72 CHAPTER 2.2 moderate Alzheimer’s dementia or Lewy Body dementia (START C3)’. In such cases, the focus for all clinicians should probably be the recognition and detection of a potential omission, rather than to actually start drug treatment. An explicit action could be to refer such patients to a geriatrician or neurologist, thus separating the trigger for potential undertreatment from the actual prescriber. Strengths and limitations To the best of our knowledge, this is the first study that explores the clarity of STOPP/START criteria. By systematically reviewing the clarity of the given action, condition and explanation, we identified facilitators (high clarity) and barriers (low clarity) that may be used to improve the content on a language level. As a result, element-specific strategies can be extracted to improve items requiring refinement. Although no previous studies have reviewed the clarity of singular recommendations of explicit drug screening tools, comparable research has been conducted concerning clarity of monitoring instructions in CPGs and drug labels. Their conclusions to improve ambiguous instructions concerning the monitoring of laboratory values are in line with our suggestions to add clear statements about the what, why, when and how of recommendations [24,25]. Moreover, studies to refine the methodology of developing deprescribing guidelines to facilitate the deprescribing process were conducted [26,27]. A good example are the tools provided by the Bruyère Research Institute, based on their research about developing deprescribing guidelines. The Bruyère research group has published evidence-based clinical practice guidelines (for instance how to deprescribe benzodiazepines), accompanied by clear algorithms including well-described populations (including for which patients the recommendation does not apply), a list of available drugs and dosages, monitoring recommendations and tapering regimes, thereby complementing the clarity some STOPP-recommendations are lacking [28]. Tools that have been developed to review the quality of entire CPGs underline the importance of clear and unambiguous recommendations [29], but no validated tool exists to rate singular clinical recommendations. As clarity of presentation is both part of the AGREE II Instrument and described by GUIDE-M, we used tools from the AGREE Consortium to develop a reviewmethod. Moreover, the AGREE II Instrument is internationally formally endorsed for guideline assessment and provides a Likert scale that allowed us to quantify clarity. Clarity ratings were scored by appraisers who are experienced in applying STOPP/ START criteria in clinical practice, as they contributed to a large multicentre, randomized controlled trial that evaluated the impact of a STOPP/START-based medication review in older people with polypharmacy. We believe that these
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