OBJECTIVES: We 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. DESIGN: This 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. SETTING: GP respondents from European General Practice Research Network (EGPRN) countries, Brazil and New Zeeland. SUBJECTS: This study included 2543 GPs from 29 countries. MAIN OUTCOME MEASURES: GP 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. RESULTS: Of 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). CONCLUSIONS: GPs' 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.

b Department of Clinical Sciences Family Medicine Lund University Malmö Sweden

b Department of Public Health and Primary Care Leiden University Medical Center Leiden The Netherlands

c Senior Researcher Region Kronoberg Växjö Sweden

c Vennesla Primary Health Care Centre Bergen Norway

Department of Family Medicine Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education Kiev Ukraine

e Department of Family Medicine Semmelweis University Budapest Hungary

e Department of Nephrology and Department of Family Medicine University Clinical Centre University St Cyril and Metodius Skopje Macedonia

f Department of Family Medicine Faculty of Medicine Riga Stradiņs University Riga Latvia

f LIMICS INSERM Paris France

Family Medicine Department Wroclaw Medical University Wroclaw Poland

g Institute for Health and Behaviour Research Unit INSIDE University of Luxembourg Luxembourg Luxembourg

g Leeds Centre for Respiratory Medicine St James's University Hospital Leeds UK

h Department of General Practice and Family Medicine Center for Public Health Medical University of Vienna Vienna Austria

h Kemaliye Town Hospital Erzincan University Erzincan Turkey

i Department of Family Medicine NOVA Medical School Lisbon Portugal

i Timis Society of Family Medicine Sano Med West Private Clinic Timisoara Romania

Institute of Primary Health Care University of Bern Bern Switzerland

Irish College of General Practitioners Dublin Ireland

j Danish College of General Practitioners Copenhagen Denmark

j Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel

k Centre for Primary Health Care University of Basel Basel Switzerland

k School of Population Health University of Auckland Auckland New Zealand

l Department of General Internal Medicine Inselspital Bern University Hospital University of Bern Bern Switzerland

l Department of General Practice University of Tampere Tampere Finland

m Family Medicine Department Health Center Tuzla Medical School University of Tuzla Tuzla Bosnia and Herzegovina

o Primary Care and Health Sciences Keele University Keele UK

p Primary Care Unit Faculty of Medicine University of Geneva Geneva Switzerland

q Institute of Primary and Community Care Lucerne Lucerne Switzerland

r Institute of Family Medicine Lausanne Lausanne Switzerland

Research Unit for General Medicine and Primary Health Care Faculty of Medicine School of Health Sciences University of Ioannina Ioannina Greece

s Institute of General Practice Goethe University Frankfurt Main Germany

t Hospital Israelita Albert Einstein São Paulo Brazil

u Department for Family Medicine Medical Faculty University of Ljubljana Ljubljana Slovenia

v SNAMID Caserta Italy

w Department of Clinical Sciences Centre for Primary Health Care Research Lund University Malmö Sweden

x Institute of Primary Care University Hospital Zurich University of Zurich Zurich Switzerland

y SSLMG Societé Scientifique Luxembourgois en Medicine generale Luxembourg Luxembourg

z Ordinace Řepy s r o Prague Czech Republic

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