Treatment intensification and risk factor control: toward more clinically relevant quality measures

Med Care. 2009 Apr;47(4):395-402. doi: 10.1097/mlr.0b013e31818d775c.


Background: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality.

Objective: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California.

Design: Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003.

Patients: Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively.

Measurements: Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control.

Results: Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively.

Conclusions: Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Validation Study

MeSH terms

  • Aged
  • Antihypertensive Agents / administration & dosage
  • Antihypertensive Agents / therapeutic use
  • California
  • Cardiovascular Diseases / prevention & control
  • Chronic Disease / drug therapy*
  • Diabetes Mellitus / drug therapy
  • Drug Therapy / methods
  • Drug Therapy / standards*
  • Female
  • Humans
  • Hyperlipidemias / drug therapy
  • Hypertension / drug therapy
  • Hypoglycemic Agents / administration & dosage
  • Hypoglycemic Agents / therapeutic use
  • Hypolipidemic Agents / administration & dosage
  • Hypolipidemic Agents / therapeutic use
  • Male
  • Managed Care Programs
  • Middle Aged
  • Outcome and Process Assessment, Health Care*
  • Quality Indicators, Health Care / standards*
  • Risk Factors


  • Antihypertensive Agents
  • Hypoglycemic Agents
  • Hypolipidemic Agents