18 CHAPTER 1 from 42% to 24% (P<0.01) compared to a pharmacotherapy analysis without clinical decision support . However, unlike the aimed improvement in efficacy, participants spent more time using STRIPA attributed to the prototypical design of the software’s user interface, and the users’ unfamiliarity with the application. Further development of STRIPA aimed to improve usability, incorporate the updated STOPP/START criteria version 2 and make the tool suitable for application in a hospital setting . Effectiveness of medication review on clinical outcomes Although the aforementioned explicit screening tools have been shown to improve medication appropriateness in older people, the effect of medication reviews as a multicomponent intervention on clinical outcomes remains uncertain [81,82]. The low quality of currently available studies (e.g. short follow-up, small sample sizes, high risk of bias) impedes drawing firm conclusions [81,82]. In addition, heterogeneity in study designs, settings and outcomes also hamper comparing studies investigating the effectiveness of medication review [83,84]. Knowledge gap and thesis rationale Although geriatric-specific clinical practice guidelines have been developed to guide safe and effective pharmacotherapy, drug-related adverse outcomes in older patients remain a major problem. Thus, healthcare professionals and older patients still need evidence-based strategies to reduce potentially preventable drug-related harm. The question arises whether the existing tools for medication optimisation recommended by clinical practice guidelines are suitable for implementation in clinical practice or how their applicability can be improved. Hence, the uncertainty of the effectiveness of medication reviews in older people with polypharmacy and multimorbidity on clinical outcomes was the rationale to design a large, randomised controlled trial explicitly addressing the limitations of previous trials. The aim of the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial assessed the effectiveness of an in-hospital structured medication review compared to usual care on drugrelated hospital admissions and other clinical outcomes, using a core outcome set previously developed by European healthcare professionals and patients [85,86]. A detailed evaluation of the different steps of this in-hospital medication review could provide relevant insights to optimise this complex process.