Audits on gout management: Far from excellence, but working on it
It would be desirable for excellent gout management to be common practice within the specialist rheumatology setting. But achieving excellent practice may require complex, time-consuming procedures that may be limited within the tight daily agenda of visits, especially in public health settings. This may be interpreted as a lack of interest in gout by specialists compared with other systemic diseases, such as rheumatoid arthritis (RA).
However, a recent audit of RA management  demonstrated that around 40% of patients did not show any meaningful improvement of DAS28 scores after 3 months of disease management by specialists, showing that the management of RA was also unsatisfactory.
Therefore, the explanation that gout is not specifically perceived as an important field of specialty for rheumatologists, resulting in lack of proper management of the disease, cannot be sustained. Audits of other diseases such as RA show that management of these conditions is far from excellent, despite being perceived as being of the utmost importance in rheumatology practice.
A recent paper by Roddy et al  has reported the results of an audit of gout management in the rheumatology setting, compared with the EULAR 2006 recommendations and BSR 2007 guidelines. This report found that the diagnostic gold standard of presence of monosodium urate (MSU) crystals occurred in just 13% of cases, whereas urate lowering therapy (ULT) was prescribed or continued in 76% of patients. The authors also found that prophylaxis, which was prescribed in over 90% of patients starting ULT, was most effective in achieving target serum uric acid (sUA) levels of < 6 mg/dL or 0.36 mmol/L.
The majority of gout patients are managed by primary care (PC) teams. Management of gout in PC has been associated with low rate of initiation of urate-lowering treatment and scarce achievement of target therapeutic sUA levels . Indeed, in a nationwide study in the UK, the median rate of patients with gout prescribed ULT was 32.5%, but ranged from 0% to 100% depending on the clinical practice .
Control of sUA levels have even worsened over time in some studies . In New Zealand, where gout is very prevalent, less than half of patients admitted to hospital or with prolonged stay due to a gout flare were on ULT, and of those on ULT, less than half had been tested for sUA . Worse than that, after admission for gout as primary diagnosis, of those patients who were not on ULT, less than one third were prescribed ULT while at hospital or recommended for prescription after discharge .
One would expect a different landscape in countries that have developed a highly efficient and universal healthcare system. On the contrary, an increase in rates of hospital admission, duration of stay, and therefore costs have been reported recently to have occurred in Sweden . The report showed that less than one third of patients admitted had been on ULT during the previous 6-month period, with prescriptions being mostly associated with the presence of severe comorbidities . Similar figures have also been reported from other developed countries.
Audits may show areas for improvement. Similar results to those reported by Roddy et al were also observed some years ago in a Spanish national audit , where the rate of crystal-based diagnosis was 26% and the rate of patients achieving sUA target levels of < 6 mg/dL was only 42%. A second, follow-up audit disclosed a 50% improvement during a 6-year period, with over two thirds reaching sUA target levels. However, the advent of febuxostat may have helped with this improvement, as clinical inertia in increasing medication dosage or switching medication was persistent .
A proof-of-concept study  has shown that nurse support has helped in achieving close to excellent results in the management of gout. Furthermore, a striking improvement in the management of gout was observed after implementing the use of electronic templates in patients’ files . The rates of sUA testing and achieving sUA target levels in a primary setting doubled in a few months.
Although the reasons why gout is not well managed are not known for certain, it has been suggested that an incorrect perception that gout is a self-inflicted disease induced by overindulgent attitudes towards lifestyle has resulted in scarce academic interest compared with other serious and life-threatening systemic conditions, and lack of awareness that gout is one of the few “curable” rheumatologic conditions . Preference of rheumatologists to dedicate most of their time-limited efforts to treating the most “serious” diseases may also contribute. Education at all levels, including among the general population, academics, physicians, and patients, may help to improve management in the long-term.
We cannot, as specialists, honestly intend to lead science and practice when audits reflect that we are still far from excellent. Increase in awareness due to the appearance of new medications, education to improve adherence, and even electronic templates for management may all help to improve the management of gout. General practitioners may mirror or copy attitudes and procedures observed in specialists, therefore it is much better for patients if rheumatologists follow excellent practice as closely as possible.
About the author
- Ledingham JM, Snowden N, Rivett A et al. Patient- and clinician-reported outcomes for patients with new presentation of inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis. Rheumatology (Oxford) 2017; 56(2): 231-238.
- Roddy E, Packham J, Obrenovic K, Rivett A, Ledingham JM. Management of gout by UK rheumatologists: a British Society for Rheumatology national audit. Rheumatology (Oxford) 2018; 57(5): 826-830.
- Cottrell E, Crabtree V, Edwards JJ, Roddy E. Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice. BMC Fam Pract 2013; 14: 170.
- Kuo CF, Grainge MJ, Mallen C, Zhang W, Doherty M. Eligibility for and Prescription of Urate-Lowering Treatment in Patients With Incident Gout in England. JAMA 2014; 312(24): 2684-2686.
- Reaves E, Arroll B. Management of gout in a South Auckland general practice. J Prim Health Care 2014; 6(1): 73-78.
- Kennedy NJ, Healy PJ, Harrison AA. Inpatient management of gout in a New Zealand hospital: a retrospective audit. Int J Rheum Dis 2016; 19(2): 205-210.
- Wright S, Chapman PT, Frampton C et al. Management of Gout in a Hospital Setting: A Lost Opportunity. J Rheumatol 2017; 44(10): 1493-1498.
- Dehlin MI, Sigudardottir V, Privelegka P, Svärd A, Jacobson LT. Trends and costs for gout hospitalization in Sweden. Ann Rheum Dis 2017; 76: 164-165. (Abstract)
- Dehlin MI, Ekström EH, Petzold M et al. Factors associated with initiation and persistence of urate-lowering therapy. Arthritis Res Ther 2017; 19: 6.
- Perez-Ruiz F, Carmona L, Yebenes MJ et al. An audit of the variability of diagnosis and management of gout in the rheumatology setting: the gout evaluation and management study. J Clin Rheumatol 2011; 17(7): 349-355.
- Perez RF, Sanchez-Piedra CA, Sanchez-Costa JT et al. Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice. Rheumatol Ther 2017; 5(1): 243-253.
- Rees F, Jenkins W, Doherty M. Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study. Ann Rheum Dis 2013; 72(6): 826-830.
- Moffat K, McNab D. Improving management of gout in primary care using a customised electronic records template. BMJ Qual Improv Rep 2015; 4(1): u204832.w2038.
- Doherty M, Jansen TL, Nuki G et al. Gout: why is this curable disease so seldom cured? Ann Rheum Dis 2012; 71(11): 1765-70.