341 Hospital physicians’ and older patients’ agreement with individualised STOPP/START recommendations such as sepsis, pain or dehydration. Lastly, communication with the GP was solely through a written report with recommendations to consider after discharge (separately from the hospital discharge letter) and could easily have been missed by the GP. It is likely that adherence by GPs to the postponed recommendations could be improved by discussion through follow-up phone calls to explain and motivate the patients’ GPs to implement prescribing recommendations post-discharge. Implications In this study high willingness among hospitalised multimorbid older patients and their attending physicians to follow pharmacotherapy optimisation recommendations was found, however, some important areas for improvement were also identified. Disagreement with recommendations was related to the patient’s reluctance to change pharmacotherapy in approximately 40% of cases. Better patient education regarding the potential benefits and harms of pharmacotherapy and training of physicians/pharmacists in shared-decision-making (SDM) to more effectively communicate this information to the patient could attribute to better informed decision-making and possibly higher agreement [29]. More and better education and explanation about the potential benefits of implementing the suggested pharmacotherapy recommendations is also important for the hospital physicians, because they felt that some medication groups were beyond their own area of expertise. The discussion with the patient and physician revealed that medical records were not always up to date, making 13% of the recommendations irrelevant at the time of discussion. To increase the specificity of CDSS-assisted medication reviews, it is important that the necessary clinical information in medical records is current and accurate. Low implementation rates of pharmacotherapy optimisation recommendations in clinical trials impedes drawing firm conclusions about the impact of medication reviews on clinical end points like readmissions and mortality, as was recently found in the OPERAM trial [26]. Also, medication reviews should not be performed at a single time point during admission, but need to be repeated after discharge in close collaboration with the GP and community pharmacists, since nearly 50% of patients are unable to recall medication changes implemented inhospital [22,30]. The effects of medication adjustments (both positive and negative) should be closely monitored and recommendations continuously evaluated and adjusted when necessary. In addition, discussion of medication changes with older patients during hospital admissions for acute illnesses and corresponding disturbances of homeostasis, may not be the ideal time to optimise long-term pharmacotherapy. Both patients and prescribers often have other priorities and certain medication changes could have detrimental effects in unstable patients. Not surprisingly, the patient’s GP appears to have particularly strong influence on medication withdrawal (both for and against) [31,32]. Trials focusing on optimising pharmacotherapy in multimorbid older people conducted in, or in close collaboration 4
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