Rodondi N et al. (2006) Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med 144: 475–484

Suboptimal control of diabetes and other cardiovascular risk factors is common, despite the publication of evidence-based guidelines for treating patients with these risk factors. It is unclear, however, whether suboptimal control is caused by poor health-care provision, poor compliance with treatment, or the presence of particularly severe disease that is unresponsive to optimal treatment. Measures that assess health-care quality, in relation to the control of cardiovascular risk factors, should ideally take these factors into account. Rodondi et al., therefore, suggest that assessing the response of health-care providers to the presence of poorly controlled risk factors might be more helpful than simply assessing levels of testing, or the proportion of patients with well-controlled risk factors.

The authors retrospectively identified 253,238 adult patients in Northern California who had poor control of one or more cardiovascular risk factors (hypertension, dyslipidemia, and diabetes mellitus). Few patients received multiple medications or maximal doses at onset of poor control. Most patients received therapy intensifications within 6 months. Notably, patients with high cardiovascular risk were more likely to experience therapy intensification—an encouraging finding, given that recent guidelines emphasize the importance of tight control of blood pressure and lipids for these patients. Overall, 18–41% of patients (depending on the risk factor present) did not receive a therapy modification for or achieve control of an elevated cardiovascular risk factor within 6 months. The authors suggest that identifying such patients might lead to improved quality of care.

The authors noted intriguing variations with ethnicity that should be investigated further.