293 Frequency and acceptance of CDSS-generated STOPP/START signals Discussion Frequency and acceptance In 819 out of 826 patients (99%), at least one signal for potential inappropriate prescribing was generated by the CDSS using a set of 110 algorithms based on STOPP/START criteria v2 [3]. In 96% of patients ≥1 STOPP signals and in 82% of patients ≥1 START signals were generated. The pharmacotherapy team accepted 39% (n=1,990) of the total of 5,080 CDSS-generated STOPP/START signals. Overall, there was high variability in both the frequency and acceptance of the individual criteria. To discontinue a drug without a clinical indication (STOPP A1) was the most frequently generated signal (28% of all signals) and accepted in 54% of cases. Although more STOPP (68%) than START (32%) signals were generated, no significant difference was found between their respective mean acceptance rates. The detection of potential inappropriate prescribing in older patients has been investigated in several studies using a CDSS in a hospital setting. Heterogeneity in reported frequencies of medication overuse, underuse and misuse can generally be explained by differences in the study population, types of tools used and differences in tool application (e.g. prospective vs retrospective). For instance, a recent study found a lower prevalence for potential overuse (56%) and for potential underuse (58%) after application of STOPP/START v2 algorithms on a database with medical information from older hospitalised patients [19]. Retrospective database studies are often limited by incomplete documentation of relevant medical information directly affecting the prevalence of STOPP/START signals. Dalton et al. included four controlled studies in a systematic review reporting acceptance (range 29.3%–95.0%) of computer-generated recommendations for medication overuse in hospitalised older adults [20]. However, the computerised intervention tools were rather heterogeneous and did not include detection of potential underuse, which impedes comparison with our findings. More comparable to our research in relation to the study design and population is the SENATOR trial. This multicenter clinical trial investigated the impact of CDSSgenerated STOPP/START criteria v2 on the occurrence of adverse drug reactions (ADRs) within 14 days of inclusion in in-hospital multimorbid older patients [21]. The frequency of generated START signals (1.8 vs 2 per patient) was similar to that in our findings, but we detected higher overuse (2.8 vs 4.0 per patient) which may be explained by the exclusion of STOPP A1 (no clinical indication for the drug) in the SENATOR trial. In contrast to the medication review process in OPERAM, CDSSgenerated signals were directly presented to the attending physicians without assessment for clinical applicability by a pharmacotherapy team. The clinical relevance of the CDSS-generated signals according to attending physicians was 4
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