Advertisement

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

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.

KEY WORDS

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

Notes

Acknowledgements

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.

References

  1. 1.
    Malik S, Lopez V, Chen R, Wu W, Wong ND. Undertreatment of cardiovascular risk factors among persons with diabetes in the United States. Diabetes Res Clin Pract. 2007;77(1):126–33.PubMedCrossRefGoogle Scholar
  2. 2.
    Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335–42.PubMedCrossRefGoogle Scholar
  3. 3.
    Neyer JR, Greenlund KJ, Denny CH, Keenan NL, Labarthe DR, Croft JB. Prevalence of heart disease—United States, 2005. JAMA. 2007;297:1308–9.CrossRefGoogle Scholar
  4. 4.
    Pearson TA, Blair SN, Daniels S, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation. 2002;106:388–91.PubMedCrossRefGoogle Scholar
  5. 5.
    Anonymous. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383–9.Google Scholar
  6. 6.
    Anonymous. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1997;157:2413–46.Google Scholar
  7. 7.
    Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486–97.CrossRefGoogle Scholar
  8. 8.
    ADA. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 1999;22:S32–41.Google Scholar
  9. 9.
    Greenland P, Knoll MD, Stamler J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA. 2003;290:891–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–52.PubMedCrossRefGoogle Scholar
  11. 11.
    American Diabetes Association. Implications of the diabetes control and complications trial. Diabetes Care. 2003;26:S25–7.CrossRefGoogle Scholar
  12. 12.
    Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004;140:644–9.PubMedGoogle Scholar
  13. 13.
    Snow V, Weiss KB, Mottur-Pilson C. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus. Ann Intern Med. 2003;138:587–92.PubMedGoogle Scholar
  14. 14.
    Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension. 1995;25:305–13.PubMedGoogle Scholar
  15. 15.
    Hyman DJ, Pavlik VN, Vallbona C. Physician role in lack of awareness and control of hypertension. J Clin Hypertens. 2000;2:324–30.Google Scholar
  16. 16.
    Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med. 2000;160:2281–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Stafford RS, Blumenthal D, Pasternak RC. Variations in cholesterol management practices of U.S. physicians. J Am Coll Cardiol. 1997;29:139–46.PubMedCrossRefGoogle Scholar
  18. 18.
    Vittinghoff E, Shlipak MG, Varosy PD, et al. Risk factors and secondary prevention in women with heart disease: the Heart and Estrogen/Progestin Replacement Study. Ann Intern Med. 2003;138:81–9.PubMedGoogle Scholar
  19. 19.
    Shrank WH, Asch SM, Adams J, Setodji C, Kerr EA, Keesey J, Malik S, McGlynn EA. The quality of pharmacologic care for adults in the United States. Med Care. 2006;44:936–45.PubMedCrossRefGoogle Scholar
  20. 20.
    Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Khot UB, Khot MB, Bajzer CT, et al. Prevalence of conventional risk factors in patients with coronary heart disease. JAMA. 2003;290:898–904.PubMedCrossRefGoogle Scholar
  22. 22.
    Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Hypertension control: how well are we doing? Arch Intern Med. 2003;163:2705–11.PubMedCrossRefGoogle Scholar
  23. 23.
    Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, Narayan KM. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006;144:465–74.PubMedGoogle Scholar
  24. 24.
    Vittinghoff E, Shlipak MG, Varosey PD, et al. Risk factors and secondary prevention in women with heart disease: the Heart and Estrogen/progestin replacement study. Ann Intern Med. 2003;138:81–9.PubMedGoogle Scholar
  25. 25.
    Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA. 2005;294:466–72.PubMedCrossRefGoogle Scholar
  26. 26.
    Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, Moskowitz MA. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339:1957–63.PubMedCrossRefGoogle Scholar
  27. 27.
    Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia. Ann Intern Med. 2001;135:825–34.PubMedGoogle Scholar
  28. 28.
    Asai Y, Heller R, Kajii E. Hypertension control and medication increase in primary care. J Hum Hypertens. 2002;16:313–18.PubMedCrossRefGoogle Scholar
  29. 29.
    Oliveria SA, Lapuerta P, McCarthy BD, L’Italien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med. 2002;162:413–20.PubMedCrossRefGoogle Scholar
  30. 30.
    Ziemer DC, Miller CD, Rhee MK, Doyle JP, Watkins C Jr, Cook CB, Gallina DL, El-Kebbi IM, Barnes CS, Dunbar VG, Branch WT Jr, Phillips LS. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educ. 2005;31:564–71.PubMedCrossRefGoogle Scholar
  31. 31.
    Hirsch AT, Gotto AM Jr. Undertreatment of dyslipidemia in peripheral arterial disease and other high-risk populations: an opportunity for cardiovascular disease reduction. Vasc Med. 2002;7:323–31.PubMedCrossRefGoogle Scholar
  32. 32.
    Sueta CA, Massing MW, Chowdhury M, Biggs DP, Simpson RJ Jr. Undertreatment of hyperlipidemia in patients with coronary artery disease and heart failure. J Card Fail. 2003;9:36–41.PubMedCrossRefGoogle Scholar
  33. 33.
    Andrade SE, Gurwitz JH, Field TS, Kelleher M, Majumdar SR, Reed G, Black R. Hypertension management: the care gap between clinical guidelines and clinical practice. Am J Manag Care. 2004;10:481–6.PubMedGoogle Scholar
  34. 34.
    Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. 2005;28:337–442.PubMedCrossRefGoogle Scholar
  35. 35.
    Wei L, Wang J, Thompson P, Wong S, Struthers AD, MacDonald TM. Adherence to statin treatment and readmission of patients after myocardial infarction: a six year follow up study. Heart. 2002;88:229–33.PubMedCrossRefGoogle Scholar
  36. 36.
    Sclar DA, Robison LM, Skaer TL, Dickson WM, Kozma CM, Reeder CE. Sulfonylurea pharmacotherapy regimen adherence in a Medicaid population: influence of age, gender, and race. Diabetes Educ. 1999;25:531–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288:455–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.PubMedCrossRefGoogle Scholar
  40. 40.
    Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Med Care. 2005;43:521–30.PubMedCrossRefGoogle Scholar
  41. 41.
    Ho PM, Rumsfeld JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, Magid DJ. Effect of medication nonadherence on hospitalizations and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166:1836–41.PubMedCrossRefGoogle Scholar
  42. 42.
    Lau DT, Nau DP. Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes. Diabetes Care. 2004;27:2149–53.PubMedCrossRefGoogle Scholar
  43. 43.
    Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health. 1992;182:703–10.CrossRefGoogle Scholar
  44. 44.
    Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, Tang S, Pettitt D, Kerr EA, Selby JV. Treatment intensifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144:475–84.PubMedGoogle Scholar
  45. 45.
    Karter AJ, Moffett HH, Liu J, Parker MM, Ahmed AT, Ferrara A, Selby JV. Achieving good glycemic control: initiation of new antihyperglycemic therapies in patients with type 2 diabetes from the Kaiser Permanente Northern California Diabetes Registry. Am J Manag Care. 2005;11:262–70.PubMedGoogle Scholar
  46. 46.
    Steiner JF, Koepsell TD, Fihn SD, Inui TS. A general method of compliance assessment using centralized pharmacy records. Description and validation. Med Care. 1988;26:814–23.PubMedCrossRefGoogle Scholar
  47. 47.
    Steiner JF, Prochazka AV. The assessment of refill compliance using pharmacy records: methods, validity, and applications. J Clin Epidemiol. 1997;50:105–16.PubMedCrossRefGoogle Scholar
  48. 48.
    Choo PW, Rand CS, Inui TS, et al. Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy. Med Care. 1999;37:846–57.PubMedCrossRefGoogle Scholar
  49. 49.
    Pladevall M, Williams LK, Potts LA, Divine G, Xi H, Lafata JE. Clinical outcomes and adherence to medications measured by claims data in patients with diabetes. Diabetes Care. 2004;27:2800–5.PubMedCrossRefGoogle Scholar
  50. 50.
    Schultz JS, O’Donnell JC, McDonough KL, Sasane R, Meyer J. Determinants of compliance with statin therapy and low-density lipoprotein cholesterol goal attainment in a managed care population. Am J Manag Care. 2005;11:306–12.PubMedGoogle Scholar
  51. 51.
    Grant R, Adams AS, Trinacty CM, Zhang F, Kleimna K, Soumerai SB, Meigs JB, Ross-Degnan D. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care. 2007;30:807–12.PubMedCrossRefGoogle Scholar
  52. 52.
    Berlowitz DR, Ash AS, Glockman J, Friedman RH, Pogach LM, Nelson AL, Wong AT. Developing a quality measure for clinical inertia in diabetes care. Health Serv Res. 2005;40:1854–61.CrossRefGoogle Scholar
  53. 53.
    Chaudry SI, Berlowitz DR, Concato J. Do age and comorbidity affect intensity of pharmacological therapy for poorly controlled diabetes mellitus? J Am Geriatr Soc. 2005;53:1214–6.CrossRefGoogle Scholar
  54. 54.
    Ziemer DC, Doyle JP, Barnes CS, Branch WT Jr, Cook CB, El-Kebbi IM, Gallina DL, Kolm P, Rhee MK, Phillips LS. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: improving primary care of African-Americans with diabetes (IPCAAD) 8. Arch Intern Med. 2006;166:507–13.PubMedCrossRefGoogle Scholar
  55. 55.
    Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors associated with medication refill adherence in cardiovascular-related diseases: A focus on health literacy. J Gen Intern Med. 2006;21:1215–21.PubMedCrossRefGoogle Scholar
  56. 56.
    Chapman RH, Benner JS, Petrilla AA, Tierce JC, Collins SR, Battleman DS, Schwartz S. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147–52.PubMedCrossRefGoogle Scholar

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

Personalised recommendations