Bastiaan Sallevelt

74 CHAPTER 2.2 recommendations into effective software assistance starts with a clear message of the initial statements. To make the current version of STOPP/START criteria suitable for software engines, multiple multidisciplinary expert rounds turned out to be necessary to reach consensus on how to interpret ambiguous wordings [32]. For instance, due to different lists of anticholinergic drugs in current literature, expert opinion is needed to translate this drug class to clinically relevant, individual drugs with high anticholinergic burden. Furthermore, it was found that some recommendations, such as to ‘stop any drug beyond the recommended duration (STOPP A3)’ were too general or unspecific to convert into an algorithm. Selecting specific recommendations concerning potentially inappropriate long-term use of medication, such as long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthritis (STOPP H4) or continuing bisphosphonates >5 years without evaluating efficacy (not a criterion), will probably result in a better uptake among clinicians and can be easily integrated into clinical decision support systems. Consequently, the lack of clear statements may impede software implementation [32,33]. Another advantage to present clear recommendations in an electronic, dynamic format, is that content could be easily modified based on updates in evidence, country specific guidelines, available drugs and local expertise. Collaboration of guideline developers with experts in medical informatics for considering content formatting could therefore be of great value to facilitate future implementation of recommendations in clinical practice. Conclusion In conclusion, for future development of clinical practice guidelines (CPGs), our findings provide direction to assure the clarity of recommendations. We believe in the opportunity to transform STOPP/START from a tool to detect inappropriate prescribing to a guideline that provides clear statements on how to act after detection. The use of specific and unambiguous language in CPG recommendations is likely to assist physicians in prescribing the right drug to the right patient at the right time.