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. 2008 May;23(5):588-94.
doi: 10.1007/s11606-008-0554-8. Epub 2008 Mar 4.

Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification

Julie A Schmittdiel  1 , Connie S Uratsu, Andrew J Karter, Michele Heisler, Usha Subramanian, Carol M Mangione, Joe V Selby
Affiliations

Why don't diabetes patients achieve recommended risk factor targets? Poor adherence versus lack of treatment intensification

Julie A Schmittdiel et al. J Gen Intern Med. 2008 May.

Abstract

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.

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Figures

Figure 1
Figure 1
Medication adherence and intensification for glycemic control in patients not on insulin at baseline. *Among patients who had a follow-up laboratory value within 6 months (44%). + p < .001 difference between treatment intensification group and other 2 groups.
Figure 2
Figure 2
Medication adherence and intensification for hyperlipidemia among diabetes patients. *Among patients who had a follow-up laboratory value within 6 months (46%). + p < .001 difference between treatment intensification group and other 2 groups.
Figure 3
Figure 3
Medication adherence and intensification for hypertension among diabetes patients. *Among patients who had a follow-up laboratory value within 6 months (49%). + p < .001 difference between treatment intensification group and other 2 groups.
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