392 CHAPTER 5 Based on these lessons learned, we elaborate on the following main topics: 1. The applicability of screening tools for medication optimisation 2. The process of in-hospital medication reviews 3. Outcome measures of medication reviews 4. Medication reviews in older people – who, when, where and how? 1. The applicability of screening tools for medication optimisation Previous research has demonstrated that most drug-related harm in the older population is caused by a few commonly used drug classes [18–22]. Consequently, screening tools targeting these drugs have emerged in geriatric CPGs. To identify older people at risk for inappropriate pharmacotherapy, the ADR trigger tool recommended by the Dutch geriatric guideline and the more widely used STOPP/ START criteria are examples of explicit screening tools based on drugs frequently associated with drug-related harm. We showed that both screening tools had predictive value for detecting ADRs and potentially inappropriate prescribing in a hospital setting. The positive predictive value (PPV) of the ADR trigger tool was 42% (Chapter 2.1) when applied to acutely admitted older people, and the acceptance of software-generated STOPP/START signals by a pharmacotherapy team was 39% (Chapter 4.1) when applied as clinical decision support [23]. Therefore, these tools could contribute to identifying patients at risk for ADRs and potentially inappropriate prescribing. Moreover, we found that the prevalence of potentially inappropriate prescribing by screening older people with multimorbidity and polypharmacy using STOPP/START was very high; in 99% of OPERAM intervention patients at least one STOPP/START signal was generated by a CDSS with a median of 6 (IQR 4–8) generated signals per patient. After evaluation of these signals by a pharmacotherapy team in the clinical context of the individual patient, a median of 2 (IQR 1–3) recommendations per patient was discussed with the attending physician and the patient (Chapter 4.1) [23]. These results implied that potentially inappropriate prescribing among older people is still remarkably common, thereby highlighting the gap between CPGs and prescribing behaviours in clinical practice, including the potential for interventions to improve appropriate pharmacotherapy. The next paragraphs reflect on 1) improving the applicability of screening tools by increasing the clarity of CPGs 2) integrating screening tools in CDSS and 3) improving the applicability by increasing the availability of structured electronic patient data.
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