Application of STOPP and START criteria: interrater reliability among pharmacists

Ann Pharmacother. 2009 Jul;43(7):1239-44. doi: 10.1345/aph.1M157. Epub 2009 Jul 7.


Background: Inappropriate prescribing is a well-documented problem in older people. The new screening tools, STOPP (Screening Tool of Older Peoples' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) have been formulated to identify potentially inappropriate medications (PIMs) and potential errors of omissions (PEOs) in older patients. Consistent, reliable application of STOPP and START is essential for the screening tools to be used effectively by pharmacists.

Objective: To determine the interrater reliability among a group of clinical pharmacists in applying the STOPP and START criteria to elderly patients' records.

Methods: Ten pharmacists (5 hospital pharmacists, 5 community pharmacists) were given 20 patient profiles containing details including the patients' age and sex, current medications, current diagnoses, relevant medical histories, biochemical data, and estimated glomerular filtration rate. Each pharmacist applied the STOPP and START criteria to each patient record. The PIMs and PEOs identified by each pharmacist were compared with those of 2 academic pharmacists who were highly familiar with the application of STOPP and START. An interrater reliability analysis using the kappa statistic (chance corrected measure of agreement) was performed to determine consistency between pharmacists.

Results: The median kappa coefficients for hospital pharmacists and community pharmacists compared with the academic pharmacists for STOPP were 0.89 and 0.88, respectively, while those for START were 0.91 and 0.90, respectively.

Conclusions: Interrater reliability of STOPP and START tools between pharmacists working in different sectors is good. Pharmacists working in both hospitals and in the community can use STOPP and START reliably during their everyday practice to identify PIMs and PEOs in older patients.

MeSH terms

  • Aged
  • Community Pharmacy Services / organization & administration
  • Drug Interactions
  • Drug Utilization Review / methods*
  • Female
  • Humans
  • Male
  • Medication Errors / prevention & control*
  • Observer Variation
  • Pharmacists / standards*
  • Pharmacy Service, Hospital / organization & administration
  • Practice Patterns, Physicians' / standards*
  • Prescription Drugs / administration & dosage
  • Prescription Drugs / adverse effects
  • Reproducibility of Results


  • Prescription Drugs