2. 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

3. 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 /s
Part 1

4. 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

5. 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”

6. 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 %

7. 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

8. 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

9. 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

10. 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

11. 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

13. 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)

14. 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)

15. Brazil
New Zealand
Israel
Thank you!