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 (3
). 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
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.