Improving Quality of Gout Management in Primary Care

Quality of Care Gaps in Gout

There are major gaps in quality of care in management of gout. Health care professionals should assess the serum urate level in patients at risk for gout and monitor serum urate regularly during urate-lowering therapy (ULT) for established gout. Broader understanding of treatment targets and the common issue of patient nonadherence in gout should improve outcomes for the gout population at large. Patient education in gout needs to be improved to assure better outcomes via adherence. Gout patients not only exhibit poorer health-related quality of life (QOL) and physical function than controls without gout but also more frequently have comorbidities and adverse outcomes of cardiovascular disease. In addition, gout patients have substantial health care costs, including higher health care costs than do matched patient controls without gout. Cost-effectiveness of gout care requires systematic study in this financially challenging era. Fortunately, newer generations of therapies are emerging, but we need to better understand how to effectively implement the current armamentarium for gout.

Sections Pharmacologic Urate-Lowering Therapy and Comprehensive Disease-Management Plan for Gout focused on ULT and overall gout management strategies advocated by the authors of this handbook, based on evidence from the literature and the handbook authors’ synthesis of the data and their own experience, with Assessment and Management focused on summarizing approaches to acute gout flare treatment, diet and gout flare prophylaxis. Difficult Gout and Hyperuricemia summarized our recommended approach to difficult disease and refractory hyperuricemia in gout, including gout in chronic kidney disease (CKD), elderly individuals, in major organ transplants and when and how combination oral ULT, or pegloticase, are recommended and employed. Treatment Guidelines provided a synopsis of the 2020 ACR Gout Management Guidelines, which culminated from a formal review and consensus process driven by rheumatologists, but which included active participation by primary care, nephrology and patient advocate representatives. However, the great majority of gout is managed in primary care, with a small fraction of ambulatory care visits being to rheumatology.

Most patients diagnosed with gout are not prescribed ULT, and many who receive ULT are not regularly monitored for serum urate level and do not sustainably achieve recommended serum urate target levels that promote lessening and resolution of tissue urate crystal deposits and improved outcomes. Resultant worsening of gout patient outcomes includes:

• Acute gout flares, some of which promote hospitalization
• Permanent joint damage.

The shortfall in ULT use in the United States is stunning, when measured with reference to the previous (2012) ACR Gout Guidelines and particularly so in CKD, or with past urolithiasis, or with current ULT use, and gout with an indication for ULT and a uric acid level of ≥6 mg/dL (Figure 14-1). In a 2023 observational cross-sectional study using the 2013-2018 biannual National Health and Nutrition Examination Study (NHANES) data, the estimated prevalence of ULT utilization among patients with gout 30 years of age and older was 28.9% (95% CI 24.3–33.9%). The shortfalls in quality of care for appropriate prescribing of colchicine (and dosing it correctly) for gout flare prophylaxis also appear remarkable.

It is universally accepted that gout patients rarely receive education about the ability of ULT to place the disease in long-term remission of “cure,” let alone what the pathophysiologic rationale is for flare prophylaxis and long-term ULT. Concordantly, medication adherence in gout is remarkably low, with as few as ~10% of gout patients, in some studies, adhering to prescribed treatment. Methods to improve patient education and adherence in gout are clear. Moreover, outstanding results on both serum urate reduction (i.e., >80% of patients meeting serum urate target) and also gout flare reduction, have been by produced by engaging allied health care professionals, with use of ACR Gout Guidelines as the foundation of ULT “treat to target strategy.” In this way, implementation of allied health professional-managed “gout clinics” mirrors results from oral warfarin oral anticoagulation clinics and hyperlipidemia treatment clinics. In the “gout clinic” model, patients can be entered into the gout clinic for a limited period to conduct disease education and achieve better gout flare control and time-consuming ULT dose titration and optimization and they can then be followed in large part by phone calls and electronic correspondence that accompanies lab and medication orders, with subsequent discharge back to primary care once better gout control is achieved. Clearly, such clinics for gout will need to be studied more in different practice environments and with gout cases from varied socioeconomic and cultural backgrounds.

It is evident that these gaps in quality of gout care are partly the result of a bridge in thinking about the disease by both rheumatologists and primary care providers (PCPs). This has been reinforced by the 2016 Agency for Healthcare Research and Quality (AHRQ) gout care systematic comparative effectiveness review and guidance for the American College of Physicians. The primary care-driven AHRQ process, whose findings are summarized in Table 14-1, concluded that benefits and harms of long-term urate-lowering therapy need further investigation and that patient preferences and other patient by patient clinical circumstances factor into decisions about treating patients with gout.

Evidently, the primary long-term ULT management approach advocated by all rheumatology society guidelines of a foundational ULT “treat to target” approach (using a SUA target, at a minimum, of <6.0 mg/dL), does require more clinical trial studies and with more potent oral urate-lowering regimens, largely because a therapeutic course of only 6 to 12 months of oral ULT, in clinical trials to date, has not routinely shown reduction of gout flare frequency or resolution of tophi. However, gout is only placed into long-term control and remission when there is major reduction in body uric acid stores, with marked and linked improvements in gout flares, tophus burden and health-related quality of life of gout patients, as demonstrated in short-term pegloticase responders and longer term in collective clinical research studies of extended oral ULT beyond 12 months. The conclusion in 2016 by AHRQ of “moderate-strength evidence” to support a “role for ULT in reducing the risk of acute gout attacks after about 1 year of treatment” is a step forward for primary care. As summarized from interpretation of the evidence, elsewhere in this module the ULT treat-to-target approach remains the underpinning of a sound and comprehensive management program for gout.

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Take-Away Messages

• Quality of life and quality of medical care gaps remain substantial in gout.
• Most patients diagnosed with gout are not prescribed ULT and many who receive ULT are not regularly monitored for serum urate levels and therefore do not sustainably achieve recommended serum urate target levels that promote lessening and resolution of tissue urate crystal deposits and improved outcomes.
• The ULT treat to target approach remains the underpinning of a sound and comprehensive management program for gout.
• Gaps in quality of gout management care in gout remain partly the result of a bridge in thinking about the disease by rheumatologists and primary care providers. However, primary care provider education has been improved by AHRQ recognition, by systematic review, that there is moderate-strength evidence, from the literature to date, that supports the role for oral ULT in reducing the risk of acute gout attacks after about 1 year of treatment.
• Patient education in gout needs to be improved to assure better outcomes via adherence and can be done so by engaging allied health care professionals.