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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Arthritis Care Res (Hoboken). Author manuscript; available in PMC Sep 1, 2011.
Published in final edited form as:
PMCID: PMC2943024
NIHMSID: NIHMS221925
A National Survey of Veterans Affairs Rheumatologists for Relevance of Quality of Care Indicators for Gout Management
Jasvinder A Singh, MBBS, MPH,1,2 Michael D Alpert, BA,3,4 and Gail Kerr, MDFRCP(Edin)4
1Medicine Service, Birmingham VA Medical Center and University of Alabama, Birmingham, AL
2Departments of Health Sciences Research and Orthopedic Surgery, Mayo Clinic School of Medicine, Rochester, MN
3Yale School of Medicine, New Haven, Connecticut
4VA Medical Center, Georgetown and Howard University Hospitals, Washington DC
Correspondence: Jasvinder A. Singh, MBBS, MPH, University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294 (Formerly, Minneapolis VA Medical Center, Minneapolis, MN 55417). Phone: 205-934-8158 ; Jasvinder.md/at/gmail.com
Objective
To determine the relevance of current gout Quality indicators (QIs).
Methods
Members of the Veterans Affairs Rheumatology Consortium were invited to participate in an online survey and provide opinions (rank 0–10) regarding existing gout QIs. Opinions sought on each QI were 1) relevance to United States Veterans, 2) likelihood to improve gout care, and 3) ease of electronic capture. Participants were also asked to rank their top 3 gout QIs.
Results
Participating VA rheumatologists were mainly male, of mean age 51.3 years and experienced in the management of gout. All 10 gout QIs were considered relevant, with a score of 8.2 of higher. The initiation of urate lowering therapy, monitoring of urate levels after initiation of urate lowering therapy, and treatment of acute gout with anti-inflammatory agents scored the highest with regards to likely to improving gout care, with the first 2 QIs also felt to be most relevant. Adjustment of initial allopurinol dosing in patients with renal impairment and in those receiving concurrent azathioprine/6-mercaptopurine were perceived as the QIs most amenable to electronic capture. The top ranked QIs were initiation of urate-lowering therapy with frequent gout attacks, serum urate monitoring after initiation of urate lowering therapy and adjustment of initial allopurinol dose to renal function.
Conclusions
In a national survey of VA rheumatologists, most gout QIs were thought to be highly relevant. QIs related to initiation of urate lowering therapy, serum urate monitoring, and initial dosing of allopurinol were ranked the most important for veterans with gout.
Keywords: Quality Indicators, Gout, Veterans Affairs
Evidence-based quality of care indicators for patients with gout have recently been developed (1) using the RAND/UCLA appropriateness panel method. With this method, a panel assesses the existing evidence and develops quality indicators (QI) based on the consensus of experts (2). Current gout QIs are minimally-acceptable standards of care that have been linked to outcomes directly or indirectly in published clinical studies and are believed by the experts to produce good outcomes. Among the ten gout QIs described (1), seven pertain to uric acid-lowering therapy (allopurinol and probenecid), two to anti-inflammatory medications (colchicine and non-steroidal anti-inflammatory drugs (NSAIDs)) and one to lifestyle modification. Studies have shown that adherence to these QI is low in the U.S., ranging between 24–78% (35).
A key publication in this area was “Crossing the Quality Chasm….” published by the Institute of Medicine in 2001 (6). Since this proclamation a deaced ago, the quality of care movement has become a priority in most U.S. health care organizations. While most health care systems are just beginning to implement QIs for common conditions, others, such as the Department of Veterans Affairs (VA), have taken the lead in this area (7). Considering the wide range of QIs available for each disease and the time constraints on outpatient office visits, determining which QIs are most effective at improving the quality of patient care is a challenge. As a first step towards achieving this objective, this study was designed to gather opinions from the VA rheumatologists regarding current published gout QIs. Specifically, this survey study assessed VA rheumatologist’s opinion regarding the relevance of these gout QIs to the care of veterans with gout and the likelihood of these QIs to improve care.
Survey Participants
We performed a national survey of rheumatologists employed by the Department of Veterans Affairs (VA). The VA is the largest integrated health care system in the U.S. serving more than 4.9 million veterans nationally with a budget in 2003 of $25 billion (8). The email list was obtained from the Veterans Affairs Rheumatology Consortium (VARC). VARC, founded in 2001, is comprised of VA-employed rheumatologists that meet on a semi-annual basis to discuss issues relevant to the care of US Veterans with rheumatic diseases. We chose VA rheumatologists for this survey, since the knowledge gained from this survey could potentially lay the foundation for implementing gout quality indicators in the VA, a nationwide health care system. The study was approved by the Minneapolis VA Institutional Review Board.
We designed a survey that included each of the 10 gout QIs described by Mikuls et al. (1), along with the level of clinical evidence supporting each. The survey questionnaire was preceded by a cover letter that summarized the purpose of the survey, described the scale used for evaluating each QI, and explained the IF-THEN-BECAUSE format of the QI (Appendix 1). We asked the VA rheumatologist to grade each QI on 3 aspects, on a 0–10 scale (10, best). They were asked to provide their opinion on 1) the relevance of each QI to veterans with gout (0=not relevant, 10=extremely relevant); 2) likelihood to improve gout care (0=not likely, 10=extremely likely) and 3) the ease of electronic capture for each QI (0=not easy, 10=extremely easy). The physicians were provided an opportunity at the end of the survey to provide their comments in a free text box.
Responders also provided their demographics including age, gender, years in practice, percent time spent in rheumatology versus general medicine, and number of gout patients seen weekly. Rheumatologists were also asked to list in rank order what they believed were the three most important gout QIs. The survey was performed using the Surveymonkey® tool (http://www.surveymonkey.com/).
VA rheumatologists who did not respond to the first email request received two reminder emails to complete the survey. Physicians who chose not to participate, were given the alternative to “opt-out” in their survey response.
Quality Indicators
The survey included all 10 quality indicators described for gout by Mikuls et al. (Appendix 1). The QIs address several different treatment and management areas, including indications and initial dose of urate-lowering therapy, surveillance of serum uric acid, asymptomatic hyperuricemia, indications for use of anti-inflammatory therapy in acute flares and during initiation of urate-lowering therapy, and lifestyle modifications.
Statistical Analyses
Sample characteristics were described as mean (±standard deviation) or proportions. For each QI, the scores (0–10) were averaged for all valid responses from survey responders and presented as mean (±standard deviation). For the top three QIs chosen by each responder, we calculated the percent votes for each of the ten QIs. We also calculated the total votes for the top three QI and aggregated them as a single sum to find out which QI was the most often recommended among the top three QIs.
Survey Participants and Non-response Bias
Of the 147 unique email addresses for VA rheumatologists, 139 rheumatologists with valid email addresses were eligible to participate (6, not at VA or not rheumatologists; 2 email addresses were invalid). Of these, 34 (25%) were non-responders and 6 (4%) opted out, resulting in 71% response rate (n=99). No demographics were available on non-responders.
The VA rheumatologists who responded to the survey had mean (standard deviation) age of 51.3 (10.3) years. 65% of respondents were male; 9% had been in rheumatology practice for <5 years, 16% for 5–9 years, 10% for 10–14 years, 14% for 15–19 years and 50% for ≥20 years. The monthly volume of gout patients seen was moderate-high: 9% saw <4 patients/month; 38% saw 4–14 patients; 35% saw 15–24 patients and 18% saw ≥25 patients. Proportion of time spent providing rheumatology care was <25% in 4%, 25–49% in 4%, 50–74% in 1% and ≥75% in 90% of the rheumatologists.
Quality Indicators
The survey responders ranked all 10 QIs with a score of 8.2 or higher with regards to relevance to veterans (Table 1). Quality indicators concerning initiation of urate-lowering therapy in patients with gouty arthritis (QI 6), monitoring of uric acid after urate-lowering therapy initiation (QI 7) and treatment of acute gouty arthritis with anti-inflammatory agents (QI 9) scored the highest, with scores of 9 or higher.
Table 1
Table 1
Scores (mean (SD)) for 10 quality indicators
With regards to likelihood to improve care, the scores for the 10 QIs were all 7.5 or higher (range, 7.5–9.0). Initiation of urate-lowering therapy in patients with gouty arthritis (QI 6) and monitoring of uric acid after urate-lowering therapy initiation (QI 7) scored the highest (≥ 9).
Opinions relating to the ease of electronic capture of the 10 QIs scored 5.9 or higher (range, 5.9–8.8). Monitoring of serum urate after allopurinol initiation (QI7), renal dose adjustment for initial allopurinol dose (QI 1) and adjustment of doses of azathioprine/6-mercaptopurine when used concurrently with allopurinol (QI 2) ranked highest (≥8.6).
Top Three Quality Indicators (Qualitative Analysis)
We asked the physicians to select the top three quality indicators that would most improve the care of gout patients. The most important QI to be recommended by VA physicians was adjustment of allopurinol dose at the time of initiation (n=31, (33%); QI 1), followed by recommendation to start urate-lowering therapy in gout patients with frequent attacks, radiographic changes, or tophaceous deposits (n=24, (25%); QI 6). Monitoring serum urate levels after allopurinol initiation (n=15, (16%); QI 7), was ranked third (Table 2). If all the votes for the top three QIs recommended were aggregated, the three top QIs were 1) monitoring serum urate after allopurinol initiation (QI 7), 2) starting urate lowering therapy in patients with symptomatic gout (QI 6) and 3) adjusting initial allopurinol dose in patients with renal failure (QI 1).
Table 2
Table 2
VA Physician Choice of 3 Most Important Quality Indicators
Free-Text Comments
Survey responders made several comments related to quality indicators in the free-text comment box (Table 3). Many comments were related to the lack of evidence regarding renal-dose adjustment during long-term treatment (for which no QI exists) versus at the time of initiation of allopurinol therapy (related to QI1), and the need for titrating allopurinol dose to reduce uric acid below 6.8 mg/dl to reduce gout symptoms and flares (related to QI 7).
Table 3
Table 3
Free comments from survey responders and non-responders
In this national survey of VA rheumatologists, we assessed 10 quality indicators for gout (1). All 10 QI were rated highly in terms of their relevance to US Veterans, with urate monitoring, treatment of acute gouty arthritis with anti-inflammatory agents, and treatment of symptomatic gout with urate-lowering agents ranked as most relevant to veterans with gout. Similarly, most QI were regarded as very significant with regards to likelihood of improving the care of gout in veteran patients. Use of urate lowering therapy in patients with symptomatic gout (QI 6), serum urate level monitoring in patients on urate-lowering therapy (QI 7) and adjustment of initial allopurinol dose in patients with renal failure (QI 1) were rated the top three QI for implementation. Use of anti-inflammatory agents for prophylaxis at initiation of urate-lowering therapy was ranked a close fourth (QI 3). Our study findings provide data that can be considered by VA policy makers during future implementation of gout QIs in the VA health care system. An advanced completely electronic medical records in the VA lends to the institution of QIs that can lead to optimum care of veterans with gout.
Several study findings deserve further discussion. The QI recommending monitoring of serum urate level within 6-months of initiation of urate-lowering therapy in patients with gout received not only one of the highest ranking, but also several free-text comments of endorsement. Recent studies involving several large databases indicate low compliance with this QI, with only approximately 25% of gout patients started on a urate-lowering therapy receiving serum urate monitoring (35, 9). Reasons for such low compliance with serum urate monitoring are unclear, especially since this is a laboratory assay that is readily available, relatively inexpensive and allows the titration of medication to achieve a target serum uric acid of < 6 mg/dl, which has been linked to less frequent gout flares. (10). One may conceptually think of serum urate monitoring similar to target levels in monitoring cholesterol after starting lipid-lowering therapy or of prothrombin time after the initiation of warfarin. Further, the standard 300 mg dose of allopurinol achieves this target serum urate level in only half of all patients (11). While it may be challenging to achieve target serum urate in 100% of gout patients due to renal failure, medication compliance, and adverse drug-related events, it seems that with current adherence rates of only 25% patients being monitored, there is significant room for improvement. The adherence to this QI among patients seen by survey responders is unknown. Our previous data from a VA medical center indicated that the overall adherence to gout quality indicators by all health professionals was suboptimal (3, 12).
The need for initiation of urate-lowering therapy in gout patients with frequent symptoms and/or radiographic joint destruction was also opined as a significant QI for implementation. Although intuitive, it was nonetheless felt to be very important. There are currently no data available with regards to physician non-compliance with this quality indicator, since definition of symptomatic gout is challenging to extract from electronic records and would need adjudication.
There was an agreement among VA rheumatologists that the initial dose of allopurinol should be 300 mg or less in patients with gout and renal failure. Several comments indicated that this QI, which has been defined for initial allopurinol dose, has the potential for misinterpretation as being related to long-term allopurinol dosing. There are emerging data that suggest that long-term maintenance therapy with allopurinol may not require dose adjustment to renal function (13). Our survey could not determine if there was such a distinction in interpretation of this QI amongst responders.
Use of anti-inflammatory prophylaxis at initiation and titration of urate-lowering therapy to decrease acute flares received attention from responders. Low adherence 48% to this QI has previously been reported (12). Further, in elderly populations and in patients with multiple comorbidities such as the VA, NSAIDs and corticosteroids may be contraindicated, especially for chronic use lasting 2–6 months. Therefore, most practitioners will use colchicine as anti-inflammatory prophylaxis with renal adjustments with close monitoring in the elderly and in those at risk for toxicity. Certainly, toxicity monitoring with any medication is essential in order to decrease the likelihood of adverse events, and gout therapies are no exception.
Our study has several limitations. Current gout QIs do not address or account for non-compliance. Non-response bias limits generalization. The aim of this study was to assess gout QIs with regards to US Veterans with gout and therefore our findings may not be applicable to non-veterans and need to be reproduced in other health care settings. However, there is no reason to believe that VA rheumatologists differ in any significant way from non-VA, US rheumatologists, and our results may indeed have some general applicability. With the advent of new urate-lowering therapies, these QI may also be revisited. However, most QI related to available gout therapies are still applicable, and in the absence of additional data from randomized controlled trials, is unlikely to change significantly. Therefore, the results of this survey will remain pertinent despite the advent of new therapies.
The strengths of our study include response rate of 71%, a rate higher than average reported response rate of 61% for physician surveys (14), and speaks to the commitment of the VARC membership to the care of US Veterans. Our pool of responders included physicians with extensive expertise in the management of gout, in a population with significant comorbidity (15). We used published, evidence-based quality indicators rather than expert opinion only.
In patients with multiple medical diseases, it is impractical to capture and implement all quality indicators for all comorbidities. It is therefore desirable to implement key indicators for each disease. However, such selection is often arbitrary and rarely based on evidence. In this study we found support from VA rheumatologists for the published quality indicators for gout. Implementation of prioritized QI as performance measures may serve as an incentive to practitioners to improve adherence, which we believe will improve patient outcomes in gout.
Acknowledgement
We would like to acknowledge all members of the Veterans Affairs Rheumatology Consortium (VARC), for their continued dedication to the care of veterans with rheumatic diseases.
Grant support: NIH CTSA Award 1 KL2 RR024151-01 (Mayo Clinic Center for Clinical and Translational Research).
Appendix 1
Improving Gout Care For the U.S. Veterans
The VA leadership is very interested in getting input from the VA rheumatologists regarding quality indicators for key rheumatic conditions including gout and osteoarthritis. Your INPUT IS CRITICAL for this exercise.
Following are the 10 Gout Quality Indicators selected based on prospective, retrospective studies or randomized controlled trials or expert opinion (in absence of any evidence), published in Arthritis and Rheumatism in 2004. The indicators are in the IF—THEN—BECAUSE format.
“In contrast to treatment guidelines that are promulgated as best practice strategies, these indicators represent minimal acceptable standards of care in gout management to which health-care providers and health-care organizations could be held accountable.”
The RATING OF VALIDITY of each recommendation is shown for each quality indicator on a 9-point ordinal scale, in which ratings of 1–3, 4–6, and 7–9 were considered “invalid,” “intermediate,” and “highly valid,” respectively, following each recommendation.
While you may not agree with parts of the indicators or the entire indicator, these are the only evidence-based indicators to our knowledge and constitute the most likely the quality indicator set that health care organizations will choose from. You will have opportunity to type free text regarding your thoughts/opinions/disagreements regarding one or more of them at the end of the survey. Please rank each of them on a 0–10 scale (0=WORST, 10=BEST) with regards to
  • relevance to veterans
  • most likely to improve care and patient outcomes
  • Easy to measure with electronic capture from electronic medical record system.
This survey will take 5–10 minutes. Your responses are very valuable to us. Thank you for participation.
Use of uric acid–lowering therapy
  • 1. 
    IF a gout patient is receiving an initial prescription for allopurinol and has significant renal impairment (a serum creatinine level ≥2 mg/dl or measured/estimated creatinine clearance ≤50 ml/minute), THEN the initial daily allopurinol dose should be <300 mg per day, BECAUSE the risk of allopurinol-related toxicity is increased in the presence of significant renal impairment in gout patients given a daily allopurinol dose equal to or exceeding 300 mg.
    RATING OF VALIDITY BASED ON EVIDENCE: 8.5 (3–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 2. 
    IF a gout patient is given a prescription for xanthine oxidase inhibitor in the setting of required therapy with either 1) azathioprine (Imuran) or 2) 6-MP, THEN the dose of azathioprine/6-MP should be reduced by a minimum of 50%, BECAUSE concurrent use of a xanthine oxidase inhibitor leads to a substantial increase in serum levels of azathioprine (and 6-MP) and increases the risk for severe drug-related myelosuppression.
    RATING OF VALIDITY BASED ON EVIDENCE: 8.5 (5–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 3. 
    IF a patient with tophaceous gout is given an initial prescription for a urate-lowering medication (xanthine oxidase inhibitor, probenecid, or sulfinpyrazone) and lacks both 1) significant renal impairment (a serum creatinine level ≥2 mg/dl or measured/estimated creatinine clearance ≤50 ml/minute) and 2) peptic ulcer disease, THEN a prophylactic antiinflammatory agent (colchicine or NSAID) should be given concomitantly, BECAUSE prophylactic antiinflammatory therapy reduces the risk of rebound gout attacks, which frequently follow the initiation of urate-lowering therapy.
    RATING OF VALIDITY BASED ON EVIDENCE: 7.5 (5–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 4. 
    IF a patient has asymptomatic hyperuricemia characterized by 1) no prior history of gouty arthritis or tophaceous deposits and 2) no prior history of nephrolithiasis or hyperuricosuria and 3) no ongoing treatment of malignancy, THEN urate-lowering therapies should not be initiated, BECAUSE there is currently no widely accepted indication for the treatment of asymptomatic hyperuricemia.
    RATING OF VALIDITY BASED ON EVIDENCE: 8 (7–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 5. 
    IF a gout patient is started on urate-lowering therapy and has either 1) a history of nephrolithiasis or 2) significant renal insufficiency (serum creatinine level ≥2 mg/dl or measured/estimated creatinine clearance ≤50 ml/minute), THEN a xanthine oxidase inhibitor should be started as the initial urate-lowering medication rather than a uricosuric agent (probenecid or sulfinpyrazone), BECAUSE in contrast to xanthine oxidase inhibitors, uricosuric agents increase the renal excretion of urate, enhancing the risk of nephrolithiasis, and may have diminished efficacy in the context of significant renal insufficiency.
    RATING OF VALIDITY BASED ON EVIDENCE: 8.5 (5–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 6. 
    IF a patient has hyperuricemia and gouty arthritis characterized by any of the following clinical characteristics, 1) tophaceous deposits, 2) gouty erosive changes on radiographs, or 3) gout attack frequency of ≥2 attacks per year, THEN the patient should be offered treatment with a urate-lowering drug, BECAUSE urate-lowering drugs have been well-tolerated and effective in decreasing the attack frequency and disease severity for those with severe gout.
    RATING OF VALIDITY BASED ON EVIDENCE: 8 (7–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 7. 
    IF a gout patient is given a prescription for a xanthine oxidase inhibitor, THEN a serum urate level should be checked at least once during the first 6 months of continued use, BECAUSE periodic serum urate measurements are required for appropriate dose adjustments of xanthine oxidase inhibitors (escalations or reductions).
    RATING OF VALIDITY BASED ON EVIDENCE: 9 (6–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
Behavioral modifications
  • 8. 
    IF a patient is diagnosed with gout and has either 1) obesity (defined as a body mass index ≥28 kg/m2) or 2) frequent alcohol use (≥1 alcoholic beverage per day), THEN as part of their overall therapy, patients should be advised on the importance of weight loss and/or decreased alcohol use, BECAUSE weight loss and reduction of alcohol intake may be beneficial components of gout therapy.
    RATING OF VALIDITY BASED ON EVIDENCE: 8.5 (4–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
Use of antiinflammatory agents
  • 9. 
    IF a patient has acute gouty arthritis and lacks both of the relative contraindications to gout treatment, 1) significant renal impairment (a serum creatinine level ≥2 mg/dl or measured/estimated creatinine clearance ≤50 ml/minute) and 2) peptic ulcer disease, THEN the patient should be treated with an antiinflammatory agent to include one of the following: 1) NSAID, 2) ACTH or glucocorticoid (either systemic or intraarticular administration), or 3) colchicine, BECAUSE antiinflammatory agents have been shown to be both effective and well-tolerated for the short-term treatment of acute gout. Patients with renal impairment and a history of peptic ulcer disease may be at a higher risk for gout medication toxicity.
    RATING OF VALIDITY BASED ON EVIDENCE: 8.5 (5–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
  • 10. 
    IF a gout patient receives long-term prophylactic oral colchicine (defined as a minimum daily dose of 0.5 mg for a duration of 6 months or longer) and has significant renal insufficiency (a serum creatinine level ≥2 mg/dl or measured/ estimated creatinine clearance ≤50 ml/minute), THEN a complete blood cell count and creatine kinase should be evaluated a minimum of one time for every 6 months of continued use, BECAUSE the risk of colchicine-related myopathy and myelosuppression appears to be substantially increased in the context of reduced renal function.
    RATING OF VALIDITY BASED ON EVIDENCE: 7.5 (2–9)
    Relevance to veterans
    Not                                          Extremely
    relevant                                      relevant
           0   1   2   3   4   5   6   7   8   9   10
    
    Likelihood to improve care
    Not                                          Extremely
    likely                                          likely
           0   1   2   3   4   5   6   7   8   9   10
    
    Ease of electronic capture
    Not                                          Extremely
    easy                                              easy
           0   1   2   3   4   5   6   7   8   9   10
    
IF YOU WERE TO RECOMMEND ONLY THREE QUALITY INDICATORS TO BE MONITORED IN PATIENTS WITH GOUT, WHICH INDICATORS WOULD YOU RECOMMEND IN DECREASING ORDER OF IMPORTANCE:
  • Choice #1 (most important) ___________________________
  • Choice #2 ___________________________
  • Choice #3 ___________________________
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Practitioner Details: (please DO NOT write your name to maintain ANONYMITY of the survey)
  • What is your gender? ______ M _______F
  • What is your age? _______ yrs
  • How many years have you been in practice?
    • More than 20 years
    • 15–19 years
    • 10–14 years
    • 5–9 years
    • <5 years
  • How many gout patients do you see per month?
    • >25 (more than one patient per day)
    • 15–24 (more than one patient every other day)
    • 4–14 (more than one patient every week)
    • <4 (less than one patient per week)
  • What % of your practice is rheumatology (vs. general medicine)?
    • More than 75%
    • 50–74%
    • 25–49%
    • <25%
Footnotes
Financial Conflict: There are no financial conflicts related to this work. The study was approved by the Minneapolis Institutional review board and that all investigations were conducted in conformity with ethical principles of research. J.A.S. has received speaker honoraria from Abbott; research and travel grants from Allergan, Takeda, Savient, Wyeth and Amgen; and consultant fees from Savient and URL pharmaceuticals. G.K. has received speaker honoraria and/or research funding from Abbott, Amgen, Savient andBristol-Myers Squibb. Veterans Affairs Rheumatology consortium has received unrestricted educational grants from Abbott, Amgen, Centocor and Savient.
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