Appraisal of the references supporting the STOPP/START.version 3 criteria

Abstract Background. The strength of evidence underlying the STOPP/START version 3 (SS.v3) criteria has not been reported and remains controversial, potentially limiting their clinical implementation. This aim of this study was to critically appraise the references supporting the SS.v3 criteria. Methods. All references cited for the 190 SS.v3 criteria were independently evaluated by a clinical pharmacist–geriatrician pair and a geriatrician expert in literature appraisal. The main endpoint was the evidence level classified by data study design (level I: randomised controlled trials; II: cohort studies; III: case-control; IV: case series; V: expert opinion). References were classified as inappropriate if they showed mismatch, lacked supporting content, or were clinically discordant with the criterion. Results. Of the 455 SS.v3 references, 319 are reviews (STOPP 70%, START 71%), either systematic (STOPP 29%, START 44%) or narrative (STOPP 41%, START 26%). Evidence is level I (STOPP 28%, START 64%), level II (STOPP 13%, START 8%), level III-IV-V (STOPP 45%, START 19%), or was downgraded because of inappropriateness (STOPP 15%, START 8%). At the level of the 190 criteria, the best evidence is level I (STOPP 43%, START 88%), level II (STOPP 13%, START 7%), level III-IV-V (STOPP 35%, START 4%), while 10 criteria (STOPP 8%, START 0%) lack appropriate supporting reference. Conclusion. A substantial proportion of STOPP criteria are not supported by high-level evidence, and some criteria lack appropriate reference. These findings support a reassessment of certain criteria, as well as reconsideration of the types of references deemed acceptable in their development.