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

Streit, Sven; Verschoor, Marjolein; Rodondi, Nicolas; Bonfim, Daiana; Burman, Robert A.; Collins, Claire; Biljana, Gerasimovska Kitanovska; Gintere, Sandra; Gómez Bravo, Raquel and Hoffmann, Kathryn, et al. (2017) In BMC Geriatrics 17(1). p.1-7
Abstract

Background: In 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. Methods: Using 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... (More)

Background: In 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. Methods: Using 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. Results: The 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). Conclusions: Across 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.

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Clinical variation, Elderly, Frailty, General practitioners, Hypertension, Oldest-old
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BMC Geriatrics
volume
17
issue
1
pages
7 pages
external identifiers
  • scopus:85018500043
  • wos:000400891300004
ISSN
1471-2318
DOI
10.1186/s12877-017-0486-4
language
English
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yes
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b219a1f7-611a-4cd1-a0ce-ca90febd9fd5
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2017-05-19 10:27:24
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2017-09-18 11:36:28
@article{b219a1f7-611a-4cd1-a0ce-ca90febd9fd5,
  abstract     = {<p>Background: In oldest-old patients (&gt;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. Methods: Using 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. Results: The 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 &gt;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). Conclusions: Across 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.</p>},
  author       = {Streit, Sven and Verschoor, Marjolein and Rodondi, Nicolas and Bonfim, Daiana and Burman, Robert A. and Collins, Claire and Biljana, Gerasimovska Kitanovska and Gintere, Sandra and Gómez Bravo, Raquel and Hoffmann, Kathryn and Iftode, Claudia and Johansen, Kasper L. and Kerse, Ngaire and Koskela, Tuomas H. and Peštić, Sanda Kreitmayer and Kurpas, Donata and Mallen, Christian D. and Maisoneuve, Hubert and Merlo, Christoph and Mueller, Yolanda and Muth, Christiane and Šter, Marija Petek and Petrazzuoli, Ferdinando and Rosemann, Thomas and Sattler, Martin and Švadlenková, Zuzana and Tatsioni, Athina and Thulesius, Hans and Tkachenko, Victoria and Torzsa, Peter and Tsopra, Rosy and Canan, Tuz and Viegas, Rita P.A. and Vinker, Shlomo and De Waal, Margot W.M. and Zeller, Andreas and Gussekloo, Jacobijn and Poortvliet, Rosalinde K.E.},
  issn         = {1471-2318},
  keyword      = {Clinical variation,Elderly,Frailty,General practitioners,Hypertension,Oldest-old},
  language     = {eng},
  month        = {04},
  number       = {1},
  pages        = {1--7},
  series       = {BMC Geriatrics},
  title        = {Variation in GP decisions on antihypertensive treatment in oldest-old and frail individuals across 29 countries},
  url          = {http://dx.doi.org/10.1186/s12877-017-0486-4},
  volume       = {17},
  year         = {2017},
}