Explicit versus implicit evaluation to detect inappropriate medication use in geriatric outpatients.

Understanding how clinicians apply explicit medication criteria in older patients remains limited. While tools like STOPP v2 are widely used, little is known about how often clinicians deviate from them and why. Prior research has shown that explicit criteria can identify potentially inappropriate prescriptions, but these findings are based on systematic assessments. The gap motivating this work lies in the lack of comparative data between explicit and implicit evaluation methods. Clinicians often rely on comprehensive geriatric assessments, which are considered the gold standard. However, it is unclear how these assessments align with explicit criteria. This paper addresses that uncertainty by comparing STOPP v2 with implicit clinical judgment. No prior work had resolved how frequently clinicians reject explicit criteria and the reasons behind those decisions. This study aims to clarify the relationship between explicit and implicit evaluation in identifying inappropriate prescriptions.

This study aimed to compare the effectiveness of STOPP v2, an explicit tool for identifying inappropriate prescriptions, with an implicit clinical evaluation approach in geriatric outpatients. The specific problem addressed is the lack of understanding about how clinicians interpret and apply explicit criteria in real-world settings. The motivation stems from the need to improve medication safety in older adults. Researchers wanted to determine whether clinicians agree with the recommendations of explicit criteria and under what conditions they might deviate from them. The study also sought to identify the clinical factors associated with non-compliance with STOPP v2. By examining both systematic and implicit evaluations, the authors aimed to shed light on the variability in how inappropriate prescriptions are detected. This approach allows for a more nuanced understanding of clinical decision-making in geriatric populations.

The study involved 206 outpatients aged 65 or older. Researchers used a retrospective, cross-sectional, and randomized design. They applied STOPP v2 criteria systematically to pre-admission treatment records. Following this, clinicians conducted an implicit evaluation to assess the validity of the STOPP v2 recommendations. Two key questions guided the implicit evaluation: whether the STOPP criteria applied to the individual patient and whether other potentially inappropriate prescriptions were present. The researchers documented the reasons for non-compliance and the associated clinical features. This method allowed for a direct comparison between explicit and implicit approaches. The data collection focused on identifying discrepancies and understanding the rationale behind clinical decisions.

Systematic application of STOPP v2 identified 62.6% of potentially inappropriate prescriptions, with an average of 0.6 per patient. Clinicians identified 53.4% of potentially inappropriate prescriptions, averaging 0.5 per patient. Non-compliance with STOPP v2 occurred in 14.7% of cases, with 21.7% of 83 patients affected. In two-thirds of non-compliant cases, clinicians chose to continue a drug despite anticipated side effects. In one-third of cases, they continued the drug even without expected side effects. Non-compliance was significantly linked to lower functional levels in patients. Implicit evaluation revealed an additional 59.2% of potentially inappropriate prescriptions in 38.8% of patients. Overall, the combined rate reached 112.6% of potentially inappropriate prescriptions.

Most STOPP v2 recommendations were accepted by clinicians, indicating general alignment with explicit criteria. However, in patients with higher functional dependency, clinicians often chose not to follow the recommendations. This may reflect a focus on palliative care or patient and family preferences. The study suggests that implicit evaluation can identify as many potentially inappropriate prescriptions as explicit tools in a significant portion of geriatric patients. These findings highlight the importance of comprehensive geriatric assessments in clinical practice. The authors propose that explicit tools like STOPP v2 should be used alongside clinical judgment. They suggest that functional status is a key factor in determining whether explicit criteria are followed. The results do not support the idea that explicit criteria alone are sufficient for identifying inappropriate prescriptions.