Introduction: Existing appropriateness measures, 1,2 and those in development 3 involve a number of clinically defined indices. The evaluation of appropriateness is dependent upon many factors, not least those who make the evaluation (patient or healthcare professional), and those that the evaluation concerns (patient, patient's family, or carer). Research into peoples' experiences of illness suggests that it is likely that individual patients will conceptualise the appropriateness of their treatment and care, in a combination of social, psychological and physical terms 4.

Aim: of this multi-centred Q-study was to explore how patients and general practitioners (GPs) constructed the concept of appropriateness in the context of hypertension management.

Method: One hundred and twenty patients with hypertension and twelve GPs, recruited via community pharmacies in four cities within England, participated in this Q-study. Each participant ranked forty statements, comprising clinical and non-clinical attributes relating to hypertension management. These statements were developed from a previous qualitative study, involving semi-structured interviews with patients with hypertension and their nominated GPs. The focus of the ranking was to determine what each participant (patient or GP) considered appropriate hypertension management. Factor analysis of the data was undertaken using PQMethod 5, a dedicated computer software.

Findings: The findings indicated that patients and GPs consider appropriate hypertension management in different ways. The majority of GPs (n=10) indicated that they considered non-pharmacological measures to be highly important in appropriate hypertension management, whereas patients were ambivalent. The majority of patients (n=92) clustered to one of five appropriateness evaluations, which varied in the degree of involvement patients had, or wished to have, in their hypertension management. Of these five evaluations, two were chosen by the seventy-three patients. This choice seemed be influenced by the patient's age, duration of treatment and number of prescribed antihypertensives.

Conclusion: The study suggests that the existing measures of appropriateness are unable, in their present form, to encompass patients' appropriateness evaluations, as they do not take account of non-clinical attributes. Evaluations made by GPs differ from those made by patients, and there is also variation between patients. Further research to explore variation in patients' appropriateness evaluations across a variety of medical conditions would be a valuable contribution to the Health Services Research agenda. This study has shown that Q-methodology is well suited to exploring this difficult arena. These findings have important implications for patient centred care.

References
(1) Hanlon JT, Schamader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45:1045-1051.
(2) Cantrill JA, Sibbald B, Buetow A. Indicators of the appropriateness of long term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability. Quality in Health Care 1998; 7:130-135.
(3) Britten N, Jenkins J, Barbour C, Stevenson F. Developing a measure for the appropriateness of prescribing in general practice. Quality and Safety in Health Care 2003; 12:246-250.
(4) Sharpe VA, Faden AI. Appropriateness in patient care: A new conceptual framework. The Millbank Quarterly 1996; 74:115-138.
(5) Schmolck, P. PQMethod (version 1.09) http://www.rz.unibw-muenchen.de/~p41bsmk/qmethod/ (January/2002)