433 Summary Conclusion and future perspectives The investigated screening tools recommended by geriatric CPGs have predictive value in detecting potential drug-related risks in hospitalised older people with polypharmacy (ADR trigger tool, PPV: 42%; STOPP/START, signal acceptance: 39%). Therefore, these tools could contribute to identifying patients at risk for inappropriate prescribing. However, they also pose a risk of alert fatigue if implemented as clinical decision support in electronic health records. For future guideline development, it is important to formulate specific recommendations that ease integration in software systems and may contribute to increased guideline adherence. In addition, to bridge the potential gap between guideline recommendations and clinical practice, it is important to evaluate the performance of clinical decision support if implemented in electronic healthcare systems. These results obtained from clinical practice could be used to further develop and specify CPGs, for instance, to identify patients and settings in which interventions are most successful. However, even with optimal software assistance, the interaction between attending physicians, patients and healthcare professionals with expertise in geriatric care remains essential in translating evidence-based signals for potentially inappropriate prescribing to the most appropriate pharmacotherapy at the individual patient level. The barriers to the non-implementation of proposed recommendations differed between prescribers and patients and varied per drug class. Thus, more research is necessary to identify the most effective strategies to overcome these barriers. The results of the OPERAM trial showed that a single, structured in-hospital medication review reduced potentially inappropriate prescribing in older people with no detriment to patient outcomes. However, it did not significantly reduce drug-related hospital readmissions. To explain these results, we found that the prior single in-hospital medication review did not address medication errors identified at readmission because either these errors occurred after the medication review, no recommendation was given during the medication review or the recommendation was not implemented. Therefore, future research should focus on optimising the medication review timing, setting and frequency and implementing of proposed medication recommendations across health care settings. Overall, we learned that the association between a patient-specific medication review and the clinical outcome ‘drug-related hospital admission’ is difficult to establish with a randomised controlled trial because both the intervention and outcome are highly variable. Thus, to further explore the potential clinical benefits of medication optimisation interventions in older people, we recommend exploring research designs based on large, real-world data rather than randomised clinical trials. 6
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