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

S. Streit, M. Verschoor, N. Rodondi, D. Bonfim, R.A. Burman, C. Collins, G.K. Biljana, S. Gintere, R. Gómez Bravo, K. Hoffmann, C. Iftode, K.L. Johansen, N. Kerse, T.H. Koskela, S.K. Peštić, D. Kurpas, C.D. Mallen, H. Maisoneuve, C. Merlo, Y. MuellerC. Muth, M.P. Šter, F. Petrazzuoli, T. Rosemann, M. Sattler, Z. Švadlenková, A. Tatsioni, H. Thulesius, V. Tkachenko, P. Torzsa, R. Tsopra, T. Canan, R.P.A. Viegas, S. Vinker, M.W.M. De Waal, A. Zeller, J. Gussekloo, R.K.E. Poortvliet

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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. © 2017 The Author(s).
Original languageEnglish
Pages (from-to)1-7
Number of pages7
JournalBMC Geriatrics
Issue number1
Publication statusPublished - 20 Apr 2017


  • Clinical variation
  • Elderly
  • Frailty
  • General practitioners
  • Hypertension
  • Oldest-old
  • antihypertensive agent
  • aged
  • blood pressure
  • clinical competence
  • clinical decision making
  • clinical trial
  • drug effects
  • female
  • general practitioner
  • global health
  • human
  • hypertension
  • male
  • multicenter study
  • odds ratio
  • prevalence
  • questionnaire
  • very elderly
  • Aged
  • Aged, 80 and over
  • Antihypertensive Agents
  • Blood Pressure
  • Clinical Competence
  • Clinical Decision-Making
  • Female
  • General Practitioners
  • Global Health
  • Humans
  • Male
  • Odds Ratio
  • Prevalence
  • Surveys and Questionnaires


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