A Simple Intervention to Improve Patient Education and Adherence in Gout

Ongoing research at the Hospital for Special Surgery (HSS) in New York City is demonstrating that an easy-to-implement, multidisciplinary approach to managing gout can significantly improve patient education and clinical outcomes. Medscape recently spoke with two of researchers behind the project—rheumatologist Theodore Fields, MD, and social worker Adena Batterman, MSW, LCSW—about how their findings can be implemented at other healthcare centers involved in gout management.

Medscape: Can you tell us how this project got started?

Dr Fields: The biggest motivation behind it was the fact that many, many gout treatment studies have shown poor outcomes. Patients just don't do well. And these studies have looked at both the community treatment of gout and treatment by rheumatologists.

If you look at how many patients get their uric acid down below 6 mg/dL—where we want them to be—around 30%-40% do not and end up doing poorly. It's been felt that often, this is an education-related issue. Patients feel better after a gout attack; they don't appreciate the importance of long-term therapy, and they stop their medicine. So, it's been widely accepted that we need better ways to get patients to adhere to their medicine.

There is also literature on self-efficacy for patients that suggests that if people understand why they're taking the medicine, it really helps. There are data looking at nurse-led treatment for gout, where the nurses would keep calling the patients and meeting with the patients. There are also data on pharmacists working with the patients and managing gout. Both approaches were successful, and we thought that because we're in a large institution, such as HSS—where we have many different disciplines under one roof—if we let each group do what they're best at and take a portion of the overall education and monitoring responsibilities, then we might be able to see better outcomes. And also, this might be something that could be replicated elsewhere.

So that was our goal: to put together a multidisciplinary team that also included social work, which Adena represents. As part of this, we wanted to make sure that anything we were giving patients was written at a reading level that everyone can understand. We want to help patients deal with financial aspects of care, and such things as transportation. We want to get them to adhere to their medicine, get the correct lab tests they need, and come back for their follow-up visits. Together, the various members of the team, we found, can help make this happen.

Medscape: You've published a clinical study testing the effects of this approach on patient outcomes, correct?

Dr Fields: Right. We decided that if we were going to do this, we really ought to study it, because maybe other groups could benefit from what we did. We decided to put together an institutional review board request and monitor what we did, and use electronic documentation that everyone involved can access.

For example, as part of the approach, pharmacists called the patients and could document the kind of issues they found, and how hard or easy it was to get the patients on the phone. Also, after patients gave consent to take part in our study, the nurse participants were able to record patient scores on a gout self-efficacy exam with 12 questions about their knowledge of gout. They were then seen by a rheumatologist, a nurse practitioner, or one of the fellows in the clinic. We then had the registered nurse meet with them to go over the answers to the survey questions and review with them with a gout education curriculum.

Every month after that, the pharmacist investigators would call the patients and inquire about whether or not they're taking their medicine, whether they know when they should be getting their lab tests done, and whether they know when their next visit with the doctor is. Then, at the 6-month mark, the nurse would meet with the patients again and administer the same test to see how their gout knowledge-based had changed or improved, and review the answers and the gout curriculum.

Because this was a pilot study, we were also very interested in what their responses were to the program itself, which was a major primary outcome for us. Did it help them to manage their gout? Did they find the program useful? What did they think of the pharmacist's input? What did they think of the nursing input? We also had the doctors, the investigators, and the noninvestigators who referred patients in to the study fill out questionnaires about what they thought of the program.

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