Understanding the STOPP/START Toolkit
The STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) toolkit is a set of evidence-based criteria developed to assist healthcare professionals in identifying and addressing medication-related issues in older adults. Developed by international panels of experts, it has evolved through several versions to reflect the latest evidence in geriatric pharmacology. It is a structured, physiological systems-based guide that moves beyond simple drug avoidance to promote a more balanced and comprehensive approach to medication review.
The STOPP Criteria: Identifying Inappropriate Prescriptions
The STOPP criteria focus on identifying potentially inappropriate medications (PIMs)—drugs that carry a higher risk of adverse effects in older adults than the potential benefits. Organized by physiological systems, the criteria provide a detailed checklist for clinicians to review a patient's medication list. A PIM can be an unnecessary drug, an incorrect dosage, or a harmful drug-disease or drug-drug interaction.
Examples of STOPP criteria include:
- Cardiovascular: Aspirin for primary prevention of cardiovascular disease in older adults without established disease.
- Central Nervous System: Long-term use of benzodiazepines for four weeks or longer due to increased risk of falls and cognitive impairment.
- Gastrointestinal: Proton pump inhibitors prescribed at full dose for more than eight weeks for uncomplicated peptic ulcer disease.
The START Criteria: Addressing Prescribing Omissions
The START criteria are designed to identify potential prescribing omissions (PPOs)—beneficial medications that are indicated for a patient's condition but have not been prescribed. In older adults with multimorbidity, there is often a tendency to underprescribe important, evidence-based therapies, and the START tool helps correct this imbalance.
Examples of START criteria include:
- Cardiovascular: Initiating an ACE inhibitor or angiotensin receptor blocker in patients with heart failure.
- Endocrine: Prescribing a bisphosphonate for patients on long-term systemic corticosteroids to prevent osteoporosis.
- Vaccinations: Ensuring older adults receive recommended immunizations, such as the SARS-CoV-2 vaccination.
STOPP/START vs. The Beers Criteria
The STOPP/START toolkit is often compared to the Beers Criteria, another widely used tool for medication safety in older adults. While both serve to improve prescribing, they have distinct differences.
| Feature | STOPP/START Toolkit | Beers Criteria |
|---|---|---|
| Focus | Identifies potentially inappropriate medications to STOP and potentially omitted medications to START. Balanced approach. | Primarily focuses on potentially inappropriate medications to AVOID. Largely stop-focused. |
| Organization | Organized by physiological systems (e.g., cardiovascular, CNS) for systematic review. | Organized by drug classes and specific clinical scenarios. |
| Geographic Applicability | Developed by European experts with broader international applicability, referencing drug classes rather than specific brand names. | Developed in the US and includes some medications not available in other countries, though later versions have expanded. |
| Completeness | Addresses both prescribing errors (stopping harmful drugs) and prescribing omissions (starting beneficial drugs). | Primarily addresses prescribing errors. |
How Clinicians Implement the Toolkit
Integrating the STOPP/START criteria into clinical practice requires a team-based approach involving physicians, pharmacists, and nurses. Implementation strategies often include:
- Pharmacist-Led Medication Reviews: Pharmacists can use the toolkit to systematically screen patients' medication lists and provide recommendations to physicians.
- Electronic Health Record (EHR) Integration: Automated clinical decision support systems can generate alerts based on the criteria, flagging potential issues for clinicians.
- Training and Education: Providing training for healthcare professionals to enhance their understanding of geriatric pharmacotherapy and the use of the toolkit.
- Patient Engagement: Engaging patients and caregivers in discussions about medication optimization, ensuring their preferences and goals are considered.
Benefits and Limitations
The use of the STOPP/START criteria has demonstrated several benefits, including a significant improvement in medication appropriateness and a reduction in adverse drug events (ADEs), particularly in hospitalized older patients. This can lead to decreased hospital stays and improved patient outcomes. By promoting better prescribing, the toolkit can also lead to cost savings by reducing unnecessary medications and ADE-related hospitalizations.
However, limitations exist. The process of applying the criteria can be time-consuming, and some clinicians express concerns about balancing the explicit, checklist-style rules with nuanced clinical judgment. Furthermore, while the toolkit is evidence-based, much of the research relies on consensus methods, and further studies are needed to validate the impact of the latest versions on specific clinical outcomes.
The Role of Deprescribing
Deprescribing, the process of reducing or discontinuing medications that are no longer necessary or may be causing harm, is a key component of the toolkit's use. The STOPP criteria, in particular, serve as a guide for identifying medications suitable for deprescribing. This process is crucial for managing polypharmacy, where patients take numerous medications concurrently, often increasing the risk of negative side effects and drug interactions. A structured approach to deprescribing ensures that medications are only continued when the benefits outweigh the risks.
Conclusion
The STOPP/START toolkit is a vital instrument for enhancing medication safety and quality of life for older adults. By offering a systematic framework for reviewing prescriptions, it empowers healthcare teams to make more informed decisions about which medications to stop, avoid, or initiate. While its application requires clinical judgment and careful implementation, its evidence-based approach helps mitigate the risks of polypharmacy and inappropriate prescribing, contributing significantly to healthier aging. For further reading, see the comprehensive resource provided by AHRQ.
