340 CHAPTER 4.2 In the OPERAM main trial, at least one of the recommendations was successfully implemented at 2 months follow-up in 62.2% of the patients who received ≥1 recommendation during the intervention (across all participating countries). This primarily concerned the discontinuation of potentially inappropriate medications (STOPP A1) and duplicate drug class prescriptions (STOPP A3) [28]. Interestingly, the recommendation by PTs to discontinue benzodiazepines used ≥4 weeks (STOPP D5), was implemented in 39.1% at 2 months, suggesting that the majority (80%) of these recommendations agreed upon during discussion (55.1% in our study) were actually implemented after discharge and still discontinued at 2 months. As for START criteria, implementation was considerably lower at 2 months ranging from 12.7% for ‘bone antiresorptive treatment’ in osteoporosis (START E4) to 38.8% for vitamin D supplements in housebound patients (START E5). Although these OPERAM results reflect all participating trial sites and the agreement presented in this study concerns only the Dutch trial site, these numbers confirm our hypothesis that many possible factors impede the actual and persistent implementation of (verbally) agreed upon recommendations after hospital discharge. Limitations This study has some limitations. Firstly, data were collected in a single centre and represent a relatively small sample. Secondly, the entire intervention including CDSS analysis and discussion with both patient and attending hospital physician (in cases where STOPP/START recommendations were applicable), as intended by the OPERAM trial protocol [15], was not completed in 66 of 229 (28.8%) Dutch patients which could have introduced bias to the results. Also, according to the OPERAM protocol, only numbers of diseases and medications, rather than the prevalence of common diseases and medications, are presented at baseline [28]. This might compromise the generalisability of the results. Thirdly, reasons for disagreement were collected by the PT after discussion with patients and attending physicians, thereby possibly introducing bias during documentation of the reasons. In addition, the ‘patient does not agree’ option could also be interpreted as ‘PT failed to convince the patient’ in some cases. Furthermore, agreement with recommendations mentioned in our study was based on ‘oral consent’ to follow the suggested recommendations by both patients and physicians. Although these percentages might considerably change over time, agreement/disagreement was not re-evaluated after discharge. Moreover, actual implementation of the STOPP and START recommendations at hospital discharge was at the discretion of the attending physician and not measured in this OPERAM substudy. It is likely, however, that whilst attending physicians agreed upon medication adjustments verbally, implementation rates were lower due to practical/logistical reasons (e.g. busy clinical practice, pressure to discharge patients once stable etc.) or patient-related factors like additional changes in medication due to (acute) intercurrent conditions
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