297 Frequency and acceptance of CDSS-generated STOPP/START signals Lastly, the reasons for rejection of CDSS-generated STOPP/START signals were not collected, which makes it difficult to distinguish whether CDSS-related or setting-related restrictions had a larger impact on low acceptance of signals by the pharmacotherapy teams. Implications The use of STOPP/START v2 criteria as algorithms is a helpful approach to detect medication overuse, underuse and misuse in older patients within a hospital setting, but it may also result in signal overload. Given that more than half of all generated signals were rejected, an expert team’s involvement in translating population-based CDSS signals to individual patients is essential. Furthermore, our most frequently recommended action was ‘to stop a drug without a clear indication’ (STOPP A1), which requires critical clinical evaluation. Without such an expert team, signal overload will probably lead to low implementation rates in usual care, as shown in the SENATOR trial (15%) [22]. Our detailed description of the combined frequency and acceptance of STOPP/ START v2 within a large European hospital population could help to differentiate which STOPP/START algorithms provide the highest clinical benefit in a hospital setting. Future research investigating factors that affect patients’ and physicians’ agreement with medication changes recommended by expert teams may gain further insights for implementation in clinical practice. In addition, our results were based on decisions made by a pharmacotherapy team in a hospital setting, which may not be the most appropriate setting in which to change chronic medication. It would be highly interesting to compare the results of this study with those of the OPTICA (Optimising PharmacoTherapy In the multimorbid elderly in primary CAre) trial, in which the application of a similar STOPP/START-based CDSS is being investigated in a primary care setting [32]. Conclusion Nearly all hospitalised patients with polypharmacy and multimorbidity had at least one signal for potential medication overuse, underuse or misuse, and 39% of them were accepted by a pharmacotherapy team on the individual patient level. There was a high variability in the frequency and subsequent acceptance of individual STOPP/ START v2 signals. In general, the investigated patient-related determinants were poor predictors for STOPP/START v2 recommendation acceptance in a hospital setting. The moderate overall acceptance and the site-specific differences in acceptance emphasize the important role of a pharmacotherapy team in translating population-based STOPP/START signals to individual patients. 4
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