(110) Analysis of Discordantly Identified Criteria in STOPP/START – Problems Underlying Poor Reliability in Practice

Saturday, August 27, 2022

8:00 AM – 6:00 PM CEST

Location: Hall C

Publication Number: 784

Presenting Author(s)

Naldy Parodi L�pez
– University of Gothenburg, Gothenburg, Sweden

Co-Author(s)

Staffan A. Svensson, MD, PhD
– University of Gothenburg, Dept of Pharmacology, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
Susanna M. Wallerstedt
– University of Gothenburg, Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, G�teborg, V�stra G�talands l�n, Sweden

Background: The inter-rater agreement regarding identification of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) using the Screening Tool of Older Persons’ Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, has been reported to be high. When applied on patient data in medical records, however, we have experienced reliability issues; PIMs/PPOs according to some criteria were consistently identified by one assessor and not the other.

Objectives: To describe underlying reasons for PIMs/PPOs according to some STOPP/START criteria that were completely discordantly identified by two general practitioners (GPs).

Methods: This descriptive study was based on PIM/PPO assessments, by two GPs according to STOPP/START version 2 based on information in the medical records, performed in a study investigating the clinical relevance of PIMs/PPOs as well as the adequacy of drug treatment in 302 consecutive, older, primary care patients (65-99 years; 59% female, median: 6 drugs in the medication list). Commonly occurring criteria, that were consistently identified by one assessor but not the other, were categorised and described in terms of underlying reason for the discordant identification.

Results: The STOPP criterion NSAID with severe hypertension (n=14), and the START criteria Bone anti-resorptive/anabolic therapy in patients with documented osteoporosis without contraindication (n=13), Beta-blocker with stable systolic heart failure (n=10), and Vitamin D and calcium supplement in patients with known osteoporosis/previous fragility fracture (n=9) were included in the analysis. In these 46 occasions, encountered in 34 patients and by one assessor only, the discordant identification could be attributed to diverging understanding of the wording of the criteria regarding the condition at issue (n=20, 43%), uncertainties regarding the drug treatment indication (n=9, 20%), insufficient information in the medical records (n=7, 15%), patients being treated with an adequate alternative (n=6, 13%), and patients declining treatment (n=4, 9%).

Conclusions: Several seemingly clear STOPP/START criteria are in practice difficult to interpret and apply using medical records as information source. This aspect could be worth considering in the design and interpretation of studies reporting PIM/PPO results.