A Step in The Right Direction: Optimization of STOPP/START Recommendations for Pharmacists

Pharmacists and prescribers have adopted a screening tool to identify potentially inappropriate/harmful medications used in older populations. The tool has 2 parts: Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START).

A 2019 analysis of STOPP/START-based medication optimization recommendations evaluated elderly patients’ acceptance of medication recommendations in a hospital setting. With such a high prevalence of multiple chronic conditions and medications in this community, it is important for health care professionals to evaluate and de-prescribe when appropriate.

In the cluster, randomized, controlled OPERAM trial, 139 patients completed and discussed the medication review. Patients included in this study were those with at least 3 chronic conditions, and patients older than 70 years of age with at least 5 chronic medications.

A physician and pharmacist completed a medication review for each patient to reduce hospital admission. This intervention was composed of 5 steps, including acquiring patient information, screening by a Clinical Decision Support System (CDSS), developing individualized recommendations, discussing with the patient and attending physician, and transferring recommendations to the general practitioner. Together, patients and physicians discussed 371 recommendations from the CDSS-assisted pharmacotherapy analysis.

The study showed patients agreed with 61.6% of STOPP recommendations and 60.7% of START recommendations. The initiation of osteoporosis agents (primarily vitamin D and calcium) and discontinuation of proton pump inhibitors for gastrointestinal disorders had the highest agreement rate of 74%.

Physicians proposed STOPP recommendations to the majority of patients who had “no evidence-based clinical indication” for the current medication. Overall, patient consistency with implementing STOPP criteria was considerably higher than START when evaluating 2-month follow-ups.

The study highlights the most common factors resulting in agreement or disagreement as follows:

• Agreement:
  • Female gender
  • ≥ 1 fall in the past year
  • Renal impairment
• Disagreement:
  • Reluctance to discontinue or initiate medication by the patient

A key finding from this study was that many patients desired to reduce the number of medications taken daily but did not want to discontinue benzodiazepines/Z-drugs from their regimens.

This study suggests that clinicians need to develop ways to further promote adherence in this population. Polypharmacy and multimorbidity pose a threat to the elderly.

The authors concluded that health care professionals need to work closely with patients in understanding polypharmacy and the risk/benefit of patients’ pharmacotherapy. The data from this study are promising in increasing adherence to STOPP/START recommendations long-term.

About the Author

Karisse Lora is a 2023 PharmD candidate at the University of Connecticut.

REFERENCE

Huibers CJA, Sallevelt BTGM, Heij JMJO, et al. Hospital physicians' and older patients' agreement with individualised STOPP/START-based medication optimisation recommendations in a clinical trial setting. Eur Geriatr Med. 2022;13(3):541-552. doi:10.1007/s41999-022-00633-5