Treatment Intensification and Risk Factor Control: Toward... : Medical Care (original) (raw)

Original Article

Toward More Clinically Relevant Quality Measures

Selby, Joseph V. MD*; Uratsu, Connie S. BA*; Fireman, Bruce MA*; Schmittdiel, Julie A. PhD*; Peng, Tiffany MA*; Rodondi, Nicolas MD†; Karter, Andrew J. PhD*; Kerr, Eve A. MD‡

From the *Division of Research, Kaiser Permanente Medical Care Program, Oakland, California; †Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland; and ‡Center for Clinical Management Research, Division of General Medicine, University of Michigan Medical School, Ann Arbor, Michigan.

Supported in part by Pfizer Pharmaceuticals, Inc. By contract, J.V.S. retained right to publish findings without approval from Pfizer. Dr. Rodondi supported by a grant from the Swiss National Foundation (PBLAB-102353). Dr. Kerr's time was funded in part by the VA HSR&D Quality Enhancement Research Initiative for Diabetes Mellitus (DIB 98-001) and by the Measurement Core of the Michigan Diabetes Research and Training Center (P60DK-20572).

Reprints: Joseph V. Selby, MD, MPH, Division of Research, 2000 Broadway, Oakland, CA 94612. E-mail: [email protected].

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.lww-medicalcare.com).

Abstract

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 ≤ 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.