Article Figures & Data
Figures
- Figure 1.
Flow diagram illustrating both criteria for blood pressure (BP) control from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the numbers (percentages) of patients at each step. CKD, chronic kidney disease.
- Figure 2.
Flow diagram illustrating National Cholesterol Education Program (NCEP) criteria for low-density lipoprotein (LDL) control and numbers (percentages) of patients at each step. *Coronary heard disease (CHD) equivalent includes diabetes, cerebral vascular disease, peripheral vascular disease, and abdominal aortic aneurysm. †NCEP nonlipid risk factors include age (male >45 years, female >55 years); family history of premature coronary artery disease; current cigarette smoking; hypertension (blood pressure >140/90 or taking antihypertensive medication); low high-density lipoprotein (HDL) (>40 mg/dL; if HDL >60 mg/dL, subtract one risk factor).
- Figure 3.
Comparison of rank-order of clinics by unadjusted and risk-adjusted blood pressure (BP) control.
- Figure 4.
Comparison of rank-order of clinics by unadjusted and risk-adjusted low-density lipoprotein (LDL) cholesterol control.
- Figure A1.
Risk-adjusted percentage of patients with uncontrolled blood pressure (BP), by clinic.
- Figure A2.
Risk-adjusted percentage of patients with uncontrolled low-density lipoprotein (LDL)-cholesterol, by clinic.
Tables
Selected Patient Characteristics and Risk-Adjustment Variables Prevalence Adverse drug effects 1,134 (0.49) Age (years) 18–40 95,639 (41.2) 41–60 94,978 (40.9) 61–80 35,971 (15.5) >80 5,584 (2.4) Alcohol or drug abuse 11,326 (4.9) Anemia 10,442 (4.5) Body mass index (kg/m2) <18.5 (underweight) 3,557 (1.5) 18.5–24.9 (normal) 67,834 (29.2) 25.0–29.9 (overweight) 73,852 (31.8) 30.0–34.9 (class I obese) 39,744 (17.1) 35.0–39.9 (class II obese) 16,041 (6.9) ≥40.0 (class III obese) 9,967 (4.3) Missing 21,177 (9.1) Cataract/aphakia 4,081 (1.8) Cerebral vascular disease or CVA 3,612 (1.6) Congestive heart failure 1,518 (0.7) Depression or anxiety 50,822 (21.9) Diabetes mellitus 14,804 (6.4) Ischemic heart disease 6,007 (2.6) Hepatitis or mononucleosis 2,356 (1.0) Hyperlipidemia 65,343 (28.1) Hypertension 58,849 (25.3) Chronic kidney disease 2,667 (1.1) Male sex 101,184 (43.6) Medical or surgical aftercare 12,871 (5.5) Neoplasm, benign 26,926 (11.6) Neoplasm, malignant 3,308 (1.4) Obesity 16,089 (6.9) Peripheral vascular disease 1,835 (0.8) Personality disorders 192 (0.1) Pulmonary disease, chronic obstructive 3,709 (1.6) Prostatitis/BPH 7,821 (3.4) Psychosocial problem 1,463 (0.6) Respiratory tract infection, acute lower 22,820 (9.8) Respiratory tract infection, acute upper 47,984 (20.7) Rhinitis, chronic 49,977 (21.5) Routine health maintenance 126,419 (54.5) Schizophrenia or affective psychosis 5,660 (2.4) Visits per year (n) 1 or 2 141,393 (60.9) 3 or 4 47,948 (20.7) 5 or 6 17,764 (7.7) >6 25,067 (10.8) Data are n (%).
BPH, benign prostatic hyperplasia; CVA, cerebrovascular accident.
- Appendix Table 1. International Classification of Diseases, Ninth Revision (ICD-9), Code Criteria for Comorbidity and Coronary Heart Disease Risk Factors Used to Construct a Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (BP) Guideline Concordance Algorithm*
Classification Disease ICD-9 Code I. Higher risk (BP goal <130/80 mmHg) Diabetes 249.xx, Secondary diabetes mellitus
250.xx, Diabetes mellitusChronic kidney disease 403.xx, Hypertensive chronic kidney disease 404.xx, Hypertensive heart and chronic kidney disease 581, Nephrotic syndrome
582, Chronic glomerulonephritis585.x, Chronic kidney disease
585, Renal failure, unspecifiedV42, Organ or tissue replaced by transplant: V42.0, Kidney V45, Other postprocedural states V45.1x, Renal dialysis status V56.xx, Encounter for dialysis and dialysis catheter care II. Lower risk (BP goal <140/90 mmHg) No diabetes diagnoses (see above) No chronic kidney disease diagnoses (see above) Data from Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1205–52 (http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm); and the 2009 ICD-9-CM (http://icd9cm.chrisendres.com/).
↵* See Figure 1.
- Appendix Table 2. International Classification of Diseases, Ninth Revision, Code Criteria for Comorbidity and Coronary Heart Disease (CHD) Risk Factors Used to Construct the National Cholesterol Education Program Guideline Concordance Algorithm*
Coronary heart disease 410.xx, Acute myocardial infarction 411.xx, Other acute and subacute forms of ischemic heart disease 412, Old myocardial infarction 413.x, Angina pectoris 414.xx, Other forms of chronic ischemic heart disease 429, Ill-defined descriptions and complications of heart disease 429.7 Certain sequelae of myocardial infarction, not elsewhere classified 429.71 Acquired cardiac septal defect 429.79 Other V45, Other postprocedural states V45.8, Other postprocedural status V45.81, Aortocoronary bypass status V45.82 Percutaneous transluminal coronary angioplasty status CHD equivalent Diabetes 249.xx, Secondary diabetes mellitus 250.xx, Diabetes mellitus 648, Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium 648.0 Diabetes mellitus Peripheral arterial disease 440.xx, Atherosclerosis 443, Other peripheral vascular disease 443.8, Other specified peripheral vascular diseases 443.81, Peripheral angiopathy in diseases classified elsewhere 443.9, Peripheral vascular disease, unspecified 444, Arterial embolism and thrombosis 444.2, Of arteries of the extremities 444.21, Upper extremity 444.22, Lower extremity 445, Atheroembolism 445.0, Of extremities 445.01, Upper extremity 445.02, Lower extremity Cerebral vascular disease 433.xx, Occlusion and stenosis of precerebral arteries 434.xx, Occlusion of cerebral arteries 435.x, Transient cerebral ischemia 436, Acute, but ill-defined, cerebrovascular disease 437.x Other and ill-defined cerebrovascular disease 438.xx, Late effects of cerebrovascular disease V12, Personal history of certain other diseases V12.5, Diseases of circulatory system V12.54, Transient ischemic attack and cerebral infarction without residual deficits Abdominal aortic aneurysm 441, Aortic aneurysm and dissection 441.0, Dissection of aorta 441.02, Abdominal 441.03, Thoracoabdominal 441.3, Abdominal aneurysm, ruptured 441.4, Abdominal aneurysm without mention of rupture 441.5, Aortic aneurysm of unspecified site, ruptured 441.6, Thoracoabdominal aneurysm, ruptured 441.7, Thoracoabdominal aneurysm, without mention of rupture 441.9, Aortic aneurysm of unspecified site without mention of rupture Risk factors used in assessing risk category for primary prevention† HDL cholesterol ≥60 mg/dL (−1) Age Men, ≥45 years; women ≥55 years (1) Cigarette smoking Yes (1) Hypertension BP ≥140/90 mmHg (average of 2 most recent measurements) or taking antihypertensive medication (1) Low HDL cholesterol <40 mg/dL (1) High HDL cholesterol ≥60 mg/dL (−1) Family history of premature CHD CHD in male first-degree relative <55 years old; CHD in female first-degree relative <65 years old (not consistently available in DARTNet) (1) Data from Ref. 14 or http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm and the 2009 ICD-9-CM (http://icd9cm.chrisendres.com/).
↵* See Figure 3.
↵† In patients without CHD or CHD equivalent. Risk factor score is the sum of bolded numbers in parentheses at end of statements 1–6.
BP, blood pressure; HDL, high-density lipoprotein.
- Appendix Table 3. International Classification of Diseases, Ninth Revision (ICD-9), Diagnostic Code Clusters for Morbidity Assessment in Ambulatory Care
No. Diagnostic/Process Cluster ICD-9 Codes to Include From To 1 Hernia (external abdominal) 550 551.0 551.2 552.0 552.2 553.0 553.2 2 Abdominal pain 789 3 Acne, diseases of sweat and sebaceous glands 695.3 705 705.9 706.0 706.9 4 Intestinal infectious diseases/scute gastroenteritis 001 005.9 006.0 006.2 007 009 558.9 5 Acute sprains, strains 840 848.9 6 Adverse effects of medicinal agents 960 979.9 995 995.2 995.4 7 Alcohol and drug abuse 291 292.9 303 305.8 571.0 571.3 648.3 8 Allergic reaction 995.3 9 Allergy treatment/desensitization V07.1 V72.7 10 Iron deficiency and other deficiency anemias 280 281.9 11 Arrhythmia 427 427.9 785.0 12 Asthma 493 493.9 13 Breast lump 611.72 14 Burns 940 949.9 15 Bursitis, dynovitis, tenosynovitis 726 727.00 727.01 727.04 727.9 727.2 727.3 16 Cataract, aphakia 366 366.9 379.3x 743.3x 998.82 V45.61 17 Cerebral vascular disease/CVA 430 438.9 18 Chest pain 786.5x 19 Heart failure 428 428.9x 20 Conjunctivitis, keratitis 053.21 054.42 054.43 077 077.9x 130.1 370 370.9 372 372.3x 21 Contraception v25.0 v25.9 22 COPD/chronic bronchitis 491 492.9 494 494.9 496 496.9 23 Deafness 387 387.9 388.2 389 389.9 24 Degenerative joint disease 715 717.x 25 Depression, anxiety, neuroses (nonpsychotic) 300.0 300.4 300.5 306 308 309 311 313 799.2 26 Dermatitis and eczema 690 693.9 698.2 698.4 706.3 27 Dermatophytosis 110 111.9 28 Diabetes mellitus 250 648.0 29 Diaphragmatic hernia 551.3 552.3 553.3 30 Disease of hair and hair follicles 704 704.9 31 Diverticular disease 562 32 Thrombophlebitis, pulmonary embolism 415.1 451 453 673 V12.51 V12.52 33 Impacted cerumen (wax in ear) 380.4 34 Enlarged tonsils 474 35 Fibrocystic breast disease 610 36 Fibrositis and myalgia 719.4 719.5 729.0 729.1 729.4 729.5 37 Foreign body in eye 930 930.9 360.5x 360.6 38 Fractures and dislocations 800 839.9 39 Ganglion 727.4x 40 Gall bladder and biliary tract diseases 574 576.9 41 Glaucoma 365 42 Gout 274 43 Headache 339 346 784 307.81 44 Hematuria 599.7x 45 Helminthiasis, scabies, lice 120 129.9 132 133.9 46 Hemorrhoids/perirectal disease 455 455.9 565 566.9 569 569.4 47 Hepatitis/mononucleosis 070 075 573.3 48 Hyperlipidemia 272 272.4 49 Hypertension 401 405.9 437.2 796.2 50 Infections of eyelid 373 373.2 373.4 373.6 51 Infertility 606 628 v26.0 v26.2 v26.8 v26.9 52 Irritable bowel syndrome 564.1 564.5 53 Ischemic heart disease 410 414.9 429.7 V45.81 V45.82 54 Keratoses 702.0 702.1 55 Lacerations/contusions 530.7 618.7 620.6 622.3 623.4 624.4 664 665.3x 665.4 800.1x 800.6x 801.1x 801.6x 803.1x 803.6x 804.1x 804.6x 851 861 865 866 870 887.x 890 891 897.x 900 904.x 910 929.x 950 957.x 959.x 998.2 56 Low back pain 720 721.3 721.42 722.10 722.52 724.02 724.2 724.3 724.6 724.7 57 Lymphadenopathy 785.6 58 Medical and surgical aftercare V51.0 V55 V58.7 V58.9 V67.0 V67.9 59 Menopausal symptoms 256.3x 627.2 627.4 627.9 60 Menstrual disorders 625.3 625.4 626 627.1 61 Neoplasm, malignant, involving skin 172 173.9 232 232.9 62 Neoplasm, malignant, not involving skin 140 165.9 170 171.9 174 176.9x 179 209.x 230 231.9 233 234.9 63 Neoplasm, benign 210 229.9 235 239.9 64 Nonfungal skin infections 607.1 607.2 680 686.9 65 Obesity 278 66 Otitis externa 380.1 380.2 67 Otitis media 381 381.4 382 382.9 384 384.1 388.7 385.1 68 Parkinson's disease 332.x 69 Peptic diseases 530.1 530.2 531 535.9 530.81 70 Peripheral neuropathy 354 355.9 356.1 356.4 357 357.9 71 Peripheral vascular disease 440.2 440.4 443.x 72 Personality disorders 301 301.9 73 Pregnancy and abortion 630.x 633x 634.x 639.9 640 646.4 646.7 646.9 650 666.x 670 677.x v22.0 v24.9 74 Prostatitis and benign prostatic hypertrophy 600.0 601.9 75 Psoriasis/pityriasis 696 696.9 76 Psychosocial problem v60.0 v62.9 77 Refractive errors 367.0 367.9 78 Renal calculi 592.0 592.9 79 Respiratory tract infection, acute upper 032.0 034.9 460 460.9 462 465.9 475 475.9 487.1 487.9 519.8 80 Respiratory tract infection, acute lower 466 466.9 480 488 490 490.9 81 Rheumatoid diseases 714 714.9 82 Rhinitis, chronic 472.0 472.2 477 477.9 83 Routine health maintenance V01.0 V07.0 V07.2 V07.9 V20.0 V21.9 V28.0 V28.9 V30.0 V37.9 V39.0 V39.9 V65.5 V70.0 V72.6 V72.8 V82.9 84 Schizophrenia and affective psychosis 295 298.9 85 Scoliosis/kyphosis 737 737.9 86 Seizure disorder 345 345.9 780.3 779.0 87 Sexually transmitted diseases 054.1 090 99.9 112.1 112.2 608 614 614.99 616.x 88 Sinusitis 461 461.9 473 473.9 89 Skin ulcer 707 707.9 90 Strabismus 378 378.9 91 Thyroid disease 240 246.9 648.1 92 Urethral stricture 598 598.9 753.6 93 Urinary tract infection 590 590.9 595 595.9 599.0 646.5 646.6 771.82 V13.02 94 Urticaria 708 708.9 995.1 95 Uterine prolapse 618.1 618.4 96 Vaginitis 112.1 131.00 131.01 616.1 623.5 627.3 97 Valvular heart disease 391.1 391.9 394 397.9 424 424.9 98 Varicose veins 454 454.9 99 Vertiginous syndromes 386 386.9 780.4 100 Viral exanthem 051 059.x 74.3 101 Warts 78.1 102 Chronic kidney disease 403 404.x 581 582.x 585 586 V42.0 V45.11 V45.12 V56.xx 103 Abdominal aortic aneurysm 441.xx COPD, chronic obstructive pulmonary disorder; CVA, cerebrovascular accident.
- Appendix Table 4. Forward Logistic Regression Model of Patient-Level Factors with Blood Pressure Noncontrol per Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guideline*
Covariate Parameter Estimate P Value Odds Ratio (95% CI) Cumulative C-Index Intercept −3.1521 <.0001 Hypertension 1.7286 <.0001 5.63 (5.46–5.81) 0.735 Diabetes mellitus 1.5772 <.0001 4.84 (4.64–5.06) 0.764 Body mass index (kg/m2) <18.5 (underweight) −0.0544 .45 0.95 (0.82–1.09) 0.802 18.5–24.9 (normal) Reference 25.0–29.9 (overweight) 0.4171 <.0001 1.52 (1.46–1.58) 0.802 30.0–34.9 (obesity, class I) 0.7208 <.0001 2.06 (1.97–2.14) 0.802 35.0–39.9 (obesity, class II) 0.9440 <.0001 2.57 (2.44–2.71) 0.802 >40.0 (obesity, class III) 1.1896 <.0001 3.29 (3.09–3.50) 0.802 Visits (n) 1–2 Reference 3–4 −0.2921 <.0001 0.75 (0.72–0.77) 0.806 5–6 −0.3149 <.0001 0.73 (0.69–0.77) 0.806 >6 −0.3348 <.0001 0.72 (0.68–0.75) 0.806 Age (years) 18–40 Reference 41–60 −0.3831 <.0001 1.47 (1.42–1.52) 0.812 61–80 0.6374 <.0001 1.89 (1.81–1.98) 0.812 >80 0.9475 <.0001 2.58 (2.38–2.79) 0.812 Male sex 0.3835 <.0001 1.47 (1.43–1.51) 0.817 Hyperlipidemia −0.2812 <.0001 0.75 (0.73–0.78) 0.818 Kidney disease, chronic 0.8324 <.0001 2.30 (2.09–2.53) 0.819 Ischemic heart disease −0.4755 <.0001 0.62 (0.58–0.67) 0.820 Prostatitis and benign prostatic hyperplasia −0.3367 <.0001 0.71 (0.67–0.76) 0.821 ↵* Number of observations read: 227,123; number of observations used: 209,582.
CI, confidence interval.
- Appendix Table 5. Forward Logistic Regression Model of Patient-Level Factors Associated with Low-Density Lipoprotein Cholesterol Noncontrol per the National Cholesterol Education Program Guideline*
Covariate Parameter Estimate P Value Odds Ratio (95% CI) Cumulative C-Index Intercept −3.3493 <.0001 Hyperlipidemia 0.9236 <.0001 2.52 (2.43–2.61) 0.654 Diabetes mellitus 0.8920 <.0001 2.44 (2.33–2.56) 0.682 Body mass index (kg/m2) <18.5 (underweight) 0.0269 .78 1.03 (0.85–1.25) 0.710 18.5–24.9 (normal) Reference 25.0–29.9 (overweight) 0.4519 <.0001 1.57 (1.50–1.65) 0.710 30.0–34.9 (obesity, class I) 0.6028 <.0001 1.83 (1.73–1.92) 0.710 35.0–39.9 (obesity, class II) 0.6231 <.0001 1.86 (1.75–1.99) 0.710 ≥40.0 (obesity, class III) 0.6632 <.0001 1.94 (1.79–2.10) 0.710 Age (years) 18–40 Reference 41–60 0.5888 <.0001 1.80 (1.72–1.89) 0.719 61–80 0.4737 <.0001 1.61 (1.52–1.70) 0.719 >80 0.5006 <.0001 1.65 (1.48–1.83) 0.719 Cerebral vascular disease/CVA 0.9993 <.0001 2.72 (2.49–2.96) 0.726 Male sex 0.2206 <.0001 1.25 (1.20–1.29) 0.731 Visits/year (n) 1–2 Reference 3–4 −0.1678 <.0001 0.85 (0.81–0.88) 0.731 5–6 −0.1625 <.0001 0.85 (0.80–0.90) 0.731 >6 −0.2212 <.0001 0.80 (0.76–0.84) 0.731 Alcohol and drug abuse 0.3537 <.0001 1.42 (1.34–1.52) 0.733 Anemia −0.3073 <.0001 0.74 (0.68–0.79) 0.733 Hypertension 0.1848 <.0001 1.20 (1.16–1.25) 0.734 ↵* Number of observations read: 136,771; number of observations used: 131,589.
CI, confidence interval; CVA, cerebrovascular accident.
