Why Don’t Diabetes Patients Achieve Recommended Risk Factor Targets? Poor Adherence versus Lack of Treatment Intensification

• Published in: Journal of general internal medicine : JGIM Vol. 23; no. 5; pp. 588 - 594
• Main Authors: Schmittdiel, Julie A., Uratsu, Connie S., Karter, Andrew J., Heisler, Michele, Subramanian, Usha, Mangione, Carol M., Selby, Joe V.
• Format: Journal Article
• Language: English
• Published: New York Springer-Verlag 01.05.2008; Springer; Springer Nature B.V
• Subjects: Aged; Antihypertensive Agents - therapeutic use; Biological and medical sciences; California; Cardiovascular disease; Cardiovascular Diseases - epidemiology; Cardiovascular Diseases - prevention & control; Cross-Sectional Studies; Diabetes; Diabetes Mellitus - blood; Diabetes Mellitus - drug therapy; Diabetes. Impaired glucose tolerance; Endocrine pancreas. Apud cells (diseases); Endocrinopathies; Etiopathogenesis. Screening. Investigations. Target tissue resistance; Female; General aspects; Glycated Hemoglobin - drug effects; Guideline Adherence; Health behavior; Humans; Hyperlipidemias - drug therapy; Hypertension - drug therapy; Hypoglycemic Agents - therapeutic use; Hypolipidemic Agents - therapeutic use; Internal Medicine; Male; Managed Care Programs; Medical Audit; Medical sciences; Medical treatment; Medicine; Medicine & Public Health; Middle Aged; Miscellaneous; Original; Original Article; Patient Compliance; Patient Education as Topic; Practice Patterns, Physicians; Public health. Hygiene; Public health. Hygiene-occupational medicine; Quality of care; Risk Factors; Treatment Refusal; cardiovascular disease; hyperlipidemia; quality of health care; diabetes mellitus; hypertension; adherence, treatment intensification; Endocrinopathy; Human; Hypertension; Diabetes mellitus; Metabolic diseases; Lipids; Patient; Cardiovascular disease; Adhesion; Recommendation; Care; Medicine; Target; treatment intensification; hypertension; hyperlipidemia; quality of health care; cardiovascular disease; Treatment; Quality; Risk factor; Treatment compliance; Hyperlipemia; diabetes mellitus; adherence; Dyslipemia; Comparative study; Public health
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/s11606-008-0554-8

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. Design Cross-sectional assessment. Participants In 2005, 161,697 Kaiser Permanente Northern California adult diabetes patients were included in the study. Measurement “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.