296 CHAPTER 4.1 OPERAM patients had ≥1 STOPP/START recommendation implemented at two months follow up [30]. Interestingly, the implementation of recommendations to discontinue benzodiazepines was lower in the geriatric chronic care setting (23%; n=3/13) than in the OPERAM trial at two months follow up (39.1%; n=45/115) [28,30]. These differences may illustrate that decisions to optimise pharmacotherapy are likely to differ in a hospitalised population compared to those made for long-term care facility residents or in primary care. Strengths and limitations In our study, medical information at the time of pharmacotherapy analysis was prospectively collected and assessed for clinical applicability by physicians and pharmacists with clinical experience in caring for older adults with full access to the patient’s actual medical file. Unlike in retrospective studies, essential factors, such as life expectancy, drug exposure length and time until benefit, were considered by the pharmacotherapy team. Carvalho et al. have reported that only one-third of all STOPP criteria and just one START criterion can be adequately applied if only a patient’s medication list is available without diagnostic data [31]. Consequently, applying STOPP/START using medical databases without clinical evaluation is hampered compared with its use on real-time patient data. Our structured prospective evaluation of STOPP/START signals in a large group of in-hospital older people provides accurate insight into clinically relevant signals of over- and underprescribing in this population. A limitation of this study was the relatively large number of missing data (n=137). After performing a pharmacotherapy analysis, the pharmacotherapy team had to actively save the results into the CDSS. Due to technical failure, results were not saved in the CDSS in 49 of the OPERAM intervention patients (5%). No in-hospital pharmacotherapy analysis was performed for the other missing patients due to various reasons, such as early discharge from the hospital, transfer to another ward, or withdrawal before intervention. The acceptance reflects the pharmacotherapy team’s treatment recommendations regarding presumed overuse, underuse and misuse; however, information about individualised treatment goals and patient preferences was not always available during the pharmacotherapy analysis. The proposed recommendations’ implementation after discussion with both the attending hospital physician and the patient and the persistence after discharge, were not included in the design of this study. In the main OPERAM trial results, data on implementation of recommendations at two months after index hospitalisation were provided [30]. However, in this substudy, the study population and the term ‘recommendations’ were defined differently than in the OPERAM main trial (see SI3).
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