295 Frequency and acceptance of CDSS-generated STOPP/START signals CDSS-related restrictions To incorporate guideline recommendations into the CDSS, STOPP/START criteria were converted into algorithms; however, many lacked sufficient clarity for translation [9,23,24]. STOPP A2 – ‘Any drug prescribed beyond the recommended duration, where treatment duration is well defined’ – could not be coded at all, and some elements of other criteria were left out (e.g. for START A5 – ‘…unless the patient’s status is end-of-life’). For other ambiguous criteria (e.g. STOPP M1 – ‘drugs with antimuscarinic/anticholinergic properties’), experts consisting of senior physicians and clinical pharmacists were consulted to reach consensus on which conditions or drugs should be included in the algorithms. Risk of over-detection rather than under-detection was chosen as a strategy for converting STOPP/START criteria into algorithms within the OPERAM trial. Consequently, simplifying certain criteria probably led to false-positive signals and negatively affected acceptance. In addition, multiple STOPP and START criteria could be generated recommending medication changes for the same drug, while the CDSS allowed the pharmacotherapy team to accept only one recommendation for each drug per patient. For instance, STOPP L2 – ‘use of regular (as distinct from PRN) opioids without concomitant laxative’ and START H2 – ‘laxatives in patients receiving opioids regularly’ would both be generated in a patient using opioids without a laxative. In such cases, the pharmacotherapy team could either reject both signals, or – if a drug change was clinically indicated – accept the most appropriate signal of the two, which resulted more frequently in a recommendation to initiate a laxative (Table 2, START H2: frequency n=115; acceptance 47.8%) rather than to discontinue the opioid (Table 2, STOPP L2: frequency n=56; acceptance 12.5%). Setting-related restrictions The pharmacotherapy analysis was performed in a hospital setting, but decisions to accept or reject STOPP/START signals may be different in other clinical settings as well as the willingness of patients and phycians to change long-term medication use. Hospitalisations have a significant impact on the continuity of pharmacotherapy, whereas STOPP/START criteria mainly focus on chronic drug use [25–27]. However, the pharmacotherapy team could also decide to accept but defer the implementation (e.g. drug tapering) of a clinically relevant signal until after discharge, and those signals were counted as accepted. In addition, our geriatric population was relatively functionally independent with only 8.4% of participants living in nursing homes. Results from a study investigating the impact of STOPP/ START criteria (v1) in frail geriatric chronic care residents found that 82.4% of STOPP and 92.6% of START recommendations made by a research pharmacist were implemented by the attending physician [28,29], whereas only 62.2% of all 4
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