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

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

doi:10.1007/s11606-008-0554-8

Cited by 239Medication Adherence and ComplianceDiabetes Management and EducationDiabetes, Cardiovascular Risks, and Lipoproteins

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

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Schmittdiel, Julie A., Uratsu, Connie S., Karter, Andrew J., Heisler, Michele, Subramanian, Usha, Mangione, Carol M., Selby, Joe V.·2008·Journal of General Internal Medicine

DOI 10.1007/s11606-008-0554-8PMC PMC2324158

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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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A large proportion of patients with type 2 diabetes receiving basal insulin do not achieve target HbA1c <7.0%.
“Despite significant expansion on our insulin portfolio during the past decade, a large proportion of patients with type 2 diabetes receiving basal insulin do not achieve target HbA1c <7.0%.4,6,25”
From Efficacy of a Smart Insulin Pen Cap for the Management of Patients with Uncontrolled Type 2 Diabetes: A Randomized Cross-Over Trial (2023) · cites this paper as [25]
The Results (page unavailable) report that 53% of patients not using insulin at baseline had an above-target A1c at some point in 2005. The Methods define above target as A1c ≥7.0%, but the Data Analyses section says the hyperglycemia analysis was limited to patients not on insulin at baseline. The paper therefore supports the general point about missed A1c targets, not the claim specifically about patients receiving basal insulin. (LLM, conf=0.88)
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Poor outcomes in diabetes care: is medication nonadherence or lack of treatment intensification to blame?
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Missed Opportunities in Diabetes Management: A Longitudinal Assessment of Factors Associated with Sub-optimal Quality
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Self-citation
Importance of Adherence Versus Intensification in Attaining Blood Pressure Control
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Authors: Schmittdiel, J. A., Uratsu, C. S., Karter, A. J., Heisler, M., Subramanian, U., Mangione, C. M., & Selby, J. V.
Affiliations: Kaiser Permanente (US)
University of Michigan (US)
Regenstrief Institute (US)
University of California, Los Angeles (US)
Corresponding author: Schmittdiel, Julie A.
ORCID: Schmittdiel, Julie A.
Uratsu, Connie S.
Karter, Andrew J.
Heisler, Michele
Mangione, Carol M.
Venue: Journal of General Internal Medicine
Publisher: Springer Science and Business Media LLC
Published: 2008-03-04
Volume: 23
Issue: 5
Pages: 588-594
ISSN: 0884-8734 (ISSN-L)
1525-1497
DOI: 10.1007/s11606-008-0554-8
PMC: PMC2324158
OpenAlex: W2075557567
Cited by: 239
References: 67
Citations by year: 2026: 2 · 2025: 2 · 2024: 6 · 2023: 8 · 2022: 6 · 2021: 3 · 2020: 8 · 2019: 10 · 2018: 6 · 2017: 12 · 2016: 18 · 2015: 22 · 2014: 23 · 2013: 22 · 2012: 23
FWCI: 15.83
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.springer.com/tdm (tdm)
Locations: Journal of General Internal Medicine (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
eScholarship (California Digital Library) (submittedVersion)
Funders: Kaiser Permanente
Centers for Disease Control and Prevention
U.S. Public Health Service (U58/CCU923527-04-1)
National Institute of Diabetes and Digestive and Kidney Diseases (R01DK065664)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (K12HD052163, R01HD046113)
Topics: Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords: diabetes mellitus, medication non-adherence, treatment intensification, cardiovascular risk factors, glycemic control, HbA1c, LDL cholesterol, hypertension, systolic blood pressure, hyperlipidemia, medication gaps, Kaiser Permanente
MeSH terms: Aged, Antihypertensive Agents, Hypolipidemic Agents, California, Cardiovascular Diseases, Cross-Sectional Studies, Diabetes Mellitus, Female, Glycated Hemoglobin, Humans, Hyperlipidemias, Hypertension, Hypoglycemic Agents, Male, Managed Care Programs, Medical Audit, Middle Aged, Patient Compliance, Patient Education as Topic, Practice Patterns, Physicians', Risk Factors, Treatment Refusal, Guideline Adherence

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

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