Disclosure belangen NHG spreker (Potentiële) belangenverstrengeling None Voor bijeenkomst mogelijk relevante relaties met bedrijven Sponsoring of onderzoeksgeld Honorarium of andere (financiële) vergoeding Aandeelhouder Andere relatie, namelijk … Swiss National Science Foundation Bangerter-Rhyner Foundation Swiss University Conference and State Secretariat for Education, Research and Innovation

Variation in GP decisions on anti-hypertensive treatment in oldest-old and frail individuals across 29 countries Sven Streit, MD from the ATTENTIVE Study Group: Verschoor M, Rodondi N, Bonfim D, Burman RA, Collins C, Gerasimovska Kitanovska B, Gintere S, Gómez Bravo R, Hoffmann K, Iftode C, Johansen KL, Kerse N, Koskela T, Kreitmayer Peštić S, Kurpas D, Mallen CD, Maisonneuve H, Merlo C, Mueller Y, Muth C, Petek Šter M, Petrazzuoli F, Rosemann T, Sattler M, Švadlenková Z, Tatsioni A, Thulesius H, Tkachenko V, Torzsa P, Tsopra R, Canan T, Viegas R, Vinker S, de Waal MWM, Zeller A, Gussekloo J, Poortvliet RKE Streit et al. BMC Geriatrics (2017) 17:93 DOI 10.1186/s12877-017-0486-4 Part 1

Background Ongoing debate if and how to treat hypertension in older patients Current guidelines provide no/weak evidence in those frail/oldest-old (>80years) Possibly leading to clinical variation how GPs decide to start/not start treatment Aims Investigate if there is an international variation in how GPs decide to start/not to start antihypertensive treatment in oldest-old Identify the role of frailty in this decision

Case vignette study Mr/Mrs X, 82 years, present for a routine visit with no current blood pressure related symptoms or previous antihypertensive therapy Case Frailty* Cardiovascular disease Systolic blood pressure (mmHg) 1 No 140 2 Yes 3 160 4 5 6 7 8 *Definition of frailty: Two of these criteria: unintentional weight loss, exhaustion, low level of activity, muscle weakness and slow gait speed (Fried et al, 2001) Information given “you consider this patient to be frail”

Crude proportions of cases where GPs decide to start treatment (n = 2053) Percent >70% New Zealand 60-69% 50-59% 40-49% Israel <40% 34% Brazil 88 %

GP treatment probability in frail vs. non-frail patients (adjusted*) *mixed-effects model adjusted for GP gender, years of experience, practice location, prevalence of oldest-old, guideline adherence as fixed effects and individual GP as random effects

Conclusions Large variation (34% to 88%) in Europe, Brazil, Israel, and New Zealand Frail older patients with almost 50% lower probability to receive treatment Evidence needed for older/frail patients through new hypertension trials/high quality observational studies

Burden of cardiovascular disease across 29 countries associated with GPs’ decision to treat hypertension in oldest-old Sven Streit, MD from the ATTENTIVE Study Group: Gussekloo J, Burman RA, Collins C, Gerasimovska Kitanovska B, Gintere S, Gómez Bravo R, Hoffmann K, Iftode C, Johansen KL, Kerse N, Koskela T, Kreitmayer Peštić S, Kurpas D, Mallen CD, Maisonneuve H, Merlo C, Mueller Y, Muth C, Ornelas RH, Petek Šter M, Petrazzuoli F, Rosemann T, Sattler M, Švadlenková Z, Tatsioni A, Thulesius H, Tkachenko V, Torzsa P, Tsopra R, Canan T, Verschoor M, Viegas R, Vinker S, de Waal MWM, Zeller A,, Rodondi N, Poortvliet RKE Part 2 Manuscript submitted

Background Large variation in treating hypertension in oldest-old across 29 countries (Part 1) Country-specific health characteristics such as cardiovascular disease (CVD) burden could explain part of the variation Aim To investigate if CVD burden is related to GP treatment probability to start antihypertensive treatment in oldest-old

Determinants CVD burden as disability-adjusted life years (DALYs) Covariates: Life-expectancy at age 60 Prevalence of oldest-old GP gender Years of experience DALY (stroke/myocardial infarction) per country CVD burden = Total DALY per country

Results CVD burden associated with GP treatment probability But life expectancy modified the association: In countries with lower life expectancy: adjusted OR 2.18 (95% CI 1.12 to 4.25) In countries with higher life expectancy: adjusted OR 1.06 (95% CI 0.56 to 1.98)

Conclusions In countries where a 60-year-old patients has a lower life-expectancy (about 24 years): GPs in high CVD burden countries treat hypertension more often in oldest-old than in low CVD burden countries Differences in GP treatment probability explained by: Patient characteristics (Part 1) Country-specific health characteristics (Part 2)

Brazil New Zealand Israel Thank you! s.streit@lumc.nl