A mixed methods analysis of the medication review intervention centered around the use of the ‘Systematic Tool to Reduce Inappropriate Prescribing’ Assistant (STRIPA) in Swiss primary care practices

Background: Electronic clinical decision support systems (eCDSS), such as the ‘Systematic Tool to Reduce Inappropriate Prescribing’ Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the ‘Optimising PharmacoTherapy In the multimorbid elderly in primary CAre’ (OPTICA) trial. Methods: We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis. Results: In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations. Conclusions: Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs’ overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports). Trial registration: Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018

Medication optimisation in hospitalised older people with polypharmacy and multimorbidity

The prevalence of multimorbidity and polypharmacy is increasing in the ageing population, and both are important risk factors for drug-related harm, such as drug-related hospital admissions. Previous studies have reported that 10%–30% of all hospital admissions in older people are drug-related, half of which are potentially preventable. Several tools, such as the Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert to the Right Treatment (START) criteria, have been developed to detect potentially inappropriate prescribing in multimorbid older people to improve medication appropriateness and prevent adverse outcomes. To incorporate such tools into daily clinical practice, the application of software assistance has gained attention in facilitating medication optimisation. However, previous studies investigating pharmacotherapy optimisation interventions in older people reported inconsistent results on improved clinical outcomes. In this thesis, we focus on strategies for medication optimisation in hospitalised, multimorbid older people with polypharmacy and evaluate the effectiveness of a software-assisted in-hospital medication review on clinical outcomes. Key messages - Current clinical practice guidelines (CPGs) include screening tools to identify patients at risk for drug-related harm. For future development of explicit drug optimisation tools, such as STOPP/START, the clarity on a language level can be improved to enhance clinical applicability. - Screening tools recommended by CPGs have predictive value (~40%) to identify patients at risk for adverse drug reactions (ADRs) and for potentially inappropriate prescribing. However, when screening tools are integrated as clinical decision support in electronic health systems, their clinical applicability depends on the availability of structured patient information, the setting in which these tools will be used, and their intended end-users. (Chapter 2, 4.1) - A structured in-hospital medication review, performed jointly by a physician and a pharmacist with the support of a clinical decision software system, reduced inappropriate prescribing without causing detriment to patient outcomes, however, it did not significantly affect drug-related hospital admissions. (Chapter 3) - We found that medication errors identified at readmission were not addressed by the prior in-hospital medication review because either these medication errors occurred after the medication review (~50%), or no recommendation was given during the medication review (~25%), or the recommendation was not implemented (~25%). (Chapter 4.3) Conclusion 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. Barriers to the non-implementation of proposed recommendations differed between prescribers and patients and varied per drug class. 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. 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

Evaluation of clarity of the STOPP/START criteria for clinical applicability in prescribing for older people : a quality appraisal study

OBJECTIVES: Appropriate prescribing in older people continues to be challenging. Studies still report a high prevalence of inappropriate prescribing in older people. To reduce the problem of underprescribing and overprescribing in this population, explicit drug optimisation tools like Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) have been developed. The aim of this study was to evaluate the clinical applicability of STOPP/START criteria in daily patient care by assessing the clarity of singular criteria. DESIGN: Quality appraisal study. METHODS: For each of the 114 STOPP/START criteria V.2, elements describing the action (what/how to do), condition (when to do) and explanation (why to do) were identified. Next, the clarity of these three elements was quantified on a 7-point Likert scale using tools provided by the Appraisal of Guidelines for Research and Evaluation (AGREE) Consortium. PRIMARY AND SECONDARY OUTCOMES: The primary outcome measure was the clarity rating per element, categorised into high (>67.7%), moderate (33.3%-67.7%) or low (<33.3%). Secondary, factors that positively or negatively affected clarity most were identified. Additionally, the nature of the conditions was further classified into five descriptive components: disease, sign, symptom, laboratory finding and medication. RESULTS: STOPP recommendations had an average clarity rating of 64%, 60% and 69% for actions, conditions and explanations, respectively. The average clarity rating in START recommendations was 60% and 57% for actions and conditions, respectively. There were no statements present to substantiate the prescription of potential omissions for the 34 START criteria. CONCLUSIONS: Our results show that the clarity of the STOPP/START criteria can be improved. For future development of explicit drug optimisation tools, such as STOPP/START, our findings identified facilitators (high clarity) and barriers (low clarity) that can be used to improve the clarity of clinical practice guidelines on a language level and therefore enhance clinical applicability

Evaluation of clarity of the STOPP/START criteria for clinical applicability in prescribing for older people : a quality appraisal study

OBJECTIVES: Appropriate prescribing in older people continues to be challenging. Studies still report a high prevalence of inappropriate prescribing in older people. To reduce the problem of underprescribing and overprescribing in this population, explicit drug optimisation tools like Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) have been developed. The aim of this study was to evaluate the clinical applicability of STOPP/START criteria in daily patient care by assessing the clarity of singular criteria. DESIGN: Quality appraisal study. METHODS: For each of the 114 STOPP/START criteria V.2, elements describing the action (what/how to do), condition (when to do) and explanation (why to do) were identified. Next, the clarity of these three elements was quantified on a 7-point Likert scale using tools provided by the Appraisal of Guidelines for Research and Evaluation (AGREE) Consortium. PRIMARY AND SECONDARY OUTCOMES: The primary outcome measure was the clarity rating per element, categorised into high (>67.7%), moderate (33.3%-67.7%) or low (<33.3%). Secondary, factors that positively or negatively affected clarity most were identified. Additionally, the nature of the conditions was further classified into five descriptive components: disease, sign, symptom, laboratory finding and medication. RESULTS: STOPP recommendations had an average clarity rating of 64%, 60% and 69% for actions, conditions and explanations, respectively. The average clarity rating in START recommendations was 60% and 57% for actions and conditions, respectively. There were no statements present to substantiate the prescription of potential omissions for the 34 START criteria. CONCLUSIONS: Our results show that the clarity of the STOPP/START criteria can be improved. For future development of explicit drug optimisation tools, such as STOPP/START, our findings identified facilitators (high clarity) and barriers (low clarity) that can be used to improve the clarity of clinical practice guidelines on a language level and therefore enhance clinical applicability

Evaluation of clarity of the STOPP/START criteria for clinical applicability in prescribing for older people: a quality appraisal study

OBJECTIVES: Appropriate prescribing in older people continues to be challenging. Studies still report a high prevalence of inappropriate prescribing in older people. To reduce the problem of underprescribing and overprescribing in this population, explicit drug optimisation tools like Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) have been developed. The aim of this study was to evaluate the clinical applicability of STOPP/START criteria in daily patient care by assessing the clarity of singular criteria. DESIGN: Quality appraisal study. METHODS: For each of the 114 STOPP/START criteria V.2, elements describing the action (what/how to do), condition (when to do) and explanation (why to do) were identified. Next, the clarity of these three elements was quantified on a 7-point Likert scale using tools provided by the Appraisal of Guidelines for Research and Evaluation (AGREE) Consortium. PRIMARY AND SECONDARY OUTCOMES: The primary outcome measure was the clarity rating per element, categorised into high (>67.7%), moderate (33.3%-67.7%) or low (<33.3%). Secondary, factors that positively or negatively affected clarity most were identified. Additionally, the nature of the conditions was further classified into five descriptive components: disease, sign, symptom, laboratory finding and medication. RESULTS: STOPP recommendations had an average clarity rating of 64%, 60% and 69% for actions, conditions and explanations, respectively. The average clarity rating in START recommendations was 60% and 57% for actions and conditions, respectively. There were no statements present to substantiate the prescription of potential omissions for the 34 START criteria. CONCLUSIONS: Our results show that the clarity of the STOPP/START criteria can be improved. For future development of explicit drug optimisation tools, such as STOPP/START, our findings identified facilitators (high clarity) and barriers (low clarity) that can be used to improve the clarity of clinical practice guidelines on a language level and therefore enhance clinical applicability

A mixed methods analysis of the medication review intervention centered around the use of the Systematic Tool to Reduce Inappropriate Prescribing Assistant (STRIPA) in Swiss primary care practices

Background. Electronic clinical decision support systems (eCDSS), such as the ‘Systematic Tool to Reduce Inappropriate Prescribing’ Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the ‘Optimising PharmacoTherapy In the multimorbid elderly in primary CAre’ (OPTICA) trial. Methods. We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs ( n = 21) and their patients ( n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group ( n = 8), and interview data were analyzed through thematic analysis. Results. In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations. Conclusions. Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs’ overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports). Trial registration. Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018</p

Correction: A mixed methods analysis of the medication review intervention centered around the use of the ‘Systematic Tool to Reduce Inappropriate Prescribing’ Assistant (STRIPA) in Swiss primary care practices (BMC Health Services Research, (2024), 24, 1, (350), 10.1186/s12913-024-10773-y)

In this article, the author name Corlina Johanna Alida Huibers was incorrectly written as Johanna Alida Corlina Huibers due to a typesetting mistake. The author group has been updated above and the original article has been corrected. The publisher apologises to the authors and readers for the inconvenience caused by this error

Correction to: A mixed methods analysis of the medication review intervention centered around the use of the ‘Systematic Tool to Reduce Inappropriate Prescribing’ Assistant (STRIPA) in Swiss primary care practices (BMC Health Services Research, (2024), 24, 1, (350), 10.1186/s12913-024-10773-y)

In this article, the author name Corlina Johanna Alida Huibers was incorrectly written as Johanna Alida Corlina Huibers due to a typesetting mistake. The author group has been updated above and the original article has been corrected. The publisher apologises to the authors and readers for the inconvenience caused by this error

'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial.

INTRODUCTION Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy. METHODS AND ANALYSIS Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed. ETHICS AND DISSEMINATION The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal. MAIN FUNDING Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'. TRIAL REGISTRATION NUMBERS Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013)