Primary Care Providers' Knowledge, Beliefs and Treatment Practices for Gout

Results of a Physician Questionnaire

Leslie R. Harrold; Kathleen M. Mazor; Amarie Negron; Jessica Ogarek; Cassandra Firneno; Robert A. Yood

Disclosures

Rheumatology. 2013;52(9):1623-1629. 

In This Article

Materials and Methods

A random nationwide sample of 2200 primary care physicians (internal medicine and family practice) was obtained from the master files of the American Medical Association (AMA), which included name and contact information. Physicians who were listed as retired or in training were excluded. The study was approved by the University of Massachusetts Medical School institutional review board.

Questionnaire Development

The self-administered questionnaire was designed to assess clinical knowledge and beliefs as well as to ascertain treatment practices and took approximately 7 min to complete. Development of the questionnaire was informed by prior work involving in-depth interviews with providers on gout.[8] Additionally, the questionnaire was pre-tested with three primary care physicians and revised according to their feedback.

Questionnaire Content

The questionnaire solicited information on physician demographic data (race, gender, board certification and location), physician clinical practice characteristics (practice setting, affiliation with an academic centre, hours involved in patient care weekly and years since completion of residency) and gout patient experience, including the frequency of patients seen monthly with flares. Additionally, questions explored exposure to continuing medication education lectures or journal articles on gout and specifically asked whether they were aware of the gout quality of care indicators and treatment recommendations.[9–12] Diet and alcohol intake, which have been show to be risk factors for incident gout as well as triggers for recurrent attacks, were explored as well.[14–18] Using vignettes, we examined their approaches to acute, intercritical and tophaceous gout in order to compare their reported management with the published recommendations as a gold standard. In addition, we evaluated dosing of both acute and chronic medications. Given the conflicting literature over the last decade, we chose the recommendation that the initial dose of allopurinol be ≤250 mg/day in patients with renal disease based on the gout quality indicators.[10] The first vignette featured a man with chronic kidney disease (serum creatinine of 2.0 mg/dl), borderline diabetes, a BMI of 29, daily consumption of one beer, receiving no chronic gout medications who presents acutely with his second attack of podagra. In the second vignette, a man with crystal-proven gout and renal insufficiency presents after having several gout flares in the past year but is currently asymptomatic and not receiving a ULT. The last vignette features an asymptomatic man with a tophus on examination and evidence of bony erosions due to gout on radiographic images. His acute gouty symptoms in the past responded quickly to NSAIDs and he is receiving no chronic gout therapy.

Questionnaire Administration

The Dillman approach was used for questionnaire administration.[19] Specifically, we used mailed questionnaires, with up to four mailings per administration (a letter of announcement, the questionnaire mailing, a reminder postcard to non-respondents and a final mailing with a replacement questionnaire). We tested this approach with a pilot mailing to 200 providers. In the first mailing we compared financial incentives of $40 v s $20 and enrolment in a lottery with 1 in 10 providers winning $100. Given the similar response rates, we revised the financial incentive to $25 and enrolment in a lottery. In all mailings, the procedure to opt out using a toll-free phone number was available, and postage paid reply envelopes were included. All study databases contained study identification numbers only.

Analyses

Initial analyses were performed using descriptive statistics. For continuous variables, we calculated means and s.d. For categorical variables, proportions were calculated. Reported treatment practices for acute, intercritical and tophaceous gout were compared with published quality of care indicators and treatment recommendations. We used χ2 or Fisher's exact test for discrete variables and t-test or the Wilcoxon test for continuous variables to examine whether there were differences in responses based on physician specialty.

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