Burden of cardiovascular disease across 29 countries and GPs’ decision to treat hypertension in oldest-old

Abstract

ObjectivesWe previously found large variations in general practitioner (GP) hypertension treatment probability in oldest-old (>80 years) between countries. We wanted to explore whether differences in country-specific cardiovascular disease (CVD) burden and life expectancy could explain the differences.DesignThis is a survey study using case-vignettes of oldest-old patients with different comorbidities and blood pressure levels. An ecological multilevel model analysis was performed.SettingGP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland.SubjectsThis study included 2543 GPs from 29 countries.Main outcome measuresGP treatment probability to start or not start antihypertensive treatment based on responses to case-vignettes; either low (<50% started treatment) or high (≥50% started treatment). CVD burden is defined as ratio of disability-adjusted life years (DALYs) lost due to ischemic heart disease and/or stroke and total DALYs lost per country; life expectancy at age 60 and prevalence of oldest-old per country.ResultsOf 1947 GPs (76%) responding to all vignettes, 787 (40%) scored high treatment probability and 1160 (60%) scored low. GPs in high CVD burden countries had higher odds of treatment probability (OR 3.70; 95% confidence interval (CI) 3.00–4.57); in countries with low life expectancy at 60, CVD was associated with high treatment probability (OR 2.18, 95% CI 1.12–4.25); but not in countries with high life expectancy (OR 1.06, 95% CI 0.56–1.98).ConclusionsGPs’ choice to treat/not treat hypertension in oldest-old was explained by differences in country-specific health characteristics. GPs in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old.Key Points • General practitioners (GPs) are in a clinical dilemma when deciding whether (or not) to treat hypertension in the oldest-old (>80 years of age). • In this study including 1947 GPs from 29 countries, we found that a high country-specific cardiovascular disease (CVD) burden (i.e. myocardial infarction and/or stroke) was associated with a higher GP treatment probability in patients aged >80 years. • However, the association was modified by country-specific life expectancy at age 60. While there was a positive association for GPs in countries with a low life expectancy at age 60, there was no association in countries with a high life expectancy at age 60. • These findings help explaining some of the large variation seen in the decision as to whether or not to treat hypertension in the oldest-old.

How general practitioners would deprescribe in frail oldest-old with polypharmacy — the LESS study

“…We set out to sample a group of GPs ( N = 282) from all regions of Switzerland who had taken part in earlier case-vignette studies and were open to invitations to participate in future research projects [ 33 , 34 ]. We included all respondents who were currently practicing GPs in Switzerland.…”

“…We used the same method we employed previously to describe GP decisions about antihypertensive treatment in oldest-old patients [ 33 , 34 ], and developed an online survey with three sections (A-C): A) GP characteristics and self-reported frequency of deprescribing in oldest-old; B) two case-vignettes of frail oldest-old patients with contrasting histories of CVD; and, C) questions designed to identify factors that may have affected GPs’ decisions to deprescribe. (See Additional file 1 for the complete questionnaire).…”

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

“…The surveys were distributed from spring to summer 2016. The detailed design of the ATTENTIVE Study has been described previously [14,15].…”

“…While guideline use might have no major effect on treatment decisions in frail oldest-old, frailty, systolic blood pressure and history of cardiovascular disease seemed to have an influence [14]. In addition, country-specific factors such as cardiovascular burden and life expectancy are associated with the decisions when managing hypertension in this age group [15].…”

Do patients or their physicians more accurately assess long-term risk associated with hypertension? A population-based study

“…High blood pressure is a leading risk factor for cardiovascular disease (CVD) worldwide with an increased prevalence in low-income countries in South Asia and sub-Saharan Africa [1]. Decision-making by general practitioners in countries with high CVD burden and low life expectancy at age 60 were most likely to treat hypertension in oldest-old based on case-vignettes [2].…”