Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries

Milly A van der Ploeg; Sven Streit; Wilco P Achterberg; Erna Beers; Arthur M Bohnen; Robert A Burman; Claire Collins; Fabio G Franco; Biljana Gerasimovska-Kitanovska; Sandra Gintere; Raquel Gomez Bravo; Kathryn Hoffmann; Claudia Iftode; Sanda Kreitmayer Peštić; Tuomas H Koskela; Donata Kurpas; Hubert Maisonneuve; Christan D Mallen; Christoph Merlo; Yolanda Mueller; Christiane Muth; Ferdinando Petrazzuoli; Nicolas Rodondi; Thomas Rosemann; Martin Sattler; Tjard Schermer; Marija Petek Šter; Zuzana Švadlenková; Athina Tatsioni; Hans Thulesius; Victoria Tkachenko; Péter Torzsa; Rosy Tsopra; Canan Tuz; Bert Vaes; Rita P A Viegas; Shlomo Vinker; Katharine A Wallis; Andreas Zeller; Jacobijn Gussekloo; Rosalinde K E Poortvliet

doi:10.1007/s11606-018-4795-x

Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries

J Gen Intern Med. 2019 Sep;34(9):1751-1757. doi: 10.1007/s11606-018-4795-x. Epub 2019 Jan 16.

Authors

Milly A van der Ploeg¹, Sven Streit², Wilco P Achterberg¹, Erna Beers³, Arthur M Bohnen⁴, Robert A Burman⁵, Claire Collins⁶, Fabio G Franco⁷, Biljana Gerasimovska-Kitanovska⁸, Sandra Gintere⁹, Raquel Gomez Bravo¹⁰, Kathryn Hoffmann¹¹, Claudia Iftode¹², Sanda Kreitmayer Peštić¹³, Tuomas H Koskela¹⁴, Donata Kurpas¹⁵, Hubert Maisonneuve¹⁶, Christan D Mallen¹⁷, Christoph Merlo¹⁸, Yolanda Mueller¹⁹, Christiane Muth²⁰, Ferdinando Petrazzuoli^{21

22}, Nicolas Rodondi^{2

23}, Thomas Rosemann²⁴, Martin Sattler²⁵, Tjard Schermer²⁶, Marija Petek Šter²⁷, Zuzana Švadlenková²⁸, Athina Tatsioni²⁹, Hans Thulesius^{30

31

32}, Victoria Tkachenko³³, Péter Torzsa³⁴, Rosy Tsopra³⁵, Canan Tuz³⁶, Bert Vaes³⁷, Rita P A Viegas³⁸, Shlomo Vinker³⁹, Katharine A Wallis⁴⁰, Andreas Zeller⁴¹, Jacobijn Gussekloo¹, Rosalinde K E Poortvliet⁴²

Affiliations

¹ Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands.
² Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
³ Department of Family Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.
⁴ Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
⁵ Vennesla Primary Health Care Centre, Bergen, Norway.
⁶ Irish College of General Practitioners, Dublin, Ireland.
⁷ Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁸ Department of Nephrology and Department of Family Medicine, University Clinical Centre, University St. Cyril and Metodius, Skopje, Macedonia.
⁹ Faculty of Medicine, Department of Family Medicine, Riga Stradiņs University, Riga, Latvia.
¹⁰ Institute for Health and Behaviour, Research Unit INSIDE, University of Luxembourg, Luxembourg City, Luxembourg.
¹¹ Department of General Practice and Family Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria.
¹² Timis Society of Family Medicine, Sano Med West Private Clinic, Timisoara, Romania.
¹³ Department for Family Medicine, Health Center Tuzla, Medical School, University of Tuzla, Tuzla, Bosnia and Herzegovina.
¹⁴ Department of General Practice, University of Tampere, Tampere, Finland.
¹⁵ Family Medicine Department, Wroclaw Medical University, Wrocław, Poland.
¹⁶ Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
¹⁷ Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
¹⁸ Institute of Primary and Community Care Lucerne (IHAM), Lucerne, Switzerland.
¹⁹ Department of Community Care and Ambulatory Medicine, Institute of Family Medicine Lausanne (IUMF), Lausanne, Switzerland.
²⁰ Goethe-University, Institute of General Practice, Frankfurt/Main, Germany.
²¹ Center for Primary Health Care Research, Clinical Research Center, Lund University, Malmö, Sweden.
²² SNAMID (National Society of Medical Education in General Practice), Caserta, Italy.
²³ Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
²⁴ Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
²⁵ SSLMG, Societé Scientifique Luxembourgois en Medicine generale, Luxembourg City, Luxembourg.
²⁶ Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.
²⁷ Department of Family Medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
²⁸ Ordinace Řepy, s.r.o., Prague, Prague, Czech Republic.
²⁹ Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
³⁰ Department of Clinical Sciences, Section of Family Medicine, Lund University, Malmö, Sweden.
³¹ Department of Research and Development, Region Kronoberg, Sweden.
³² Primary Care, Region Kronoberg, Växjö, Sweden.
³³ Department of Family Medicine, Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine.
³⁴ Department of Family Medicine, Semmelweis University, Budapest, Hungary.
³⁵ AP-HP, Assistance Publique des Hôpitaux de Paris, Université Paris 13, Paris, France.
³⁶ Erzincan University Family Medicine Department, Erzincan, Turkey.
³⁷ Department of Public Health and Primary Care, Universiteit Leuven (KU Leuven), Leuven, Belgium.
³⁸ Department of Family Medicine, NOVA Medical School, Lisbon, Portugal.
³⁹ Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
⁴⁰ Department of General Practice & Primary Health Care, School of Population Health Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
⁴¹ Centre for Primary Health Care (uniham-bb), University of Basel, Basel, Switzerland.
⁴² Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333 ZD, Leiden, The Netherlands. [email protected].

Abstract

Background: Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients.

Objective: To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients.

Design: We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment.

Main measures: Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (OR_adj) were calculated for GPs' advice to stop.

Key results: Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (OR_adj 13.8, 95%CI 12.6-15.1), with side effects compared to without OR_adj 1.62 (95%CI 1.5-1.7) and with frailty (OR_adj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (OR_adj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99).

Conclusions: The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.

Keywords: cardiovascular diseases; clinical decision-making; drug therapy; general practitioners; hydroxymethylglutaryl-CoA reductase inhibitors; palliative care.

MeSH terms

Aged, 80 and over
Cardiovascular Diseases / drug therapy
Cardiovascular Diseases / epidemiology
Case-Control Studies
Female
General Practitioners / standards
General Practitioners / trends*
Humans
Hydroxymethylglutaryl-CoA Reductase Inhibitors / administration & dosage*
Hydroxymethylglutaryl-CoA Reductase Inhibitors / adverse effects
Internationality*
Life Expectancy / trends
Male
Practice Patterns, Physicians' / standards
Practice Patterns, Physicians' / trends*
Surveys and Questionnaires* / standards
Withholding Treatment / standards
Withholding Treatment / trends*

Substances

Hydroxymethylglutaryl-CoA Reductase Inhibitors