Tophi and Frequent Gout Flares Are Associated With Impairments to Quality of Life, Productivity, and Increased Healthcare Resource Use

Results From a Cross-Sectional Survey

Puja P Khanna; George Nuki; Thomas Bardin; Anne-Kathrin Tausche; Anna Forsythe; Amir Goren; Jeffrey Vietri; Dinesh Khanna


Health and Quality of Life Outcomes. 2012;10(117) 

In This Article


This study demonstrates that gout patients from the US and three EU countries suffer from significantly decreased HRQOL, with the average patient suffering decreased mental as well as physical well-being, relative to population norms. These decrements in HRQOL vary across the spectrum of clinical phenotypes according to the presence and frequency of gout symptoms and signs. Patients with confirmed tophi and more frequent acute gout attacks had lower HRQOL, and the association between HRQOL, tophi and flares remained significant even after accounting for covariates. Impairments were not limited to HRQOL, and unadjusted comparisons revealed that patients reporting tophi had greater work impairment than those without, while more frequent flares were associated with increased healthcare resource use. Both flares and tophi were also associated with significant impairments in non-work activities in multivariable models.

Impairment of the physical components of quality of life have been found consistently in studies of gout patients,[22,24,34,35] and was notably related to the burden of symptoms and signs in this sample. Those with more severe gout had low PCS compared with both population norms and those gout patients who were free of tophi and flares. These differences were statistically significant, and greater than those which are generally accepted as being clinically meaningful. These studies confirm a relationship between symptom load and HRQOL previously observed in smaller samples of gout patients in the US.[20,35] The PCS levels in the most severely affected patients in these studies were comparable to those reported in previous studies of patients with severe symptomatic gout and patients with gout who had not responded to urate-lowering therapy.[20,35]

Gout patients are known to use more healthcare resources. An analysis of claims data showed that gout sufferers incurred more costs for medical claims, prescription claims, sick leave, short-term disability, and worker's compensation than did other employees.[36] Another database study of gout in the elderly found higher healthcare resource utilization in gout patients than in matched controls, which was attributable in part to having more comorbidities.[37] While comorbid conditions may account for some of the elevated resource use among gout patients, gout-related healthcare utilization increases with severity of gout.[38] A study using the MarketScan database showed that patients having 3 or more flares per year had more comorbidities, and incurred $10,222 more per year in healthcare costs than age and gender matched controls without gout.[33] Administrative claims data also show that higher sUA is associated not only with a greater number of flares, but also with higher costs per flare.[16,39]

There is evidence that gout affects worker productivity. A diary study of patients with chronic gout refractory to conventional urate-lowering therapy found an average annual workday loss of 25 days.[36] Another study showed that employees with gout missed 4.56 more days of work per year.[40] Gout symptoms and signs were also associated with impairment in daily activities, although the limited number of patients reporting tophi restricted the possibility of detecting activity impairment associated with tophi over and above the strong effect of flares. It is important to bear in mind that these impairments are compared with those of gout patients who are free of acute symptoms, rather than those in the population at large. It seems likely that comparisons between these patients and the general population would demonstrate larger differences in HRQOL and impairment of activities. The failure to demonstrate significant reduction in work productivity in the gout patients participating in these studies should not be interpreted as indicating that gout has no effect on work performance or productivity. The number of patients in employment in the study was relatively small and as the average age was 61 years, many are likely to have been in retirement. A recent diary study documented productivity impairments due to gout flares,[41] a finding that needs to be confirmed in a larger sample of employed patients. It is certainly possible, however, that patients with severe gout lose their jobs or decide to retire as a result of their disease; such loss of productivity would not be ascertained in a diary study or with the WPAI questionnaire used in this study.

In the present study, patients who reported symptoms of inadequately controlled chronic gout (similar to refractory chronic gout), defined here as at least three flares in the past year and the presence of at least one tophus, had severely impaired HRQOL, with SF-6D health utilities 0.13 below those in patients free of tophi and free of flares for the past 12 months. The magnitude of these decrements can be placed into context by comparing the health utilities of patients with gout across the spectrum of clinical phenotypes with those reported by patients with other rheumatic diseases. As indicated in Figure 3, patients with gout had similar health utilities to patients suffering from RA or SLE. Those with most severe gout, characterized by tophi and six or more flares in the past year, had health utilities that were significantly lower than the average for either RA or SLE. The findings emphasize the importance of seeking to provide effective treatment for all patients with gout and particularly those with tophi and frequent flares.

Our study has a number of limitations. As in all cross-sectional analyses based on self-reported patient information the data reported may be subject to recall bias and the ability of the patients to accurately report information about their condition. A total of 8 patients did not recall whether they had flares. While this small number was not expected to alter results significantly, to the extent that there were patients with flares in that unknown group, this would render our results more conservative. The survey did not attempt to ascertain the size or location of tophi, which may be an important determinant of impairment of HRQOL in patients with tophaceous gout. Although it is likely that comorbid status was confounded with tophi/flares in contributing to poorer health outcomes, controlling for comorbidities (and BMI) in the current study did not detract from the overall findings, in spite of the reduced statistical power. Having tophi and at least four flares in the past year were still significantly associated with the poorer outcomes. Patients' diagnosis with gout was not verified. Previous studies have, however, shown that a high proportion of self-reported cases of gout meet classification criteria when assessed by physician, hospital discharge diagnosis, or use of gout-specific medication.[20,42–44] The generalizability of the findings may be limited by self-selection of subjects into the survey panel and/or the survey itself. The relationships between variables observed are correlations which cannot be deemed to be causal. Unmeasured variables (such as the number or severity of comorbid conditions) may explain a portion of the observed effects, although an association between physical HRQOL and gout symptoms has been observed after controlling for comorbidities in a previous study.[34] The comparisons across rheumatic diseases must be interpreted with caution. No attempt was made to control for covariates or potential confounders, which may explain most or all of the observed differences in health utilities.