393 General Discussion 1.1. Improving applicability by increasing the clarity of clinical practice guidelines Clinical decision-making on (in)appropriate prescribing in older people is a highly complex process. It depends on the healthcare provider’s ability to structure and obtain all relevant patient information, relate this information to evidence-based guidelines and decide on the most appropriate treatment for and with patients. Specific and unambiguous wording in guideline recommendations is important to change prescribing behaviour and may facilitate adherence to evidence-based recommendations [24,25]. We found that the clarity of both investigated screening tools could be improved. In Chapter 2.1, we explicated the original ADR trigger tool as presented in the Dutch geriatric guideline to reduce undesirable variations in interpretation when applied to electronic health records (EHRs; e.g. specifying ‘psychotropic agents’). Then, in Chapter 2.2, we identified that refinements in the STOPP/START criteria might enhance applicability in clinical practice [26]. Thus, guideline developers should inquire whether recommendations are tailored for their intended end-users to maximise the applicability of CPGs. Explicit screening tools on polypharmacy optimisation, like STOPP/START, are likely to be developed to reach a variety of healthcare professionals since all prescribers treat older patients with polypharmacy. Clinicians less experienced with pharmacotherapy optimisation in older people will likely require more specific guidance than the current version of the STOPP/START criteria [26]. Improvements in the content clarity of STOPP/START could be made to the level of individual criteria and the level of coherence between the criteria, which in some cases contradict. Merging recommendations could increase guideline uptake and prevent potential patient harm by overlooking relevant contra-indications. For example, assessing of the indications for mono, double and triple antithrombotic therapy, the preferred type of therapy, and the recommended duration of the therapy is complex. Detailed but relevant information for this assessment is currently scattered across single-disease (cardiovascular) guidelines [27]. Integrating this information into one clinical decision model may be more effective than presenting 11 single-sentence individual STOPP criteria (version 2, section C) to alert for potential risks in antithrombotic therapy [28]. In a time where almost all evidence-based CPGs are electronically requested, additional information that can improve the clarity of recommendations (e.g. electronic linkage to deprescribing tools or referral to more in-depth information on benefits/risks in specific populations) may further increase guideline uptake in clinical practice without making the recommendations too extensive. 5
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