Title: How, when and why do STOPP/START criteria based interventions improve medicines management for older people: a realist synthesis
Funder: Department of Health and Social Care

Abstract: Background Drug-related problems and potentially inappropriate prescribing can lead to adverse drug events (ADEs), hospitalisation and death, thereby imposing a huge burden on patients and the health care system. Discontinuation of inappropriate medications through early detection can trigger a cascade of positive effects that range from improvement of care quality and reduction of ADEs to the improvement of the cost-effectiveness of pharmacological therapeutic plans and quality of life of older people. The most widely used tools for appropriate prescription in older adults in England and European countries are the STOPP/START tools. Deep understanding of how interventions based on the use of these tools work, for whom, in what contexts and why they work is currently lacking. This study aims at using a realist approach to synthesise the evidence on interventions centred around the use of STOPP/START tools. Methods Database and web searching will be carried out to find relevant evidence for the identification and testing of programme theories about how interventions based on use of the STOPP/START tools work. We will firstly identify programme theories which explain how in what circumstances interventions are supposed to work and to capture in detail the reasoning that underlie these interventions, and then we will review the evidence to determine the extent to which these expectations are met in practice. A project reference group made up of older people and carers and members of the public, health care professionals, and NHS decision makers will be set up to ground the study in real-life experience. In Phase 1 we will identify programme theories about STOPP/START interventions on how, for whom, in what contexts, and why they are intended to work, and whether patients are being involved in shared decision making in stopping or starting medicines. We will conduct electronic searches of the peer reviewed literature to identify position pieces, comments, letters, editorials and critical pieces relevant to the research questions, as well as reports of studies using the tools and will supplement them with searches of grey literature to identify generic guidance and policy documents. Discussions with experts in the field and patients and carers in our reference group will also contribute to the identification and refinements of programme theories. In Phase 2 we will test the programme theories. We will review and synthesise relevant published and unpublished empirical quantitative and qualitative evidence. Impact Through identification, testing and refining programme theories about how interventions centred around STOPP/START tools work against existing evidence of how they works in practice, we will support decision-makers in improving appropriate prescribing and patients’ health outcomes. The development of realist review methods that take into account cost and cost-effectiveness evidence is particularly innovative and challenging, and if successful will offer a new approach to synthesising economic evidence. We will produce guidance to enable NHS decision makers to tailor the use of STOPP/START interventions to local circumstances and maximise its impact on the quality of patient care and the quality of life of individuals.

Lay abstract: Medicines are prescribed to treat illnesses and to prevent their complications. However, taking many medications may also cause harm. Up to 30% of older people admitted to hospitals are so because of problems with medication. Being able to detect inappropriate use of medications early may help to prevent these problems, improve the quality of life of older adults and improve care while reducing costs to the NHS. Some recommendations can help doctors make decisions on the medications that older patients need to take, and there are “tools” to aid doctors to make decisions about medications. Two of these “tools” are: Screening Tool of Older Persons’ Prescriptions (STOPP), and Screening Tool to Alert to Right Treatment (START) which can reduce complications of medications, need for GP appointments, the time people spend in hospital and medication costs. However, we do not currently know how doctors are using these recommendations and how they work. This study aims to describe how STOPP/START recommendations are being used and to explain how they work and how they are used to involve patients in making decisions about their medication. We will undertake what is called a realist review. This is when findings from multiple studies are combined to better explain how an initiative or intervention works. We will review different sources of information including research reports and papers, policy documents and information on relevant websites on STOPP/START. We will use the information to uncover what are the ideas behind the use of STOPP/START. We will convene a group of experts and patients and carers to discuss these ideas and help us summarise these studies and to tell a story of their findings. At the end of the review we will be able to explain: 1. How and why interventions using STOPP/START work in practice? 2. What effect interventions using STOPP/START have on different doctors and patients? 3. What influences how interventions using STOPP/START work? 4. How are patients and their carers involved in making decisions about their medications using STOPP/START? With this knowledge we will be able to give guidance on how to make best use of STOPP/START for the benefit of patients, their carers, their doctors and the wider NHS. Older patients and their carers will be involved throughout the project. We will work with patients, carers and clinicians to create targeted summaries of review findings to ensure results are available to everybody with an interest in the research. We will also prepare papers for publication in respected academic journals and present the findings at scientific conferences.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE