Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population.

OBJECTIVES: To assess and profile quality of care in California Medicaid beneficiaries with chronic conditions.
DESIGN: Retrospective cohort study.
SETTING: California from 2002 to 2004. PATIENTS: 1,123,577 beneficiaries. INTERVENTION: Eligibility and claims data (2002-2004) were used to identify beneficiaries with dyslipidemia, hypertension, coronary artery disease (CAD), heart failure, or diabetes. MAIN OUTCOME MEASURES: Quality of care was based on nonadherence with clinical practice guidelines including recommended medications. Chi-square was used to evaluate nonadherence and patient characteristics.
RESULTS: The proportion of patients without a prescription fill for recommended medications varied by disease (43% hypertension, 40% dyslipidemia and CAD, and 25% diabetes and heart failure). For Medicaid-only beneficiaries with diabetes, 78% lacked glycosylated hemoglobin tests, 62% lacked low-density lipoprotein cholesterol tests, and 50% lacked eye exams. Medication nonadherence was high (69% hypertension, 64% CAD, 57% heart failure, 48% dyslipidemia, 41% diabetes). Overall, younger age, Medicaid-only status, and black/other race were associated with poorer rates.
CONCLUSION: Quality of care was suboptimal, with nonadherence varying by condition. Programs targeting both patients and providers and addressing patient-related characteristics (e.g., age, race) and policy reform addressing alterable factors (e.g., insurance eligibility) should be developed to improve guideline adherence.