Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries

Abstract

BackgroundIn oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision.MethodsUsing a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP.ResultsThe 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs’ decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48–0.59; ORs per country 0.11–1.78).ConclusionsAcross countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-017-0486-4) contains supplementary material, which is available to authorized users.

Managing hypertension in frail oldest-old – the role of guideline use by general practitioners from 29 countries

“…The complete survey described eight case vignettes where oldest-old male or female patients presented for a routine control (Additional file 1 in [11]). These patients had no symptoms suggesting hypertension and took no antihypertensive medication.…”

“…We conducted a re-analysis of data from the cross-sectional case-vignettes study called 'Antihypertensive TreaTmENT In Very Elderly' (ATTENTIVE) [11].…”

“…The design of the ATTENTIVE Study has been described previously [11,12]. In brief, we organized a network of 'national coordinators' (mostly one per country) through GP organizations like the European General Practice Research Network (EGPRN).…”

Recommendations for (Discontinuation of) Statin Treatment in Older Adults: Review of Guidelines

“…Qualitative studies have shown that both physicians and patients are generally open to statin deprescription in the case of older adults . Nevertheless, medications, including statins, are often continued until death .…”

“…Nevertheless, medications, including statins, are often continued until death . It has been reported that physicians do not feel confident about deprescribing cardiovascular preventive medication and survey studies have found considerable treatment variation in the advice regarding discontinuation of preventive medication . A likely contributing factor and an acknowledged barrier to deprescribing medications is the lack of evidence and clear guidance in clinical practice guidelines .…”