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

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


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.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Antihypertensive Agents / therapeutic use
  • California
  • Cardiovascular Diseases / epidemiology
  • Cardiovascular Diseases / prevention & control
  • Cross-Sectional Studies
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / drug therapy*
  • Female
  • Glycated Hemoglobin / drug effects
  • Guideline Adherence*
  • Humans
  • Hyperlipidemias / drug therapy
  • Hypertension / drug therapy
  • Hypoglycemic Agents / therapeutic use
  • Hypolipidemic Agents / therapeutic use
  • Male
  • Managed Care Programs
  • Medical Audit
  • Middle Aged
  • Patient Compliance*
  • Patient Education as Topic
  • Practice Patterns, Physicians'*
  • Risk Factors
  • Treatment Refusal*


  • Antihypertensive Agents
  • Glycated Hemoglobin A
  • Hypoglycemic Agents
  • Hypolipidemic Agents