Quality of Care in Gout

Key Points

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Surprisingly, instances of suboptimal treatment of gout remain frequent, even in this era of expanded and well-understood treatment options. These include errors in medication use and dosages and inadequate use of the laboratory and diagnostic approaches.
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Common diagnostic and therapeutic errors include infrequent use of diagnostic joint aspiration and crystal analysis, infrequent monitoring of serum urate, and failure to achieve an adequate target level for serum urate.
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Inappropriate dosings of allopurinol and colchicine, particularly in those with renal dysfunction, are the most common medication errors.
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Higher number of outpatient visit days, more primary care or rheumatology visits, and lower comorbidities are associated with better gout care patterns.
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Efforts aimed at improving quality of care should first focus on high-risk patients such as elderly patients and those with higher comorbidity load, most severe forms of gout, and polypharmacy. Multimodal low-cost interventions are most likely to be associated with improvements that are sustainable and can be implemented in multiple health care systems.
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Data from several studies confirmed gaps in quality of care, pertaining to both treatment and laboratory monitoring and for both effectiveness and safety.
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Most significant gaps were evident in lack of monitoring of serum urate levels after starting urate-lowering therapy, failure to achieve target serum urate, use of inappropriate doses of allopurinol, and lack of use of colchicine or NSAID prophylaxis when starting allopurinol.
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These quality care gaps can be overcome by systems-based interventions, although patient- and physician-based interventions may also help.
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The quality gaps present opportunity for improvement in quality of gout care.

Grant support: This material is the result of work supported by the resources and the use of facilities at the VA Medical Center, Birmingham ,Alabama, USA.

Financial conflict: There are no financial conflicts related to this work. J.A.S. has received speaker honoraria from Abbott; research and travel grants from Allergan, Takeda, Savient, Wyeth, and Amgen; and consultant fees from Savient, URL Pharmaceuticals, and Novartis.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Introduction

Gout, characterized by acute and chronic inflammatory arthritis, affects up to 3% to 4% of the adult population in the United States (see Chapter 6 ), with a similar prevalence in most Western countries. Furthermore, the prevalence of gout in the United States may have approximately doubled in the past 20 years with the greatest increase occurring in males that are 65 or older. Gout accounts for significant health care burden and costs. A diagnosis of gout was associated with 1.4 million outpatient visits in the United States in 2002. A recent study estimated that $27 million is spent annually for care of new acute gout cases in the United States. Thus, gout is a significant problem with public health implications.

Effective treatment options for acute and chronic gout have been available for more than half a century, yet instances of suboptimal treatment of gout remain frequent. A simulation study found that urate-lowering therapy is cost-effective in most scenarios and cost-saving in the patients with two or more acute gout attacks per year. Although new approaches are currently being developed for the treatment of gout, treating symptomatic gout with available therapies is still a major concern. Available treatment options for gout include nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids (oral, parenteral, and intraarticular), colchicine, urate-lowering medications such as allopurinol, febuxostat, and pegloticase, and uricosurics such as probenecid. With currently available therapies being effective in a majority of the patients, efficacy needs to be balanced against safety in a given patient, especially in the elderly patients with bone marrow, liver, or kidney problems. Many patients with gout continue to experience recurrent gouty attacks, which has a negative impact on health-related quality of life, function, mobility, and social roles. Thus, there is an urgent need for improving the quality of care (QOC) for patients with gout.

In this chapter, we describe the results of a systematic review of the published literature regarding compliance with evidence-based QOC indicators for gout and errors in medication use and laboratory monitoring in gout. Using the search terms “gout,” “quality of care,” “treatment guidelines,” “recommendations,” “medical errors,” and similar terms, an experienced librarian from the Cochrane musculoskeletal group (L.F.) performed a systematic search in the following databases in July 2010: (1) Ovid MEDLINE 1950 to June week 1 2010; (2) EMBASE 1980 to 2010 week 23; and (3) The Cochrane Library (including Cochrane database of systematic reviews, DARE, CENTRAL, HTA database, and NHS EED), second quarter 2010. We previously published a review of studies on QOC in gout, and several studies included in this chapter were also included in the previous review. This chapter provides an updated systematic review of studies of QOC in gout.

Definition and Measurement of Quality of Care

The Agency for Health Care Research (AHRQ) defines quality of care as the “degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” QOC for gout has been frequently measured using quality indicators (QIs) since the description of 10 gout QIs by Mikuls et al. in 2004. These QIs for gout related to medication prescription, laboratory monitoring, and behavioral modifications were derived using evidence-based UCLA appropriateness method using a panel of rheumatologists and internists. QIs are process measures of health care quality. QIs are easily measurable since they have well-defined numerator and denominator, easily extractable from readily available health care data. Prior to description of QIs for gout, QOC was measured based on what was accepted as appropriate treatment regimens and laboratory monitoring in patients with gout. The gout QIs cover the spectrum of gout management, including both effectiveness/efficacy and safety/adverse events. Efficacy QIs consist of treatment of acute gouty arthritis, urate-lowering therapies to prevent gouty arthritis flares and damage from tophaceous deposits, behavioral modification to prevent gout and gouty flares, antiinflammatory prophylaxis during the initiation of urate-lowering therapy for the prevention of acute gouty flares, and serum urate monitoring. Safety QIs address the areas of safety related to adverse events related to use of colchicine, NSAIDs, and urate-lowering therapy.

Gout QIs are in the IF-THEN-BECAUSE format. An example of a gout QI as described by Mikuls et al. is, “ IF a gout patient is given a prescription for a xanthine oxidase inhibitor, THEN a serum urate level should be checked at least once during the first 6 months of continued use, BECAUSE periodic serum urate measurements are required for appropriate dose adjustments of xanthine oxidase inhibitors (escalations or reductions).”

Search Results

The search identified 680 articles related to the QOC in gout. Eighteen articles qualified for full text review and all were included in the summary synthesis, since there were no exclusions ( Fig. 17-1 ). Two additional articles were identified as pertinent literature not captured in the search. In this chapter, we summarize all the available data in Tables 17-1 and 17-2 and highlight key studies and findings in the narrative.

Table 17-1

Overview of Studies of Quality of Care

	Type of Study	No. of Patients	Follow-up Duration
Petersel and Schlesinger, 2007	Retrospective cohort	184	Not provided
Neogi et al., 2006	Prospective case crossover Internet study	232	268 days (SD, 178)
Dalbeth et al., 2006	Retrospective	250	Not reported
Annemans et al., 2007, United Kingdom	Retrospective	7443	Not reported
Annemans et al., 2007, Germany	Retrospective	4006	Not reported
Ly, Gow, and Dalbeth, 2007	Retrospective	100	Not reported
Mikuls et al., 2005	Retrospective	63,105	3.8 y (SD, 2.8)
Mikuls et al., 2006	Retrospective	Not reported, number of medication errors 582,397	5-y study
Sarawate, 2006	Retrospective	5942	1 y
Singh, 2007	Retrospective	3658	2 y
Singh, 2009	Retrospective	643 with new allopurinol	2 y
Pal, 2000	Retrospective	429	Not reported
Smith, 2000	Retrospective	73	Not reported
Evans, 1996	Retrospective	19	Inpatient stay
Ho, 1993	Retrospective	67	Inpatient stay
Stamp, 2000	Prospective, cross-sectional	31	Cross-sectional

SD, standard deviation.

Table 17-2

Detailed Characteristics of Patients Included in Quality of Care Studies of Gout

	No. of Patients	Age, y, Mean (SD or Range)	Male, %	Body Mass Index, kg/m ², mean (SD or range)	Tophaceous Gout, %	Comorbidities
Petersel and Schlesinger, 2007	184	71 (range 40–96 y)	100%	NR	NR	Heart disease: 15 (19%) Renal insufficiency: 149 (80.9%)
Neogi et al., 2006	232	53 (range 23–85)	81%	30.8 (17.8–53.5)	35%	16% peptic ulcer disease, renal disease, or congestive heart failure
Dalbeth et al., 2006	250	56 (range 26–86)	82%	NR	134 (53.6%)	8 patients with end-stage renal failure were excluded; n was originally 258
Annemans et al., 2007, United Kingdom	7443	65.6 (SD, 13.8)	81.6%	NR	NR	Heart disease: 14.5% Renal failure: 9.5%
Annemans et al., 2007, Germany	4006	58.6 (SD, 13.1)	80.4%	NR	16.6%	Heart disease: 16.6% Diabetes: 25.9% Renal failure: 4.8%
Ly et al., 2007	100	NR	82%	NR	56 (56%)	Renal impairment: 44% of acute gout; 100% of chronic gout ^∗
Mikuls et al., 2005	63,105	61 (SD,15 y)	78%	NR	NR	Heart disease: 26% Diabetes: 7% Renal failure: 1%
Mikuls et al., 2006	Number of medication errors: 582,397	NR	NR	NR	NR	NR
Sarawate, 2006	5942	57.4 (SD, 14.1)	76%	NR	9.1%	Hypertension: 39.8% Coronary artery disease: 24.7% Diabetes: 18.3% Renal impairment: 13%
Singh, 2007	643	67.9 (SD, 9.7)	99%	NR	NR	Mean Charlson score, 2.5
Singh, 2009	643	67.9 (SD, 9.7)	99%	NR	NR	Mean Charlson score, 2.5
Pal, 2000	429	64.5 y	80%	NR	NR	NR
Smith, 2000	73	77 y	55%	NR	NR	NR
Evans, 1996 ²²	19	59 y	80%	NR	NR	Multiple comorbidities including renal and hepatic disease
Ho, 1993	67	72 y	83%	NR	NR	Hypertension: 59%Congestive heart failure: 34% Peptic ulcer disease: 32%
Stamp, 2000	31	58 y	81%	NR; weight 92 kg	55%	Renal insufficiency: 55%