280 CHAPTER 4.1 4) discussion of the feedback report with both the attending physician and the patient; and 5) generating a discharge report for the patient’s general practitioner, which included in-hospital medication changes and recommendations which were agreed upon by the attending physician and the patient but deferred to the general practitioner for implementation. This research focused on the first three steps of the medication review process and ends at the stage of either acceptance or rejection of CDSS signals by the pharmacotherapy team that resulted in medication optimisation recommendations to be discussed with the attending physician and the patient, prior to the implementation of medication changes. All consecutive steps of the OPERAM intervention and the focus of this study (step 1-3) are summarised in Figure 1. CDSS with integrated STOPP/START algorithms The CDSS used for pharmacotherapy analysis was the STRIP Assistant (STRIPA), a web-based CDSS developed to perform a digitalised STRIP analysis with integrated STOPP/START criteria v2 [8,17]. International coding systems were used for translating the STOPP/START v2 into algorithms, using the International Statistical Classification of Disease and related Health Problems, 10th revision (ICD10) codes for diseases, the Anatomical Therapeutic Chemical (ATC) coding system for medication, the Logical Observation Identifiers Names and Codes (LOINC) database for measurements (e.g. blood pressure, bone mineral density, laboratory values). The Medical Dictionary for Regulatory Activities (MedDRA) dictionary was used to register patient-reported symptoms (e.g. dizziness, fatigue) [9,15]. Seventy-nine out of 80 original STOPP criteria were encoded into algorithms. Only STOPP A2 ‘any drug prescribed beyond the recommended duration, where treatment duration is well defined’ could not be converted into an algorithm. Thirty-four original START criteria were converted to 33 algorithms as START A1 (‘Start vitamin K antagonists, direct thrombin inhibitors or factor Xa inhibitors in the presence of chronic atrial fibrillation’) and START A2 (‘Start aspirin if START A1 is contraindicated’) were merged into one algorithm (START A1/2). START I1 and I2 (‘Start influenza and pneumococcal vaccines’) were excluded from analysis because CDSS custom settings differed per country for these two criteria based on national vaccination programmes. This resulted in a total of 110 STOPP/START algorithms available for analysis. Details of the CDSS and the intervention as performed in the OPERAM trial have been published previously [15].
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