Therapy Modifications in Response to Poorly Controlled Hypertension, Dyslipidemia, and Diabetes Mellitus

4 April 2006 | Volume 144 Issue 7 | Pages 475-484

Background: Poorly controlled cardiovascular risk factors are common. Evaluating whether physicians respond appropriately to poor risk factor control in patients may better reflect quality of care than measuring proportions of patients whose conditions are controlled.

Objectives: To evaluate therapy modifications in response to poor control of hypertension, dyslipidemia, or diabetes in a large clinical population.

Design: Retrospective cohort study within an 18-month period in 2002 to 2003.

Setting: Kaiser Permanente of Northern California.

Patients: 253 238 adult members with poor control of 1 or more of these conditions.

Measurements: The authors assessed the proportion of patients with poor control who experienced a change in pharmacotherapy within 6 months, and they defined "appropriate care" as a therapy modification or return to control without therapy modification within 6 months.

Results: A total of 64% of patients experienced modifications in therapy for poorly controlled systolic blood pressure, 71% for poorly controlled diastolic blood pressure, 56% for poorly controlled low-density lipoprotein cholesterol level, and 66% for poorly controlled hemoglobin A_1c level. Most frequent modifications were increases in number of drug classes (from 70% to 84%) and increased dosage (from 15% to 40%). An additional 7% to 11% of those with poorly controlled blood pressure, but only 3% to 4% of those with elevated low-density lipoprotein cholesterol level or hemoglobin A_1c level, returned to control without therapy modification. Patients with more than 1 of the 3 conditions, higher baseline values, and target organ damage were more likely to receive "appropriate care."

Limitations: Patient preferences and suboptimal adherence to therapy were not measured and may explain some failures to act.

Conclusions: As an additional measure of the quality of care, measuring therapy modifications in response to poor control in a large population is feasible. Many patients with poorly controlled hypertension, dyslipidemia, or diabetes had their therapy modified and, thus, seemed to receive clinically "appropriate care" with this new quality measure.

Editors' Notes Context What actions do health care providers take for patients with poorly controlled cardiovascular risk factors? Content This large retrospective cohort study from Kaiser Permanente of Northern California found that, within a 6-month period, most patients received therapy modifications for the following poorly controlled risk factors: systolic blood pressure (64%), diastolic blood pressure (71%), low-density lipoprotein cholesterol level (56%), and hemoglobin A1c level (66%). The most frequent modifications were adding drugs and increasing dosages. Cautions We do not know how often patient preferences or suboptimal adherence influenced treatment decisions. The study did not directly link therapy modifications to clinical outcomes. —The Editors

 

Author and Article Information

From University of Lausanne, Lausanne, Switzerland; University of California, San Francisco, San Francisco, California; Kaiser Permanente Medical Care Program of Northern California, Oakland, California; Pfizer Outcomes Research, New York, New York; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan.

Acknowledgments: The authors thank Jon P. Edwards and Fiona Nitsche for editorial support.

Grant Support: Research funding for the collection and analysis of these data was provided by the U.S. Outcomes Research Group of Pfizer Inc. Dr. Rodondi was supported by a grant from the Swiss National Foundation (PBLAB-102353). Dr. Kerr was supported by the Veterans Affairs Health Services Research and Development Service Diabetes Mellitus Quality Enhancement Research Initiative (DIB #98-001) and the Michigan Diabetes Research and Training Center (National Institues of Health/National Institute of Diabetes & Digestive & Kidney Diseases #5 P50 DK 20572).

Potential Financial Conflicts of Interest: Employment: S. Tang (Pfizer Inc.), D. Pettitt (Pfizer Inc.); Expert testimony: J.V. Selby (Kaiser Permanente); Stock ownership or options (other than mutual funds): S. Tang (Pfizer Inc.), D. Pettitt (Pfizer Inc.); Grants received: N. Rodondi (Pfizer Inc., Swiss National Foundation), A.J. Karter (Pfizer Inc.), J.V. Selby (Pfizer Inc.); Grants pending: J.V. Selby (Pfizer Inc.).

Requests for Single Reprints: Nicolas Rodondi, MD, MAS, University Outpatient Clinic and University Institute of Social and Preventive Medicine, Department of Community Medicine and Public Health, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland; e-mail, nicolas.rodondi{at}hospvd.ch.

Current Author Addresses: Dr. Rodondi: University Outpatient Clinic and University Institute of Social and Preventive Medicine, Department of Community Medicine and Public Health, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland.

Ms. Peng and Drs. Karter and Selby: Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.

Dr. Bauer: University of California, San Francisco, 185 Berry Street, Suite 5700, San Francisco, CA 94107.

Dr. Vittinghoff: University of California, San Francisco, 1635 Divisadero, Suite 600, San Francisco, CA 94115.

Mr. Tang: Pfizer Inc. Outcomes Research, 235 East 42nd Street, New York, NY 10017.

Dr. Pettitt: Pfizer Inc. Outcomes Research, 150 East 42nd Street, New York, NY 10017.

Dr. Kerr: Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research and Division of General Medicine, University of Michigan Medical School, 2215 Fuller Road, P.O. Box 130170, Ann Arbor, MI 48113.

Author Contributions: Conception and design: N. Rodondi, A.J. Karter, E. Vittinghoff, S. Tang, D. Pettitt, J.V. Selby.

Analysis and interpretation of the data: N. Rodondi, T. Peng, D.C. Bauer, D. Pettitt, E.A. Kerr, J.V. Selby.

Drafting of the article: N. Rodondi.

Critical revision of the article for important intellectual content: A.J. Karter, D.C. Bauer, E. Vittinghoff, S. Tang, D. Pettitt, E.A. Kerr, J.V. Selby.

Final approval of the article: N. Rodondi, A.J. Karter, D.C. Bauer, S. Tang, D. Pettitt, E.A. Kerr, J.V. Selby.

Provision of study materials or patients: A.J. Karter, J.V. Selby.

Statistical expertise: N. Rodondi, E. Vittinghoff.

Obtaining of funding: D. Pettitt, J.V. Selby.

Administrative, technical, or logistic support: J.V. Selby.

Collection and assembly of data: T. Peng, A.J. Karter, J.V. Selby.

Read all Rapid Responses

"Poorly Controlled" is still "Controlled"

James S. Kennedy

Annals Online, 7 Apr 2006 [Full text]

Poorly Controlled Cardiovascular Risk Factors and ICD-9 codes

Nicolas Rodondi, et al.

Annals Online, 23 May 2006 [Full text]