Strengths and limitations of study
multimorbidity, fatigue
RECRUITMENT, RECRUITMENT, FIRE
The OPTICA trial has several strengths. Recruitment of patients was based on screening lists with random samples of each general practitioner’s patient population. The trial had minimal exclusion criteria, which resulted in the recruitment of patients who were comparable to other older patients with multimorbidity and polypharmacy in Swiss primary care.The trial also has several limitations. Owing to a requirement from the regulatory authority, general practitioners in the control group had to have a discussion about medication with their enrolled patients in line with usual care. General practitioners were explicitly asked not to deviate from their usual practice. Despite this, we cannot rule out the possibility that some of them diverged from their usual prescribing practice owing to the Hawthorne effect. The number of medications, however, did not differ between the two groups at any time point. The quality of the data exports from the FIRE database was challenging because of differences in how electronic health record software programs exported data. Therefore, the study team had to manually collect missing information from practices and use multiple imputation methods. As the intervention occurred at a single time point, its effectiveness may have been diluted over time. The implementation of an average of one STOPP/START recommendation per patient did not seem to affect the primary outcomes. Next, the different barriers faced by patients and providers related to the implementation of prescribing recommendations, which are numerous and well documented in the literature (for example, fears of negative health outcomes, alert fatigue),