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

Discussion

Our study is the first to examine gout knowledge, beliefs and reported treatment patterns in a national sample of US primary care physicians. The surveyed physicians had extensive clinical experience, with most working full time in private practice seeing patients with active gout on a monthly basis. While ~50% of primary care providers recommended optimal treatment for acute gout, for intercritical or tophaceous gout it was <20%. Inappropriate dosing of medications in the setting of renal disease and lack of prophylaxis when initiating ULTs accounted for much of the lack of compliance with treatment recommendations. This is particularly concerning given that we considered an initial dose of allopurinol ≤250 mg/day in patients with renal disease as consistent with guidelines based on the gout quality care indicators, which are more lenient than current recommendations.[10,20] Additionally, there was poor compliance with recommendations for patient education and lifestyle counselling. While internists were more likely than family physicians to report treatment practices consistent with the current recommendations, substantial numbers of physicians of both specialties did not report optimal care, particularly for intercritical and tophaceous gout.

Our findings are consistent with other studies that indicate that acute and chronic gout are suboptimally managed by primary care doctors.[21] In an online survey of gout patients, consulting a physician for an acute gout attack was associated with a two to three times increased risk of the patient receiving inappropriate therapy, which included use of allopurinol or a uricosuric agent acutely in the setting of a gout flare.[6] Studies in both the USA and Europe show that only a quarter to a third of primary care doctors monitored serum urate levels in patients receiving ULTs.[21,22] Thus it is unlikely that providers are treating to a target serum urate level as recommended by the guidelines. Additionally, patients with renal disease receive inappropriate doses of ULTs, NSAIDs and colchicine.[21,22] Finally, even when ULTs are indicated based on the presence of tophaceous deposits, gouty erosive changes on radiographs or frequent gout attacks, they are commonly not prescribed. This results in a substantial number of preventable gouty flares sometimes leading to a hospital admission or an inpatient complication.[21,23,24]

While there is a general assumption by many providers that gout is a benign disease, epidemiologic studies have associated it with an increased risk of cardiovascular events and all-cause mortality.[25–27] Additionally, undertreatment of gout affects health-related quality of life due to significant pain, limitation of activities and reduced participation in everyday activities.[28] Chronic gout also greatly impacts the health care system with increased expenditures and use of resources. Elderly patients with a diagnosis of gout have higher all-cause health care utilization and costs compared with matched elderly patients without a diagnosis of gout due to increased emergency room visits, hospitalizations and prescription drug use.[29] Given the prevalence of gout and the associated clinical and economic costs, more effort is needed to improve the management of this condition.

While deficits in gout care have been identified by several other authors, this work is unique in that it provides insight into potential causes of suboptimal care and interventions for improvement. Specifically, the majority of providers were unaware of treatment recommendations or published guidelines for gout management. As new gout recommendations are published by rheumatology specialty societies, there should be substantial effort to engage primary care colleagues in a dialogue about the suggested care strategies. This also includes educating providers on the consequences of poorly managed gout, including mortality, concomitant illnesses and health care costs.[30] In addition, health care systems and physicians need to address clinical inertia, which is the failure to reliably accelerate treatments for patients with poorly controlled disease. Lack of physician response in the face of evidence-based treatment recommendations is typical of the care of all chronic diseases.[31] Possible approaches to address this inertia include tying reimbursement to outcomes and adherence to best practice.

We propose several approaches to improve gout care. This could include continuing medical education courses on gout, online disease management tools and even applications for smart phones that provide quick tips on gout management. Additionally, health care systems should make it easier for primary care providers to appropriately manage gout patients, given the multitude of conditions primary care providers must manage in the treatment of increasingly complex patients. For example, use of nursing staff for patient education, lifestyle instruction and encouragement of medication use has been shown to be successful at improving gout care.[32] Health care system approaches to address potential inadequate treatment of gout include sending brief summaries of treatment recommendations to primary care providers when they receive laboratory results for serum urate levels on their patients or for providers with patients with multiple encounters coded with a gout diagnosis. Rheumatologists should also be a resource for primary care providers, with a focus on education during both formal and kerbside consultations as well as lectures at local meetings.

Our study has several strengths, including a nationwide sample of primary care physicians who are representative of clinicians providing care to patients with typical gout. Additionally, the survey included scenarios on commonly encountered clinical situations—acute, intercritical and tophaceous gout. There are some notable limitations. We were only able to assess a limited number of treatment approaches to assess care consistent with the recommendations. For example, we did not assess patient education on gout aetiology, serum urate monitoring and medication adherence. In addition, there are many other lifestyle and dietary factors that influence gout that we were unable to explore due to space limitations. Physician responses to the questionnaire may not reflect actual practice. However, it was expected that providers would report best care practices rather than underreport. Additionally, we had a response rate of 41%. This is consistent with trends over time showing that survey response rates from primary care physicians are decreasing despite enhanced efforts to engage these physicians.[33] However, it is reassuring that we found minimal differences in demographics between responders and non-responders and that others have shown response bias to be minimal despite these trends in response rates.[34]

In summary, this nationwide survey of primary care physicians provided several important insights. First, physicians are largely unaware of the published gout treatment recommendations and their reported treatment patterns likely reflected this. The vast majority of both internists and family practitioners suggested treatments inconsistent with the recommendations. In addition, this knowledge deficit was not offset by high consultation rates with rheumatologists, as most primary care providers (>80%) stated they referred <10% of gout patients. Increased education for primary care providers about gout is essential, as is engagement of rheumatologists as partners in patient management.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....