Denominator (ELSA variable(s) in bold font) Age>=50 years. Reported diagnosed stroke at wave 2 but not at wave 1 (Hediaa) Hepsye = yes

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1 Table C Translation of quality indicators and patient-centred questions into corresponding ELSA questions, showing numerator and denominator population criteria for quality score. Condition, quality indicator (QI) or Corresponding ELSA ( and Cerebrovascular disease cvd4. IF a person aged 50 or older has had a previous stroke, THEN the patient should be offered antihypertensive medication. Depression dep1. IF a person aged 50 or older receives a diagnosis of a new depression episode, THEN the diagnosing physician should ask on the day of diagnosis whether the person aged 50 or older had any thoughts about suicide. dep2. IF a person aged 50 or older is diagnosed with clinical depression, THEN antidepressant treatment, talking treatment, or electroconvulsive therapy should be offered within 2 weeks after diagnosis unless within that period the patient has improved, or unless the patient has substance abuse or dependence, in which case treatment may wait until 8 weeks after the patient is in a drug- or alcohol-free state. diagnosed stroke at wave 2 but not at wave 1 (Hediaa) diagnosed depression at wave 2 but not at wave 1 (Hediab) diagnosed depression at wave 2 but not at wave 1, and Hepsya none Hehibpb1 = Hepsye = Hepsyb = stroke (cerebral vascular disease) ] Hehibpb1: Did a doctor or nurse ever suggest you take any medication to lower your blood pressure? Hediab: Has a doctor ever told you that you have (or any emotional, nervous or psychiatric problems ] Hepsy: What type of emotional, nervous or psychiatric problems do you have? [includes depression ] Hepsye: When you talked about these feelings with a doctor or nurse, did they ask you on that day if you had thoughts about suicide? Hepsya: I have some questions about any treatment you may have had for your depression. Did a doctor or nurse suggest that you take medication, or see a mental health professional for counselling? Hepsyb: Did you start medication or counselling within 2 weeks of being offered this treatment?

2 dep3. IF a person aged 50 or older has no meaningful symptom response after 6 weeks of treatment, THEN one of the following treatment options should be initiated by the 8th week of treatment: medication dose should be optimised (if initial treatment was medication), or medication should be initiated (if initial treatment was psychotherapy alone), or referral to a psychiatrist should be offered. Diabetes mellitus diab1. IF a person aged 50 or older has diabetes, THEN his or her glycosylated haemoglobin or fructosamine level should be measured at least annually. diagnosed depression at wave 2 but not at wave 1, and Hepsyc = no diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2 Hepsyd = Hesuga = Corresponding ELSA ( and Hepsyc: Did you feel better within 6 weeks after starting to take medication, or seeing a mental health professional for counselling? Hepsyd: Did any doctor or nurse start you on medication, change the dose of the medication that you were taking or, change the medications to help you feel better? Heacd: Has a doctor ever told you that you have diabetes? Hesug: Have you ever had a special blood test to see how well your blood sugar was controlled? This test is called a glycosylated haemoglobin, or haemoglobin A1c, or fructosamine. This is a blood test taken at a doctor s surgery or health centre or laboratory. Hesuga: Have you had this test (glycosylated haemoglobin or fructosamine) performed in the past 12 months?

3 diab2. IF a diabetic person aged 50 or older does not have established renal disease and is not receiving an ACE inhibitor or angiotensin II receptor blocker, THEN he or she should receive an annual test for proteinuria. diab6. IF a diabetic person aged 50 or older has a fasting total cholesterol level of 5 mmol/l or greater, THEN he or she should be offered an intervention to lower cholesterol. diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2, and Hekidn = no, and Heacea = Not taking ACE inhibitor or A2 receptor blocker diabetes or high blood sugar at wave 2 but not at wave 1, and confirmed that had diagnosed diabetes at wave 2, and reported diagnosed high cholesterol at wave 2 (cholesterol question not asked at wave 1) Hewee = Hechol = Corresponding ELSA ( and Hekidn: Has a doctor ever told you that your diabetes has caused trouble with your kidneys? Heacea: I would like to check whether any of the medications you are taking are on this list of ACE inhibitor or A2 receptor blockers? [show card G ACE inhibitors] Hewee: Have you had a urine test for protein in the last 12 months? high cholesterol ] Hechol: Has any doctor talked to you about how to lower your cholesterol? This would include changing your diet, losing weight, getting more exercise or taking medication (asked if has diabetes and high cholesterol)

4 diab8. IF a diabetic person aged 50 or older has one additional cardiac risk factor (i.e., smoker, hypertension, hypercholesterolemia, or renal insufficiency/microalbuminuria), THEN he/she should be offered an ACE inhibitor or receptor blocker. diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2, and at wave 2 (Heska= yes, or (systolic blood pressure (BP) >=140 or diastolic BP >=90), or Hekidn= yes, or Heweea= yes, or reported diagnosed high cholesterol or high blood pressure or hypertension, or at wave 1 reported diagnosed hypertension. Heace = or Heacea = Corresponding ELSA ( and high blood pressure or hypertension and high cholesterol ] Hewee: Some doctors check to see if patients with diabetes have protein in their urine. Have you had a urine test for protein in the past 12 months? (This test may also be called a microalbumin test, and involves a first morning urine sample or 24-hour urine collection.) Heweea: Has a doctor ever told you that you have protein in your urine? Hekidn: Has a doctor ever told you that your diabetes has caused trouble with your kidneys? Heska: Do you smoke cigarettes at all nowadays? Sysval: valid mean systolic BP (measured) Diaval: valid mean diastolic BP (measured) Heace: Has a doctor discussed with you whether you should take a medication called an ACE inhibitor or A2 receptor blocker? Heacea: I would like to check whether any of the medications you are taking are on this list of ACE inhibitor or A2 receptor blockers? [show card G ACE inhibitors]

5 diab9. ALL diabetic persons aged 50 or older should have an annual examination of his/her feet. Falls falls3h. IF a person aged 65 or older reported 2 or more falls in the past year, or a single fall with injury requiring treatment, THEN the physician should take a basic fall history. falls3e. IF a person aged 65 or older reported 2 or more falls in the past year, or a single fall with injury requiring treatment, THEN the patient should be offered a multidisciplinary falls assessment. diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2 Age>=65 years. Heflb>2, and Heflc = Age>=65 years. Heflb>2, and Heflc = Heftchk = Hefld = Hefle = or Heflf = Corresponding ELSA ( and Heftchk: Some doctors suggest that some patients with diabetes have a regular foot examination. In the past year, has any doctor or nurse examined your bare feet? Hefla: Have you fallen down in the last 2 years/since we last talked to you? (for any reason)? Heflb: How many times have you fallen down? Heflc: In any of these falls did you injure yourself seriously enough to require treatment? Hefld: With any of your past falls, did a doctor or nurse talk with you to try to understand why you fell? Hefle: Did a doctor or nurse or physiotherapist test your balance or strength or watch how you walk to understand why you fell? Heflf: Did a doctor or nurse or physiotherapist recommend any additional tests, such as heart tests or brain scans to understand why you fell?

6 Hearing hearing2. IF a person aged 65 or older has a problem with hearing, THEN he or she should be offered a formal audiological evaluation within 3 months. hearing3. IF a person aged 65 or older is a hearing aid candidate, THEN he or she should be offered hearing rehabilitation. Hypertension hyp2. IF a person aged 50 or older remains hypertensive after nonpharmacological intervention, THEN pharmacological antihypertensive treatment should be initiated. Age>=65 years. (Hehear = fair or poor, or Hehra = ), and Hehrb = Age>=65 years. (Hehear = fair or poor, or Hehra = ), and Hehrb =, and Hehrd = diagnosed hypertension at wave 2 but not at wave 1 (Hediaa) Hehrc = Hehre =, and Hehrf = Hehibpb = Corresponding ELSA ( and Hehear: Is your hearing (using a hearing aid if you use one) excellent, very good, good, fair or poor? Hehra: Do you find it difficult to follow a conversation if there is background noise, such as TV, radio or children playing (using a hearing aid as usual)? Hehrb: Have you told a doctor or nurse about your hearing problems? Hehrc: When you told the doctor or nurse about your hearing problems, did he or she refer you to an ear specialist to check your hearing? Hehrd: Has any doctor or nurse or ear specialist recommended a hearing aid? Hehre: Did you get a hearing aid? Hehrf: Did an ear specialist or doctor or nurse teach you how to use your hearing aid? high blood pressure or hypertension ] Hehibpb: Some doctors suggest that some patients take medication to lower their blood pressure. Did a doctor or nurse ever suggest that you take medication to lower your blood pressure?

7 Ischaemic Heart Disease ihd1. IF a person aged 50 or older has established CHD and LDL cholesterol > 3 mmol/l, THEN he or she should be offered an intervention to lower cholesterol. ihd2. IF a person aged 50 or older has established CHD and is not on warfarin, THEN he or she should be offered antiplatelet therapy. ihd3. IF a person aged 50 or older with established CHD smokes, THEN he or she should be offered counselling for smoking cessation. ihd5. IF a person aged 50 or older has had a recent myocardial infarction, THEN he or she should be offered a beta blocker. diagnosed high cholesterol at wave 2, and diagnosed angina or heart attack (including myocardial infarction or coronary thrombosis) at wave 2 but not wave 1 diagnosed angina or heart attack (including myocardial infarction or coronary thrombosis) at wave 2 but not wave 1, and Hehrtc = no diagnosed angina or heart attack (including myocardial infarction or coronary thrombosis) at wave 1 or wave 2, and currently smokes cigarettes diagnosed heart attack (including myocardial infarction or coronary thrombosis) at wave 2 but not wave 1 Hechol = Hehrta = Hecgstp = Hebeta = or Hebetb = currently taking beta blockers Corresponding ELSA ( and Hechol: Has any doctor talked to you about how to lower your cholesterol? This would include changing your diet, losing weight, getting more exercise or taking medication have had) any of the conditions on this card [includes angina, MI, diabetes, stroke and high cholesterol] Hehrtc: Are you taking Warfarin? Hehrta: Did a doctor suggest that you take medication to thin your blood such as warfarin or aspirin, Plavix, Ticlid, or other blood thinning medication? Heska: Do you smoke cigarettes at all nowadays? Hecgstp: Has a doctor or nurse ever advised you to stop smoking? Hebeta: Did any doctor ever tell you that you should take a medication called a betablocker? Hebetb: Please could you show me the medications or the repeat prescription list for any medications you have taken over the last week? [checked against card F beta blockers]

8 ihd6 (previously med3). IF a person aged 50 or older is prescribed warfarin, THEN an international normalized ratio (INR) should be determined at least every 12 weeks. Osteoarthritis oa2. IF an ambulatory person aged 50 or older has had a diagnosis of symptomatic osteoarthritis of the knee for longer than 3 months and has no contraindications to exercise and is physically and mentally able to exercise, THEN a directed or supervised strengthening or aerobic exercise programme should have been prescribed at least once. diagnosed angina or heart attack (including myocardial infarction or coronary thrombosis) at wave 1 or wave 2, and Hehrtc = Hehrte = Hekneb = diagnosed osteoarthritis in wave 1 or wave 2 (Heart), and knee pain for more than 3 months (Hekne) rated 1-5, and excluding those with Hehip rated 6-10 Corresponding ELSA ( and Hehrtc: Are you taking Warfarin? Hehrtd: Many doctors ask patients on Warfarin to get their blood tested regularly. The test checks how thin their blood is, and is sometimes called an INR test. Do you get your blood checked for this? Hehrte: Have you had this blood test in the past 12 weeks? Hediab: Has a doctor ever told you that you have (or arthritis (including osteoarthritis, or rheumatism) ] Heart: Which type or types of arthritis do you have? [includes osteoarthritis ] Hehip: How would you rate the pain in your hips? ( Where 0 is no pain and 10 is severe or excruciating pain, as bad as you can imagine. Range: 0-10) Hekne: How would you rate the pain in your knees? ( Where 0 is no pain and 10 is severe or excruciating pain, as bad as you can imagine. Range: 0-10) Heknea: Has your knee pain been bothering you for more than 3 months? Hekneb: Has a doctor or nurse suggested that you receive physiotherapy or attend a supervised exercise program for your knee pain?

9 oa3. IF an ambulatory person aged 50 or older has a diagnosis of symptomatic osteoarthritis, THEN education regarding the natural history, treatment and selfmanagement of the disease should be offered at least once. oa4. IF oral pharmacological therapy is initiated to treat osteoarthritis among people aged 50 or older, THEN paracetamol should be the first drug used, unless there is a contraindication to use. oa6. IF a person aged 50 or older with severe symptomatic osteoarthritis of the knee or hip has failed to respond to non- pharmacological and pharmacological therapy, THEN the patient should be offered referral to an orthopaedic surgeon to be evaluated for total joint replacement within 6 months unless surgery is contraindicated. diagnosed osteoarthritis at wave 2 but not wave 1 diagnosed osteoarthritis at wave 2 but not wave 1 diagnosed osteoarthritis in wave 1 or wave 2, and knee or hip pain for more than 6 months (Hekne & Hehip), both rated 6-10, and not controlled by treatment (Hepae = no ) Hearta = and Heartb = and Heartc = Hearte = Hepaf = Corresponding ELSA ( and Has any doctor or nurse ever talked to you about: Hearta: What your arthritis or joint pain will be like as time goes on? Heartb: How to keep your arthritis or joint pain from getting worse? Heartc: How your arthritis or joint pain will be treated? Hearte: Did any doctor or nurse recommend you to try paracetamol before other medicines for your joint pain? Hepac: Has your knee or hip pain been bothering you for more than six months? Hepad: Are you taking or have you taken any medication or exercises to control the pain in your knee or hip? Hepae: Do exercises and medicines control the pain in your knee or hip? Hepaf: Did any doctor recommend that you should have surgery or joint replacement?

10 Osteoporosis osteop4. IF a person aged 50 or older has untreated osteoporosis, THEN calcium and vitamin D supplements should be recommended at least once. osteop6. IF a woman aged 50 or older is newly diagnosed with osteoporosis, THEN the patient should be offered treatment with hormone replacement therapy, SERMs, bisphosphonates, calcitonin, or calcium and vitamin D within 3 months of diagnosis. Pain management pain5. IF a person aged 50 or older has a newly reported chronic painful condition, THEN treatment should be offered. diagnosed osteoporosis in wave 1 or wave 2 (Hediab) Heoste = Women aged>=50 years. Heosted = Reported diagnosed osteoporosis in wave 2 but not wave 1 Age>=50 years, often troubled Hepai = (Hepain) by moderate or severe pain (Hepaa) which started within the 12 months prior to interview (Hepag), and which the respondent had told their doctor or nurse about (Hepah) Corresponding ELSA ( and Hediab: Has a doctor ever told you that you have (or osteoporosis, sometimes called thin or brittle bones ] Heoste: Has any doctor or nurse recommended taking calcium pills or Vitamin D? Heosteb: Did a doctor or nurse recommend treatment with medication for your osteoporosis or thin bones? Heostec: Did you take any of them? Heosted: Were these medicines recommended within 3 months of a doctor telling you that you had osteoporosis? Hepain: Are you often troubled by pain? Hepaa: How bad is the pain most of the time? Is it mild, moderate or severe? Hepag: Has this pain started within the past 12 months? [asked of those who had moderate or severe pain] Hepah: Have you told your doctor or nurse about this pain? Hepai: Did your doctor or nurse recommend any treatments for your pain?

11 Smoking smok3. IF a person aged 50 or older uses tobacco regularly, THEN he or she should be offered advice and/or pharmacological therapy to stop tobacco use at least once. Urinary Incontinence inc3. IF a person aged 65 or older has new UI that persists for over 1 month or UI at the time of a new evaluation, THEN a targeted history should be obtained about each of the following: (1) characteristics of voiding, (2) ability to get to the toilet, (3) prior treatment for urinary incontinence, (4) importance of the problem to the patient, and (5) mental status. Age>=50 years. Current cigarette smoker (Heska = ) Age>=65 years. Urinary incontinence during 12 months prior to interview (Heinct), lasting for at least 1 month (Heincta), which respondent mentioned to a doctor or nurse (Heinctb) Hecgstp = or Hecgnic = Heinctc = and Heinctd = and Heincte = and Heinctf = Corresponding ELSA ( and Heska: Do you smoke cigarettes at all nowadays? Hecgstp: Has a doctor or nurse ever advised you to stop smoking? Hecgnic: Has any doctor or nurse ever told you about any nicotine products, such as nicotine patches, chewing gum, lozenges or other similar products at all to help you give up smoking? Heinct: We would like to ask you about incontinence. During the last 12 months, have you lost any amount of urine beyond your control? Heincta: When you had this problem, did it last for more than 1 month? Heinctb: Have you ever mentioned this problem to a doctor or nurse? Heinctc: Did a doctor or nurse ask you when you lose urine, for example when you sneeze or laugh? Heinctd: Did a doctor or nurse ask you if you had trouble getting to the toilet? Heincte: Did a doctor or nurse ask you if you had been treated for this problem before? Heinctf: Did a doctor or nurse ask you how important this problem was to you?

12 inc4. IF a person aged 65 or older has new UI that persists for over 1 month after consulting a doctor, THEN a targeted physical exam should be performed that includes (1) a rectal exam and (2) a genital system exam (including a pelvic exam for women). inc6. IF a person aged 65 or older has new UI or UI at the time of a new evaluation, THEN treatment options should be discussed. inc8. IF a person aged 65 or older has new UI that persists for over 1 month or UI at the time of a new evaluation, THEN a dipstick urinalysis and/or mid-stream urine sample should be obtained. Age>=65 years. Urinary incontinence during 12 months prior to interview (Heinct), lasting for at least 1 month (Heincta), which respondent mentioned to a doctor or nurse (Heinctb) Age>=65 years. Urinary incontinence during 12 months prior to interview (Heinct), lasting for at least 1 month (Heincta), which respondent mentioned to a doctor or nurse (Heinctb) Age>=65 years. Urinary incontinence during 12 months prior to interview (Heinct), lasting for at least 1 month (Heincta), which respondent mentioned to a doctor or nurse (Heinctb) Heincti = or Heinctj = Heincth = Heinctg = Corresponding ELSA ( and Heincti: Did a doctor or specialist such as a urologist or gynaecologist perform an internal exam? (women) Heinctj: Did a doctor or nurse perform a rectal examination? (men) Heincth: Did a doctor or nurse talk with you about how to treat urinary incontinence? Heinctg: Did a doctor or nurse ask you to provide a sample of urine for testing?

13 Vision vision4. IF a person aged 50 or older is diagnosed with a cataract that limits the patient s ability to carry out needed or desired activities, THEN cataract extraction should be offered. Patient-centred care pat1. Some people with diabetes receive training to help manage their diabetes themselves. Have you ever participated in a course or class about diabetes, or received special training on how you can live with your diabetes from day-to-day? diagnosed cataract in wave 1 or wave 2, (Heopt), and (eyesight fair, poor or blind (Heeye), or distance eyesight fair or poor (Hefrnd), or close eyesight fair or poor (Hepap)) in wave 2 diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2 Hedreye = Heslfcr = Corresponding ELSA ( and Heopt: Has a doctor ever told you that you have any of these other conditions? [includes cataract] Heeye: Is your eyesight (using glasses or corrective lenses if you use them) excellent, very good, good, fair or poor? [or legally or registered blind] Hefrnd: [If not blind] How good is your eyesight for seeing things at a distance, like recognising a friend across the street, (using glasses or corrective lenses if you use them): excellent, very good, good, fair or poor? Hepap: [If not blind] How good is your eyesight for seeing things up close, like reading ordinary newspaper print, (using glasses or corrective lenses if you use them): excellent, very good, good, fair or poor? Hedreye: Did any doctor or optician recommend that you have your cataracts removed? Heslfcr: Some people with diabetes receive training to help manage their diabetes themselves. Have you ever participated in a course or class about diabetes, or received special training on how you can live with your diabetes from day-to-day?

14 pat2. How much do you think you know about managing your diabetes? ( just about everything you need to know or most of what you need to know ) pat3. Has a doctor or nurse explained high cholesterol in a way you could understand? pat4. Have doctors or nurses taken your preferences into account when making treatment decisions about your high cholesterol? pat5. Has a doctor or nurse explained high blood pressure in a way you could understand at any time since you were first told you had high blood pressure? diabetes or high blood sugar at wave 1 or wave 2, and confirmed that had diagnosed diabetes at wave 2 Age>=50 years, and reported diagnosed high cholesterol at wave 2 (cholesterol question not asked at wave 1) (Hediaa) Age>=50 years, and reported diagnosed high cholesterol at wave 2 (cholesterol question not asked at wave 1) (Hediaa) diagnosed hypertension at wave 2 (Hediaa) Heslfcb = 1 ( just about everything ) or 2 ( most ) Hecholb = Hecholc = Hehibp = Corresponding ELSA ( and Heslfcb: How much do you think you know about managing your diabetes? Do you know just about everything you need to know, 2 most of what you need to know, 3 some of what you need to know, 4 a little of what you need to know, 5 or almost none of what you need to know? high cholesterol ] Hecholb: Has a doctor or nurse explained high cholesterol in a way you could understand? high cholesterol ] Hecholc: Have doctors or nurses taken your preferences into account when making treatment decisions about your high cholesterol? high blood pressure or hypertension ] Hehibp: Has a doctor or nurse explained high blood pressure in a way you could understand at any time since you were first told you had high blood pressure?

15 pat6. In general, have doctors or nurses given you any choice about how to treat your high blood pressure? pat7. Has any doctor or nurse ever talked to you about what the specific purpose of the treatment for your arthritis or joint pain is? diagnosed hypertension at wave 2 (Hediaa) diagnosed osteoarthritis at wave 2 but not wave 1 (Heart), and doctor has discussed treatment (Heartc) Hehibpa = Heartd = Corresponding ELSA ( and high blood pressure or hypertension ] Hehibpa: In general, have doctors or nurses given you any choice about how to treat your high blood pressure? Hediab: Has a doctor ever told you that you have (or arthritis (including osteoarthritis, or rheumatism) ] Heart: Which type or types of arthritis do you have? [includes osteoarthritis ] Heartc: Has any doctor or nurse ever talked to you about how your arthritis or joint pain will be treated? Heartd: Has any doctor or nurse ever talked to you about what the specific purpose of the treatment for your arthritis or joint pain is? Further information on the sample, fieldwork, weighting, consent, questionnaires and other survey documents can be found in the ELSA Wave 2 User Guides and Documentation, which is available from the UK data archive: (accessed 16 May 2008) The full ELSA wave 2 questionnaire is also available from the Institute of Fiscal Studies website at: (accessed 16 May 2008) The published literature reviews that underpinned the ACOVE indicators are available from: (accessed 16 May 2008) (Wenger NS, Shekelle PG, Davidoff F, Mulrow C. Quality indicators for assessing care of vulnerable elders. Annals of Internal Medicine (Supplement) 2001; 135(8 (Part 2)): )

16 The UK adaptation of these is described in: Steel N, Melzer D, Shekelle PG, Wenger NS, Forsyth D, McWilliams BC. Developing quality indicators for older adults: transfer from the USA to the UK is feasible. Quality and Safety in Health Care 2004; 13(4): All the quality indicators rated as valid are available from the Quality and Safety in Health Care web-only appendix 1 to the above paper, at: (accessed 16 May 2008)