Bastiaan Sallevelt

71 Evaluation of clarity of the STOPP/START criteria a drug substance level was not specific enough. For instance, folic acid for patients on methotrexate therapy (START E7) only applies to patients using a low dose, weekly methotrexate schedule and not for patients on high dose methotrexate. In such cases, a more detailed description of a drug dosage, route or indication was deemed necessary. Conditions described by diseases - like ‘heart failure’ - might seem clear at first, but often need further specification (reduced vs. preserved ejection fraction) to avoid ambiguity. Moreover, international cardiology guidelines distinguish between these subtypes of heart failure, subsequently affecting treatment recommendations. Adherence to terminology of internationally used dictionaries to describe diseases, such as International Classification of Primary Care (ICPC) and International Classification of Diseases (ICD), could be a solution. Furthermore, no explanations were present for START criteria to substantiate why a potential omitted drug should be initiated. Even though the reason to start a drug might seem obvious in most cases, the risk-benefit balance should always be addressed to assist a physician’s decision-making process whether or not to expose a patient to additional drug therapies. Other remarks STOPP/START criteria provide best evidence-based practices for the over- and undertreatment of single conditions. However, it should be noted that STOPP/ START criteria provide conflicting recommendations. For example, if a patient has a clear indication for a beta blocker to treat ischaemic heart disease (START A7), this is contradicted if a patient is already using verapamil or diltiazem (STOPP B3). Merging such recommendations could increase implementation and prevent potential patient harm by overlooking relevant contra-indications. Besides making the what, how, when and why as clear as possible, guideline developers should consider whether recommendations are tailored for its intended end-users (i.e. the who). Explicit screening tools to detect inappropriate prescribing in older people such as Beers criteria and STOPP/START, are likely to be developed to reach all professionals involved in prescribing, as all prescribers encounter the problem of under- and overprescribing in older people. Clinicians with high affinity for geriatric medicine may not need explicit treatment recommendation to provide best patient care, whereas some clinicians - such as e.g. surgical specialists - who treat older people but may be less experienced with (in)appropriate prescribing in older people, probably require more clear guidance. Clear recommendations are therefore important to reach all prescribers, because the success of STOPP/ START criteria as an intervention depends on its integration and implementation in clinical practice [23]. Some recommendations may be best applied by physicians with a certain expertise, such as to start an ‘acetylcholinesterase inhibitor for mild2