326 CHAPTER 4.2 Abstract Introduction Multimorbidity and polypharmacy remain challenging in the context of rapidly ageing populations globally. Periodic evaluation of the individual patient’s pharmacotherapy by medication review is important to ensure an optimised balance between therapeutic and preventive benefits and potential harms of treatment. The aim of this study was to evaluate agreement of hospital physicians and older patients with individualised STOPP/START based medication optimisation recommendations from a pharmacotherapy team. Methods This study was embedded within a large European, multicentre, cluster randomised controlled trial examining the effect of a structured medication review on drugrelated hospital admissions in multimorbid (≥3 chronic conditions) older people (≥70 years) with polypharmacy (≥5 chronic medications), called OPERAM. Data from the Dutch intervention arm of this trial were used for this study. Medication review was performed jointly by a physician and pharmacist (i.e. pharmacotherapy team) supported by a Clinical Decision Support System with integrated STOPP/ START criteria. Individualised STOPP/START based medication optimisation recommendations were discussed with patients and attending hospital physicians. Results 139 patients were included, mean (SD) age 78.3 (5.1) years, 47% male and median (IQR) number of medications at admission 11 (9-14). In total, 371 recommendations were discussed with patients and physicians, overall agreement was 61.6% for STOPP and 60.7% for START recommendations. Highest agreement was found for initiation of osteoporosis agents and discontinuation of proton pump inhibitors (both 74%). Factors associated with higher agreement in multivariate analysis were: female gender (+17.1% [3.7;30.4]), ≥1 falls in the past year (+15.0% [1.5;28.5]) and renal impairment i.e. eGFR 30-50 ml/min/1.73m2; (+18.0% [2.0;34.0]). The main reason for disagreement (40%) was patients’ reluctance to discontinue or initiate medication. Conclusion Better patient and physician education regarding the benefit/risk balance of pharmacotherapy, in addition to more precise and up-to-date medical records to avoid irrelevant recommendations, will likely result in higher adherence with future pharmacotherapy optimisation recommendations.
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