Journal of General Internal Medicine

, Volume 23, Issue 5, pp 588–594 | Cite as

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

  • Julie A. SchmittdielEmail author
  • Connie S. Uratsu
  • Andrew J. Karter
  • Michele Heisler
  • Usha Subramanian
  • Carol M. Mangione
  • Joe V. Selby
Original Article



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.


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.


Cross-sectional assessment.


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


“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.


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.


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.


diabetes mellitus adherence, treatment intensification hypertension hyperlipidemia quality of health care cardiovascular disease 



This project was funded by the Centers for Disease Control, Contract no. U58/CCU923527-04-1. Dr. Schmittdiel is supported by the Office of Research in Women’s Health Building Interdisciplinary Careers in Women’s Health K12 Career Development Award ((K12HD052163).

The study protocol was approved by the Kaiser Permanente Northern California Institutional Review Board (CN-03JSelb-08).

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Julie A. Schmittdiel
    • 1
    Email author
  • Connie S. Uratsu
    • 1
  • Andrew J. Karter
    • 1
  • Michele Heisler
    • 2
    • 3
    • 4
  • Usha Subramanian
    • 5
    • 6
    • 7
  • Carol M. Mangione
    • 8
  • Joe V. Selby
    • 1
  1. 1.Division of ResearchKaiser Permanente Medical Care ProgramOaklandUSA
  2. 2.Veterans Affairs Center for Practice Management and Outcomes ResearchVA Ann Arbor Health SystemAnn ArborUSA
  3. 3.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  4. 4.Michigan Diabetes Research and Training CenterAnn ArborUSA
  5. 5.Roudebush VAMCIndianapolisUSA
  6. 6.Division of General Internal Medicine and Geriatrics, Department of MedicineIndiana University School of MedicineIndianapolisUSA
  7. 7.Regenstrief Institute for Healthcare, Inc.IndianapolisUSA
  8. 8.Division of General Internal Medicine and Health Services Research and the UCLA School of Public Health, David Geffen School of MedicineUniversity of California at Los AngelesLos AngelesUSA

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