Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification.
BACKGROUND
Despite the availability of effective hypertension, hyperlipidemia, and hyperglycemia therapies, target levels of systolic blood pressure (SBP), LDL-cholesterol (LDL-c), and hemoglobin A1c control are often not achieved.


OBJECTIVE
To examine the relative importance of patient medication nonadherence versus clinician lack of therapy intensification in explaining above target cardiovascular disease (CVD) risk factor levels.


METHODS
Cross-sectional assessment.


METHODS
In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study.


METHODS
"Above target" was defined as most recent A1c >/=7.0% for hyperglycemia, LDL-c >/=100 mg/dL for hyperlipidemia, and SBP >/=130 mmHg for hypertension. Poor adherence was defined as medication gaps for >/=20% of days covered for all medications for each condition separately. Treatment intensification was defined as an increase in the number of drug classes, increased dosage of a class, or a switch to a different class within the 3 months before or after notation of above target levels.


RESULTS
Poor adherence was found in 20-23% of patients across the 3 conditions. No evidence of poor adherence with no treatment intensification was found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients, and 36% of hypertension patients. Poor adherence or lack of therapy intensification was evident in 53-68% of patients above target levels across conditions.


CONCLUSIONS
Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control.
Schmittdiel
Julie A
JA
Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA, USA. Julie.A.Schmittdiel@kp.org
Uratsu
Connie S
CS
Karter
Andrew J
AJ
Heisler
Michele
M
Subramanian
Usha
U
Mangione
Carol M
CM
Selby
Joe V
JV
D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D002140:California; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000517:prevention & control; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000097:blood / Q000188:drug therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000187:drug effects; D019983:Guideline Adherence; D006801:Humans; D006949:Hyperlipidemias / Q000188:drug therapy; D006973:Hypertension / Q000188:drug therapy; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008329:Managed Care Programs; D008485:Medical Audit; D008875:Middle Aged; D010349:Patient Compliance; D010353:Patient Education as Topic; D010818:Practice Patterns, Physicians'; D012307:Risk Factors; D016312:Treatment Refusal
D000959:Antihypertensive Agents; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D000960:Hypolipidemic Agents