430 CHAPTER 6 For this reason, we concluded that implementing the ADR trigger tool at admission is unlikely to improve the detection of unrecognised ADRs in older patients acutely admitted to our geriatric ward. However, future research is needed to investigate the tool’s clinical value when applied to older patients acutely admitted to nongeriatric wards. In Europe, geriatric clinical practice guidelines endorse considering the use of the STOPP/START criteria to detect potentially inappropriate prescribing in older patients. The aim of the quality appraisal study performed in Chapter 2.2 was to evaluate the clarity of recommendations of this explicit screening tool for use in daily patient care. Clarity of the action (what/how to do), condition (when to do) and explanation (why to do) of the individual STOPP/START criteria were rated on a 7-point Likert scale using tools provided by the Appraisal of Guidelines for Research & Evaluation (AGREE) Consortium. Our results showed that the clarity of the STOPP/START criteria could be improved, with an average clarity ranging between 57%–67%. For the future development of explicit medication optimisation tools, such as STOPP/START, our findings identified facilitators (high clarity) and barriers (low clarity) to improve the clarity of clinical practice guidelines (CPGs) on a language level and therefore enhance clinical applicability. The lack of clarity of some STOPP/START criteria also made their conversion to algorithms for use in software systems challenging, as described in Chapter 2.3. Multiple multidisciplinary expert rounds were necessary to reach a consensus on how to interpret ambiguous wordings. A consensus was reached for all 34 START criteria and 76 of 80 STOPP criteria. The resulting 110 algorithms, modelled as inference rules in decision tables, were published as a template for integrating STOPP/START criteria version 2 to any software application. Process development and clinical outcomes of in- hospital medication reviews In Chapter 3.1, we developed a protocol for a medication review intervention, integrating single interventions that had demonstrated effectiveness in addressing drug-related problems in older patients. The developed intervention consisted of the following steps: a structured history-taking of medication (SHiM), a pharmacotherapy analysis according to the Systemic Tool to Reduce Inappropriate Prescribing (STRIP) method, assisted by a clinical decision support system (CDSS) with integrated STOPP/ START criteria (developed in Chapter 2.3), followed by shared decision-making with the patient and the attending physician, and lastly, sending an information letter on in-hospital medication changes to inform the general practitioner. The method integrated patient input, patient data, involvement from other healthcare
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