204 CHAPTER 3.1 STRIPA analysis The pharmaceutical analysis consists of six steps, according to the Prescribing Optimization Method [38], at the end of which a report with prescribing recommendations is generated. These steps are as follows: 1. Assignment of medication to the recorded diagnoses: the STRIPA user assigns all the entered medications to the present ICD10- codes representing the patient’s medical conditions (see Figure 2). This can be achieved by ‘dragging’ the medications by screen cursor on the ‘right side’ of the screen to the corresponding indicated medical condition on the ‘left side’ of the screen. Where no appropriate indication for a medication is present, this medication can be assigned to ICD10- code ‘R69- unknown and unspecified causes of morbidity’, i.e. a so-called ‘dummy condition’. 2. Screening for under-treatment: during this step, the entered medications and medical conditions are checked for under-treatment according to START criteria (see Fig. 3. A screenshot of triggered START criteria). All medications assigned to a medical condition are evaluated, regardless of the specific medical condition they were assigned to. For instance, where an ACE inhibitor is assigned to hypertension instead of heart failure, START rule A6 (“Angiotensin Converting Enzyme (ACE) inhibitor with systolic heart failure and/or documented coronary artery disease”) will not be triggered as the ACE inhibitor is already present in the medication list. The intervention teamwill evaluate all generated START rules on their appropriateness for a specific patient by either accepting or rejecting the advice. In the event of a rejected recommendation, the reasons for rejection are not recorded within the STRIPA software. When a START recommendation is accepted, the user can choose any medication on an ATC-5 level, including preferred dose, within the advised class from a drop-down menu. This drug is then automatically assigned to the medical condition triggering the rule. When more than one criterion is triggered advising the same drug (or drug class), the best matching criterion is chosen by the intervention team and the others are then automatically disabled. At the end of this step, the updated medication list is evaluated for potential undertreatment not highlighted in START criteria, but considered relevant according to the STRIPA software user. In such cases, these drugs can be manually added to the designated medical condition and will appear on the final advice report as ‘expert opinion’ instead of triggered by START criteria.
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