399 General Discussion an overall in-hospital implementation of 97% [46]. This study demonstrated the feasibility of discontinuing unindicated ASA in a hospital setting. In OPERAM, the implementation rate of presumed unindicated ASA at two months was lower (67%). Box 2 T wo examples to illustrate the variability in physician’s and patient’s agreement with medication optimisation recommendations Example 1 Benzodiazepine (BZD) use and increased risk of falls Only a quarter of CDSS-generated STOPP signals to discontinue long-term BZD use (STOPP D5) was implemented at two months after the in-hospital medication review (64% of signals were accepted by the pharmacotherapy team, of which 39% were implemented). In the Dutch cohort of OPERAM intervention patients, approximately 50% of recommendations to discontinue a BZD were not agreed upon and, therefore, intentionally not implemented, which in 90% of disagreed recommendations was due to patient reluctance to discontinue BZDs [44]. Example 2 Unindicated acetylsalicylic acid (ASA) and increased risk of (gastrointestinal) bleeding O ne-fifth of CDSS-generated STOPP signals to discontinue ASA combined with an oral anticoagulant for atrial fibrillation (STOPP C5) were implemented at two months after the in-hospital medication review (32% of signals were accepted, of which 67% were implemented). Although reasons for nonimplementation were not studied for this recommendation, intentional nonimplementation of ASA was unlikely if ASA was considered unindicated. In contrast to the discontinuation of BZD use, the decision to continue or discontinue anticoagulation therapy predominantly relied on a clinician’s decision based on CPGs rather than patient preferences. The implementation of medication optimisation recommendations to reduce potentially inappropriate prescribing remains challenging, especially in large multicentre clinical trials. Before OPERAM, a European randomised controlled trial (SENATOR) investigated ADR occurrence in hospitalised older people with multimorbidity and polypharmacy within two weeks of an in-hospital intervention [47]. CDSS-generated medication optimisation signals in intervention patients were directly presented to attending clinicians on a feedback report at a single time point within 60hours after hospital admission, and no difference between the intervention 5
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