Treatment Intensification and Risk Factor Control: 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 ++
47(4):395-402, April 2009.
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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.
(C) 2009 Lippincott Williams & Wilkins, Inc.