How, when and why do STOPP/START criteria based interventions improve medicines management for older people: a realist synthesis

Problem

The most widely used tools for assessing appropriate prescribing in older adults in Europe are the STOPP/START tools (SSTs). A greater understanding of how interventions based on the use of these tools work, for whom they work, in what contexts and why is currently lacking. Our aim was to conduct a two-phase project on a realist evidence synthesis on the interventions based on SSTs. We present here theory identification and development (phase I).

Approach

We identified programme theories about SSTs/SSTs-based 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 conducted electronic searches of grey literature to identify generic guidance and policy documents, and electronic searches of the peer reviewed literature (PubMed, EMBASE, others). A project reference group consisting of health care professionals, NHS decision makers, older people and members of the public were set up to embed the study in real-life experience. We discussed the identified theories in a workshop with the patient advisory group and conducted eight interviews with the experts. We used these sources of information to identify, develop and refine programme theories (contexts, mechanisms and outcome configuration). This work is still in progress.

Findings

We identified preliminary emerging both positive and counter theories about how SSTs/SSTs-based interventions are expected to work. Positive theories: The i) SSTs provide a systematic and structured way of carrying out the medication review process; ii) as SSTs are evidence-based, comprehensive and structured, the assumption is that they can be used with little need for clinical judgement (mechanism) and thus can be used by a range of clinicians (context) in older people; iii) SSTs will prompt the clinician to start or guide discussion with the patient about whether they wish to stop or start particular medications and what their priorities are. Counter theories: i) SSTs only offer resources to enable clinicians to identify potential medication problems, they do not provide resources about the context of the individual patient; ii) It is argued that one of the reasons why clinicians use the tools is that they may not enable them to identify as many potentially inappropriate medicines (outcome) as clinicians do not use them ‘rigorously’, and don’t follow through on stopping medication (mechanism); iii) When paper versions of the tools (resource/context) are used, completion is time consuming (outcome).

Consequences

These emerging theories will be further refined through conduct and analysis of additional interviews and further input from patient advisory group to help prioritise the theories from the patient perspective. In Phase 2 we will test the programme theories. We will review and synthesise relevant published and unpublished empirical quantitative and qualitative evidence.