Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus.
BACKGROUND
Poorly controlled cardiovascular risk factors are common. Evaluating whether physicians respond appropriately to poor risk factor control in patients may better reflect quality of care than measuring proportions of patients whose conditions are controlled.


OBJECTIVE
To evaluate therapy modifications in response to poor control of hypertension, dyslipidemia, or diabetes in a large clinical population.


METHODS
Retrospective cohort study within an 18-month period in 2002 to 2003.


METHODS
Kaiser Permanente of Northern California.


METHODS
253,238 adult members with poor control of 1 or more of these conditions.


METHODS
The authors assessed the proportion of patients with poor control who experienced a change in pharmacotherapy within 6 months, and they defined "appropriate care" as a therapy modification or return to control without therapy modification within 6 months.


RESULTS
A total of 64% of patients experienced modifications in therapy for poorly controlled systolic blood pressure, 71% for poorly controlled diastolic blood pressure, 56% for poorly controlled low-density lipoprotein cholesterol level, and 66% for poorly controlled hemoglobin A1c level. Most frequent modifications were increases in number of drug classes (from 70% to 84%) and increased dosage (from 15% to 40%). An additional 7% to 11% of those with poorly controlled blood pressure, but only 3% to 4% of those with elevated low-density lipoprotein cholesterol level or hemoglobin A1c level, returned to control without therapy modification. Patients with more than 1 of the 3 conditions, higher baseline values, and target organ damage were more likely to receive "appropriate care."


CONCLUSIONS
Patient preferences and suboptimal adherence to therapy were not measured and may explain some failures to act.


CONCLUSIONS
As an additional measure of the quality of care, measuring therapy modifications in response to poor control in a large population is feasible. Many patients with poorly controlled hypertension, dyslipidemia, or diabetes had their therapy modified and, thus, seemed to receive clinically "appropriate care" with this new quality measure.
University Outpatient Clinic and University Institute of Social and Preventive Medicine, Department of Community Medicine and Public Health, University of Lausanne, Lausanne, Switzerland. nicolas.rodondi@hospvd.ch
Nicolas
N
Rodondi
Tiffany
T
Peng
Andrew J
AJ
Karter
Douglas C
DC
Bauer
Eric
E
Vittinghoff
Simon
S
Tang
Daniel
D
Pettitt
Eve A
EA
Kerr
Joe V
JV
Selby
D000328:Adult; D000368:Aged; D002140:California; D003925:Diabetic Angiopathies / Q000175:diagnosis / Q000188:drug therapy*; D005260:Female; D006801:Humans; D006949:Hyperlipidemias / Q000175:diagnosis / Q000188:drug therapy*; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D017060:Patient Satisfaction; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors