Bastiaan Sallevelt

73 Evaluation of clarity of the STOPP/START criteria experiences allowed clear identification of difficulties prescribers not familiar with STOPP/START may encounter. Although the scoring process remains partly subjective, the consensus ratings show high inter-rater agreement. Differences (>1 point) were discussed with a third appraiser and consensus was reached for all items. Therefore, the final clarity ratings were considered reliable. One concern of further specifying recommendations might be that they ‘replace’ important clinical considerations made by physicians. However, guideline recommendations are never meant to fully substitute clinical judgement to treat individual patients. This is why the explanation of a recommendation – next to the action and condition sections – is important for facilitating translation to an individual patient level. A lack of strong evidence to support the recommended actions could impede formulating clear explanations. For example, clear statements on numbers needed to treat (NNT) or numbers needed to harm (NNH) might be difficult to extract from currently available evidence. In such cases, the addition of the strength of recommendations and supporting evidence could further direct clinicians. This is also endorsed by internationally renowned CPG quality assessment tools from AGREE and GRADE [30]. Furthermore, our study only highlights barriers that could be optimized to prevent unintentional deviations from STOPP/START due to unclear language. Apart from the clarity of presentation, many other factors attribute to clinical implementation of evidence-based recommendations [27,31]. Implications To clarify the action, condition and explanation sections of a recommendation, a more detailed statement is often required. This may directly affect choices regarding the presentation of recommendations. In addition to improvements in ‘language’, the presentation style or ‘format’ of a guideline could have a high impact on applicability as well. In a time where almost all evidence-based knowledge is electronically requested, a dynamic, digital format could be used to integrate information that will improve clarity of presentation without making recommendations too extensive. Integrating clinical rules within electronic healthcare systems – with an option to request more detailed information - could contribute to a continuing learning cycle as part of (but without slowing down) the usual care process. For example, a drug class (stop benzodiazepines) may be provided with a hyperlink including information on drug substance levels (ATC5-codes) and a deprescribing tool, accessible upon request. Once a prescriber has become familiar with all the details of a certain recommendation, such information is no longer required. However, converting 2