was to evaluate drug use in 2 Dutch nursing homes using different prescribing indicators based on pharmacy prescription data. In our earlier study among nursing home.
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