GPs’ perspectives on secondary cardiovascular prevention in older age: a focus group study in the Netherlands

Peet, Petra G. van; Drewes, Yvonne M.; Gussekloo, Jacobijn; Ruijter, Wouter de

doi:10.3399/bjgp15x687373

Cited by 19 publications

(15 citation statements)

References 31 publications

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“…However, in line with previous work [48], our interviews suggest that few GPs use a shared decision making approach and many refer to challenges associated with older patient involvement, including: third party involvement, a perception that older patients prefer a paternalistic relationship with their GP, and cognitive impairment. This is somewhat in contrast with a focus group study on secondary CVD prevention in which the majority of GPs mentioned using shared decision making as a way to deal with uncertainties around the management of older people [43]. The majority of the GPs in this study were highly skilled GPs (e.g.…”

Section: Discussionmentioning

confidence: 58%

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General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

et al. 2017

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BackgroundPrimary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older.Method25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.ResultsAnalysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.ConclusionOlder patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

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Section: Discussionmentioning

confidence: 58%

“…A qualitative focus group study of secondary CVD prevention in older people found similar dilemmas and uncertainties about the potential benefits and harms of secondary cardiovascular prevention, with management often based on frailty rather than chronological age [43]. …”

Section: Discussionmentioning

confidence: 99%

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

et al. 2017

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“… 21 This reluctance is, among other factors, induced by GPs’ anticipated regret, which has been previously described as a motivator to start or continue preventive treatment. 17 22 The fear of ‘causing’ a stroke by deprescribing AHM is unsupported by clinical evidence but might be instigated by results from trials like the SPRINT trial that support intensive BP lowering, 6 even though multimorbid older people are potentially under-represented in this trial and the generalisability of these results is uncertain. 8 Also for deprescribing shared decision-making is crucial.…”

Section: Discussionmentioning

confidence: 99%

Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study

et al. 2018

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ObjectivesTo explore general practitioners’ (GPs) routines and considerations on (de)prescribing antihypertensive medication (AHM) in older patients, their judgement on usability of the current guideline and needs for future support.DesignSemistructured interviews.SettingDutch general practice.ParticipantsFifteen GPs were purposively sampled based on level of experience and practice characteristics until saturation was reached.ResultsGPs appeared reluctant to start AHM, especially in patient >80 years. High systolic blood pressure and history of cardiovascular disease or diabetes were enablers to start or intensify treatment. Reasons to refrain from this were frailty and patient preference. GPs described a tendency to continue AHM regimens unchanged, influenced by daily time constraints, automated prescription routines and anticipating discomfort when disturbing patients’ delicate balance. GPs were only inclined to deprescribe AHM in terminally ill patients or after prolonged achievement of target levels in combination with side effects or patient preference. Deprescription was facilitated when GPs had experience with patients showing increased quality of life after deprescription and was withheld by anticipated regret (ie, GPs’ fear of a stroke after deprescribing). GPs felt insufficient guidance from current guidelines, especially on deprescription.ConclusionsGPs are reluctant to start or deprescribe AHM in older people and have a propensity to continue AHM within a daily routine that insufficiently supports critical medication review. (De)prescription is influenced by patient preferences and anticipated regret and current guidelines provide insufficient guidance.

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“…Even where evidence suggests benefits of preventive medication for older people, as is the case for secondary prevention, the evidence becomes uncertain in the context of complex interactions between multiple conditions and medications, the generally higher risk of side effects, declining health and limited life expectancy as trial data is not available for these groups 18 19. It is therefore not a surprise that general practitioners (GPs) are uncertain about CVD prevention in older age, and there is evidence of overtreatment and undertreatment of CVD risk in this group 20–22. This is why an SDM approach to CVD management has now been universally advocated, in particular for those who are older, frail or have comorbidities 23–26…”

Section: Introductionmentioning

confidence: 99%

Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice

et al. 2019

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ObjectivesTo explore older people’s perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.Design, setting and participantsSemi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol)orhad received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis.ResultsTwenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication.ConclusionsResults demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.

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GPs’ perspectives on secondary cardiovascular prevention in older age: a focus group study in the Netherlands

Abstract: Background

Cited by 19 publications

References 31 publications

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

Prescribing and deprescribing antihypertensive medication in older people by Dutch general practitioners: a qualitative study

Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice

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