294 CHAPTER 4.1 not prospectively measured, but a post hoc analysis of the SENATOR trial showed that only 15% of generated signals were implemented by the attending physicians [22]. However, after retrospective examination of signals by a pharmacist-physician pair, it was found that 39% of all generated signals were deemed to be of possibly important or very important clinical relevance [22]. This percentage is in line with the rate of signal acceptance by the pharmacotherapy team in our study. Determinants Country of recruitment was the most important determinant for which a significant difference in acceptance for both STOPP and START signals was found compared with Switzerland as the country of reference. The higher acceptance of signals by the pharmacotherapy team from Cork (Ireland) - the originator of STOPP/START version 1 - may be partly explained by familiarity with applying these criteria in their hospital. However, the STOPP/START criteria are now widely used across Europe, and the pharmacotherapy teams were trained according to standardised operating procedures before performing the intervention. Therefore, site-specific differences in rotation and level of clinical experience of the pharmacotherapy teams may be more likely to explain the variability in acceptance across sites, with Switzerland having a high turnover of physician-pharmacist pairs that performed the intervention compared to the other countries. The impact of other significant patient- and setting- related determinants on acceptance was relatively low, ranging from -11.8% to +10.3. Acceptance was positively associated with admission to a surgical ward for STOPP signals (+10.3%), which suggest that special attention to deprescribing in patients on surgical wards may be beneficial. Investigation of patient-related factors revealed a negative association between an increased number of co-morbidities and the acceptance of STOPP and START signals. This may indicate that the population-based STOPP/ START criteria are less suitable for application to individual patients with multiple conditions, for instance because co-existing relevant contra-indications could impede medication changes. From the patient-related determinants, one or more hospital admissions in the previous year and a history of falls were positively associated with acceptance of START signals. The higher acceptance in patients with a history of falls could be explained by the high number of accepted signals related to vitamin D, calcium supplements and bone-antiresorptive therapy. Although these patientrelated factors were statistically significant, differences were considered too small to define a clear inpatient patient population for whom the application of STOPP/ START would be of lower or higher value from a clinical perspective.
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