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Therapy Modifications in Response to Poorly Controlled Hypertension, Dyslipidemia, and Diabetes Mellitus

Nicolas Rodondi, MD, MAS; Tiffany Peng, MA; Andrew J. Karter, PhD; Douglas C. Bauer, MD; Eric Vittinghoff, PhD; Simon Tang, MPH; Daniel Pettitt, DVM, MS; Eve A. Kerr, MD, MPH; and Joe V. Selby, MD, MPH
[+] Article, Author, and Disclosure Information

From University of Lausanne, Lausanne, Switzerland; University of California, San Francisco, San Francisco, California; Kaiser Permanente Medical Care Program of Northern California, Oakland, California; Pfizer Outcomes Research, New York, New York; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan.

Acknowledgments: The authors thank Jon P. Edwards and Fiona Nitsche for editorial support.

Grant Support: Research funding for the collection and analysis of these data was provided by the U.S. Outcomes Research Group of Pfizer Inc. Dr. Rodondi was supported by a grant from the Swiss National Foundation (PBLAB-102353). Dr. Kerr was supported by the Veterans Affairs Health Services Research and Development Service Diabetes Mellitus Quality Enhancement Research Initiative (DIB #98-001) and the Michigan Diabetes Research and Training Center (National Institues of Health/National Institute of Diabetes & Digestive & Kidney Diseases #5 P50 DK 20572).

Potential Financial Conflicts of Interest: Employment: S. Tang (Pfizer Inc.), D. Pettitt (Pfizer Inc.); Expert testimony: J.V. Selby (Kaiser Permanente); Stock ownership or options (other than mutual funds): S. Tang (Pfizer Inc.), D. Pettitt (Pfizer Inc.); Grants received: N. Rodondi (Pfizer Inc., Swiss National Foundation), A.J. Karter (Pfizer Inc.), J.V. Selby (Pfizer Inc.); Grants pending: J.V. Selby (Pfizer Inc.).

Requests for Single Reprints: Nicolas Rodondi, MD, MAS, University Outpatient Clinic and University Institute of Social and Preventive Medicine, Department of Community Medicine and Public Health, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland; e-mail, nicolas.rodondi@hospvd.ch.

Current Author Addresses: Dr. Rodondi: University Outpatient Clinic and University Institute of Social and Preventive Medicine, Department of Community Medicine and Public Health, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland.

Ms. Peng and Drs. Karter and Selby: Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.

Dr. Bauer: University of California, San Francisco, 185 Berry Street, Suite 5700, San Francisco, CA 94107.

Dr. Vittinghoff: University of California, San Francisco, 1635 Divisadero, Suite 600, San Francisco, CA 94115.

Mr. Tang: Pfizer Inc. Outcomes Research, 235 East 42nd Street, New York, NY 10017.

Dr. Pettitt: Pfizer Inc. Outcomes Research, 150 East 42nd Street, New York, NY 10017.

Dr. Kerr: Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research and Division of General Medicine, University of Michigan Medical School, 2215 Fuller Road, P.O. Box 130170, Ann Arbor, MI 48113.

Author Contributions: Conception and design: N. Rodondi, A.J. Karter, E. Vittinghoff, S. Tang, D. Pettitt, J.V. Selby.

Analysis and interpretation of the data: N. Rodondi, T. Peng, D.C. Bauer, D. Pettitt, E.A. Kerr, J.V. Selby.

Drafting of the article: N. Rodondi.

Critical revision of the article for important intellectual content: A.J. Karter, D.C. Bauer, E. Vittinghoff, S. Tang, D. Pettitt, E.A. Kerr, J.V. Selby.

Final approval of the article: N. Rodondi, A.J. Karter, D.C. Bauer, S. Tang, D. Pettitt, E.A. Kerr, J.V. Selby.

Provision of study materials or patients: A.J. Karter, J.V. Selby.

Statistical expertise: N. Rodondi, E. Vittinghoff.

Obtaining of funding: D. Pettitt, J.V. Selby.

Administrative, technical, or logistic support: J.V. Selby.

Collection and assembly of data: T. Peng, A.J. Karter, J.V. Selby.

Ann Intern Med. 2006;144(7):475-484. doi:10.7326/0003-4819-144-7-200604040-00006
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In this large clinical population, many patients with poorly controlled hypertension, dyslipidemia, or diabetes were receiving relatively few medications and relatively low doses when poor control was first noted. For each condition, most patients received a therapy modification within the following 6 months. Moreover, physicians were more likely to respond to poor risk factor control when cardiovascular risk was higher. These data demonstrate that measuring therapy modifications as possible markers of quality in a large patient population is feasible. These “tightly linked” process measures (1819) might represent an additional opportunity for improving quality of care. They met an important criterion for utility as a quality measure in that variation among physicians was substantial in each measure.

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Flow of participants in the study.Appendix Table 2BP

Levels of control and poor control for each condition are defined in . Poor control of blood pressure ( ) is defined as poor control of systolic blood pressure, diastolic blood pressure, or both. LDL = low-density lipoprotein. *Exclusion of patients who were not continuously enrolled 4 months before and 6 months after the date with abnormal value.

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Submit a Comment/Letter
Poorly Controlled is still "Controlled"
Posted on April 6, 2006
James S. Kennedy
FTI Cambio Health Solutions
Conflict of Interest: None Declared
To the Editor: The article "Therapy Modifications in Response to Poorly Controlled Cardiovascular Risk Factors" ignores the reality that the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) classifies patients with "poorly controlled" cardiovascular risk factors as "well controlled". (New Paragraph) Accordingly physicians using terminology like "poorly controlled" to describe their uncontrolled hyperglycemic, hypertensive, and hyperlipidemic patients must have their records coded as "well controlled" since ICD-9-CM requires strict interpration of physician diagnosis assignment. Similarly, patients with "hypertensive emergency" and "hypertensive crisis" will be coded as well controlled hypertension by ICD-9-CM unless the physician uses the official CDC-sanctioned terminology of "accelerated" or "malignant" hypertension to describe these patients. (New Paragraph) As a result, ICD-9-CM administrative databases measuring physician quality and resource consumption (e.g. Healthgrades, Solucient, APR-DRGs) misrepresent patient severity of illness and outcomes when physicians use these unofficial terms. (New Paragraph) Annals of Internal Medicine and other highly-regarded peer review journals should consider official disease nosology and classifications when editing an author's manuscript submitted for publications. Alternatively, the American College of Physician's appointed member to the Editorial Advisory Board of the Coding Clinic for ICD-9-CM may advocate for revisions of ICD-9-CM that better match physician vocabularies in their literature and day-to-day practices. Sincerely, James S. Kennedy, M.D., C.C.S.

Conflict of Interest:

None declared

Poorly Controlled Cardiovascular Risk Factors and ICD-9 codes
Posted on May 23, 2006
Nicolas Rodondi
University of Lausanne
Conflict of Interest: None Declared

We appreciate the comments of Dr. Kennedy. We agree that it is difficult to accurately capture disease severity and control based on commonly used ICD-9 classifications. For this reason, we used ICD-9-CM codes, along with ambulatory blood pressure measurements, laboratory results and prescriptions to identify the presence of hypertension, dyslipidemia and diabetes mellitus, but not to grade their degree of severity or control. As described in the Appendix (Table 2), and in the Methods Section, we used actual ambulatory blood pressure measurements and laboratory results from the electronic records at Kaiser Permanente to define control and pharmacy records to identify medication intensification (1). Previous studies have documented the accuracy of the Kaiser Permanente clinical databases used in our study (2, 3). For example, diabetes diagnosis, myocardial infarction and stroke were all confirmed at chart review in 98%, 99% and 75% of cases, respectively, as described in our article (1). Although we cannot exclude some misclassifications in the identification of hypertension, dyslipidemia and diabetes mellitus, our diagnostic criteria are certainly more accurate than relying on the ICD-9 codes alone.

In our study, levels of control were determined using actual measurements and current clinical guidelines. As we found that measuring therapy modifications in response to poor control in a large population was feasible, future studies should examine whether giving feedback on this process of care measure to physicians may increase the levels of control (1). This kind of measurements also has limitations, but may provide a more accurate index of the quality of clinical care than relying solely on measures that examine the proportion of patients that are in defined control.


1. Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006;144(7):475-84.

2. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131(12):927-34.

3. Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV. Ethnic disparities in diabetic complications in an insured population. Jama. 2002;287(19):2519-27.

Conflict of Interest:

None declared

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