Prescriber Implementation of STOPP/START Recommendations for Hospitalised Older Adults: A Comparison of a Pharmacist Approach and a Physician Approach
Two randomised controlled trials (RCTs) conducted simultaneously in the same Irish university teaching hospital have shown that provision of Screening Tool of Older Persons’ Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) recommendations to attending prescribers by a physician or a pharmacist can reduce in-hospital adverse drug reactions (ADRs) in older adults (≥ 65 years). The aims of this study were to compare the prescriber implementation rates of STOPP/START recommendations between the physician approach and the pharmacist approach in these two RCTs and to provide a narrative summary of the comparable clinical outcomes.
Data were extracted from the two RCT published papers and their associated computerised databases to calculate the percentage prescriber implementation rates for the STOPP/START recommendations. The Chi-square test was used to quantify the differences in prescriber implementation rates, with differences considered statistically significant where p < 0.05.
Prescriber implementation rates of the STOPP and START recommendations made by the physician were 81.2% and 87.4% respectively, significantly higher than those made by the pharmacist (39.2% and 29.5% respectively), p < 0.0001. A greater absolute risk reduction in patients with ADRs was shown with the physician’s intervention compared to the pharmacist’s intervention (9.3% vs 6.8%).
This study shows that the methods of communication and the medium through which the STOPP/START recommendations are delivered significantly affect their implementation. Non-implementation of some pharmacist-delivered recommendations may be contributing to preventable ADRs in older adults. Thus, future research should aim to identify the factors influencing prescriber implementation of pharmacist recommendations in order to inform the design of more effective pharmacist interventions in optimising older patients’ pharmacotherapy.
Compliance with Ethical Standards
Kieran Dalton and Denis O’Mahony were funded by the SENATOR project, supported by the Seventh Framework Programme FP7/2007-2013 under Grant agreement number 305930. David O’Sullivan and Marie N. O’Connor were funded by a Health Research Board of Ireland grant to conduct the original RCTs (Grant HRA_HSR/2010/14). The funders had no part in the design of this study, the collection, analysis and interpretation of the data, the writing of the report, or the decision to submit the article for publication.
Conflict of interest
Stephen Byrne and Denis O’Mahony have part ownership in a patent “A Prescription Decision Support System” (based on STOPP/START prescribing rules); the patent was registered with the European Patent Office (Munich); patent no. 11757950.8– 1952. Stephen Byrne and Denis O’Mahony are also affiliated with two European Commission-funded grants that involve clinical trials in which there is computerised deployment of the STOPP/START criteria as part of an intervention designed to optimise pharmacotherapy in older adults. The first European Commission grant is called “Development and clinical trials of a new Software ENgine for the Assessment and Optimization of drug and non-drug Therapy in Older peRsons [SENATOR]”, grant agreement 305930, awarded under the Seventh Framework Programme (FP7). The trial is registered with the US National Institutes of Health (NCT02097654). Denis O’Mahony is coordinator of the SENATOR project. The second European Commission-funded project is called “OPERAM: OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly”. OPERAM is funded under the Horizon 2020 programme (PHC 17-2014). The OPERAM trial is based on another software intervention called “Screening Tool to Reduce Inappropriate Prescribing”, which uses STOPP/START rules to assess the pharmacotherapy of older people. The trial is registered with the US National Institutes of Health (NCT02986425). Kieran Dalton, David O’Sullivan, and Marie N. O’Connor have no conflicts of interest that are directly relevant to the content of this article.
Both RCTs were approved by the research ethics committee of the local teaching hospitals network, and both were registered with the National Institutes of Health in the USA: ClinicalTrials.gov identifier for RCT 1: NCT01467050; ClinicalTrials.gov identifier for RCT 2: NCT01467128. Written consent was obtained from all participating patients (or their next of kin) prior to RCT enrolment.
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