285 Frequency and acceptance of CDSS-generated STOPP/START signals Other STOPP signals from the top ten that resulted in a recommendation in more than 25% of cases included benzodiazepines (STOPP D5 – 64%), proton-pump inhibitors (STOPP F2 – 35%), unindicated dual anticoagulant and antiplatelet therapy (STOPP C5 – 32%) and duplicated drug classes (STOPP A3 – 26%). The most frequently generated START signal was a high-potency opioid in moderate-severe pain (START H1), but this signal was almost never accepted (3%). From the top ten most frequently generated signals based on START criteria, signals to initiate vitamin D, calcium or bone anti-resorptive therapy in osteoporosis (START E5 – 76%; START E3 – 61%; START E4 – 43%); a laxative with concurrent opioid use (START H2 – 48%); statin therapy with known coronary, cerebral or peripheral vascular disease (START A5 – 63%); an angiotensin-converting enzyme inhibitor with systolic heart failure and/or documented coronary artery disease (START A6 – 51%) or an anticoagulant with chronic atrial fibrillation (START A1A2 – 50%) were accepted in >25% of cases (Table 2). Detailed information on frequencies and subsequent acceptance for all STOPP/START criteria – in total and stratified per country – can be found in Supplementary Information SI1. An overview of the drugs (on ATC-2 level) involved in the medication optimisation recommendations based on accepted STOPP/START signals is provided in Supplementary Information SI2. For 9.1% (n=181) of all accepted signals, the pharmacotherapy team added the advice to defer implementing the recommended action to the patient’s general practitioner. The accepted signals that were most frequently (>10 times) recommended for deferral were: to stop a drug without indication (STOPP A1; n=43), to stop a benzodiazepine (STOPP D5; n=22), to start bone anti-resorptive therapy (START E4; n=19) and to start an ACE-inhibitor (START A6; n=16). These deferred recommendations were all included in the top ten most generated signals (Table 2). Determinants There was no difference in mean acceptance of STOPP versus START signals (+2.1 [95% CI, -1.5; +5.7]). Linear regression analysis was performed on potential patient- and setting-related determinants for STOPP and START signals. For STOPP signals, mean acceptance significantly decreased after multivariate linear regression analysis for patientswithmore co-morbidities (>9: -11.8% [95%CI, -19.2; -4.5%], Table 3). Admission to a surgical wardwas positively associatedwith acceptance (+10.3% [95%CI,3.8; 16.8]). InIreland(+26.8%[95%CI, 16.8;36.7])andtheNetherlands (+14.7 [95%CI, 7.8; 21.7]) ahigher acceptancewas foundcomparedwithSwitzerlandas reference country. For START signals, mean acceptance significantly decreased by -11.0% [95%CI, -19.4; -2.6] for patients with 7–9 co-morbidities after multivariate analysis. One or more falls 4
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