Inappropriate prescribing and prescribing omissions among drug-related problems using STOPP-START criteria

Background and objectives: Medication review has been suggested as a way to prevent drug related problems (DRPs). Screening tools have been formulated to identify potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) respectively called Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START). The aim was to determine the percentage of PIMs and PPOs present in identified potential DRPs and the implementation rates of associated recommendations in elderly patients. Setting and method: A cohort study in a primary care setting. The study was performed in 13 Dutch community pharmacies. Patients were eligible for medication review when they were aged ≥65 years and used five of more different drugs. The patient's community pharmacist interviewed patients about their medicines. A pharmaceutical care plan (including DRPs and recommendations) was proposed by the community pharmacist and implemented after agreement with patients' general practitioner. All DRPs identified were retrospectively compared with START- and STOPP-criteria. Main outcome measures: The number and types of potential DRPs identified by the community pharmacist and the implementation rate of associated recommendations. The number of PIMs and PPOs present in identified DRPs using STOPP- and START-criteria and the implementation rate of associated recommendations. Results: The total number of potential DRPs identified by pharmacists was 1,811 in 507 patients (mean 3.6 per patient). The most common DRPs were: condition undertreated (419, 23 %), no indication apparent (278, 15 %) and adverse effects (182, 10 %). Using STOPP-criteria, potential DRPs concerning PIMs were present in 15 % of the patients. 84 of 362 recommendations to discontinue a drug (23.2 %) concerned STOPP-criteria. Using STARTcriteria, PPOs were present in potential DRPs for 33.3 % of patients. START-criteria were present in 219 of 299 recommendations to add a drug (73.2 %). 59 % of all recommendations were implemented. The implementation rate for recommendations to discontinue a drug was 49.1 % compared to 56 % for the subgroup recommendations concerning STOPP-criteria. The implementation rate for recommendations to add a drug was 39.8 % compared to 36 % for the subgroup START-criteria. Conclusion: Potential prescribing omissions are more prevalent compared to potentially inappropriate drug prescribing among older people living in the community in the Netherlands. Implementation for recommendations concerning inappropriate prescribing was higher compared to recommendations concerning omissions.