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BMC Geriatr. 2017 Apr 20;17(1):93. doi: 10.1186/s12877-017-0486-4.

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

Author information

1
Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
2
Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
3
Hospital Israelita Albert Einstein, São Paulo, Brazil.
4
Vennesla Primary Health Care Centre, Bergen, Norway.
5
Irish College of General Practitioners, Dublin, Ireland.
6
Department of Nephrology and Department of Family Medicine, University Clinical Centre, University St. Cyril and Metodius, Skopje, Macedonia.
7
Faculty of Medicine, Department of Family Medicine, Riga Stradiņs University, Riga, Latvia.
8
Institute for Health and Behaviour, Research Unit INSIDE, University of Luxembourg, Luxembourg, Luxembourg.
9
Department of General Practice and Family Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria.
10
Timis Society of Family Medicine, Sano Med West Private Clinic, Timisoara, Romania.
11
Danish College of General Practitioners, Copenhagen, Denmark.
12
School of Population Health, University of Auckland, Auckland, New Zealand.
13
Department of General Practice, University of Tampere, Tampere, Finland.
14
Family Medicine Department, Health Center Tuzla, Medical School, University of Tuzla, Tuzla, Bosnia and Herzegovina.
15
Family Medicine Department, Wroclaw Medical University, Wrocław, Poland.
16
Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
17
Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
18
Institute of Primary and Community Care Lucerne (IHAM), Lucerne, Switzerland.
19
Institute of Family Medicine Lausanne (IUMF), Lausanne, Switzerland.
20
Institute of General Practice, Goethe-University, Frankfurt / Main, Germany.
21
Department for Family Medicine, Medical faculty, University of Ljubljana, Ljubljana, Slovenia.
22
SNAMID (National Society of Medical Education in General Practice), Prata Sannita, Italy.
23
Department of Clinical Sciences in Malmö, Centre for Primary Health Care Research, Lund University, Malmö, Sweden.
24
Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
25
SSLMG, Societé Scientifique Luxembourgois en Medicine generale, Luxembourg, Luxembourg.
26
Ordinace Řepy, s.r.o., Prague, Prague, Czech Republic.
27
Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
28
Family Medicine, Department of Clinical Sciences, Lund University, Malmö and senior researcher Region Kronoberg, Växjö, Sweden.
29
Department of Family Medicine, Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine.
30
Department of Family Medicine, Semmelweis University, Budapest, Hungary.
31
LIMICS, INSERM, U1142, F-75006 Paris, Université Paris 13, Sorbonne Paris Cité, UMR_S 1142, F93000 Bobigny, Sorbonne Universités, UPMC Université Paris 06, UMR_S 1142, F75006 Paris, Paris, France.
32
Leeds Centre for Respiratory Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
33
Family Medicine Specialist, Kemaliye Town Hospital, Erzincan University, Erzincan, Turkey.
34
Family Doctor, Invited Assistant of the Department of Family Medicine, NOVA Medical School, Lisbon, Portugal.
35
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
36
Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands.
37
Centre for Primary Health Care (uniham-bb), Basel, Switzerland.
38
Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands. R.K.E.Poortvliet@lumc.nl.

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 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.

KEYWORDS:

Clinical variation; Elderly; Frailty; General practitioners; Hypertension; Oldest-old

PMID:
28427345
PMCID:
PMC5399328
DOI:
10.1186/s12877-017-0486-4
[Indexed for MEDLINE]
Free PMC Article

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