222 CHAPTER 3.2 Introduction Multimorbidity defined as ≥ 2 chronic medical conditions increases with age, with an estimated prevalence of ≥70% in older populations, and is accompanied by increased mortality, healthcare utilization, hospital admissions and increased prescription rates of long-term medications [1–4]. This commonly results in polypharmacy, often defined as prescription of ≥ 5 long-term daily drugs [5]. While polypharmacy may be indicated and beneficial in many multimorbid patients, it also increases the risk of inappropriate prescribing [6,7]. Inappropriate prescribing may take the form of drug overuse (drug prescribing without an evidence-based indication), drug underuse (omission of drug prescribing despite an evidence-based indication), or drug misuse (such as inappropriate combinations with risk for drugdrug interactions, and inappropriate dosing) [8–11]. Inappropriate prescribing is highly prevalent among older people, with reported prevalence varying from 30% to 60% [10,12], and may lead to important adverse outcomes [6] Studies have reported increased risks of drug-drug interactions and adverse drug reactions [13], drugrelated hospital admissions, falls, mortality, and decreased quality of life arising from inappropriate prescribing in the context of polypharmacy [6,7,14,15]. Up to 30% of all hospital admissions in older people are drug-related, half of which are potentially preventable [15–18]. A wide variety of interventions have been designed to optimize pharmacotherapy in patients with polypharmacy, with the aim of improving medication appropriateness and lowering the risk of adverse drug reactions [7]. Most of these structured interventions consist of multifaceted interventions delivered by pharmacists [7], but more recently, software systems have been developed to support pharmacotherapy optimization [19,20]. While most computerized decision support systems focus on a single aspect, such as detecting drug-drug or drug-disease interactions, or potentially inappropriate medications [21], the Systematic Tool to Reduce Inappropriate Prescribing (STRIP) facilitated by the web-based STRIP Assistant (STRIPA) can perform multiple tasks intrinsic to pharmacotherapy optimisation simultaneously. It combines the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert to the Right Treatment (STOPP/START) criteria [22] with a more global evaluation of drug appropriateness and shared decision-making with the patient [23]. However, it remains uncertain whether these structured pharmacotherapy optimization interventions result in improved clinical outcomes. A Cochrane systematic review of interventions designed to improve the appropriate use of polypharmacy in older people found few studies investigating important clinical outcomes, such as hospital admissions or quality of life, with inconsistent results. While some prospective non-randomised studies have indicated a reduction in hospital admissions with multi-faceted interventions of pharmaceutical care [24,25], and two small single-centre randomized clinical trials (RCTs) showed a
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