Table 5 How a holistic approach of the patient challenges the PIPs detected by explicit screening tools

Elements of the patient’s record that influence the applicability of the criteria^a

• Level of severity of a disease

• Certainty of the diagnoses

• Timing of the medical history (recent event vs. long ago)

• Actual intake of the drug that differs from the prescription

• Patient’s preferences and objectives

• Mental status of the patient and associated psychiatric conditions

• Absence of alternative treatment

• Patient’s pain status

• Drug-drug interactions

• Risk factors for bleeding or for stroke

• Contra-indication

• Allergies

Situations that question the content validity of the criteria:

• START-PIP in patients already treated by suitable alternative medications e.g., “Proton pump inhibitor with severe gastroesophageal acid reflux disease” in a patient already on histamine H2-receptor antagonist.

• START-PIP “Warfarin in the presence of chronic atrial fibrillation” in patients with low stroke risk

• START-PIP “Regular inhaled β2-agonist or anticholinergic agent for mild-to-moderate asthma or COPD” in a patient with asthma due to acid reflux

• STOPP-PIP “Any duplicate drug class prescription” because insufficiently defined.

• Beers-PIPs mentioning that a medication should be avoided as “first-line therapy” because such a feature is often difficult to detect

• Beers-PIP “Avoid antidepressants in dementia & cognitive impairment” in a patient with severe depression