To determine the relevance of current gout quality indicators (QIs).
To determine the relevance of current gout quality indicators (QIs).
Members of the Veterans Affairs (VA) 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 US veterans, 2) likelihood to improve gout care, and 3) ease of electronic capture. Participants were also asked to rank their top 3 gout QIs.
Participating VA rheumatologists were mainly men, with a mean age of 51.3 years, and experienced in the management of gout. All 10 gout QIs were considered relevant, with a score of 8.2 or higher. The initiation of urate-lowering therapy, monitoring of urate levels after initiation of urate-lowering therapy, and treatment of acute gout with antiinflammatory agents scored the highest with regard to likelihood of improving gout care, with the first 2 QIs also thought to be the 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.
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.
Evidence-based quality of care indicators for patients with gout have recently been developed (1) using the RAND/University of California at Los Angeles appropriateness panel method. With this method, a panel assesses the existing evidence and develops quality indicators (QIs) 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 10 gout QIs described (1), 7 pertain to uric acid–lowering therapy (allopurinol and probenecid), 2 pertain to antiinflammatory medications (colchicine and nonsteroidal antiinflammatory drugs [NSAIDs]), and 1 pertains to lifestyle modification. Studies have shown that adherence to these QIs is low in the US, ranging between 24% and 78% (3–5).
A key publication in this area was “Crossing the Quality Chasm: A New Health System for the 21st Century,” published by the Institute of Medicine in 2001 (6). Since this proclamation nearly a decade ago, the quality of care movement has become a priority in most US health care organizations. Although 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 toward 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 rheumatologists' opinions regarding the relevance of these gout QIs to the care of veterans with gout and the likelihood of these QIs to improve care.
We performed a national survey of rheumatologists employed by the VA. The VA is the largest integrated health care system in the US, serving more than 4.9 million veterans nationally with a budget of $25 billion in 2003 (8). The e-mail list was obtained from the VA Rheumatology Consortium (VARC). The VARC, founded in 2001, is comprised of VA-employed rheumatologists who meet on a semiannual basis to discuss issues relevant to the care of US veterans with rheumatic diseases. We chose VA rheumatologists for this survey because the knowledge gained from this survey could potentially lay the foundation for implementing gout QIs in the VA, a nationwide health care system. The study was approved by the Minneapolis VA Institutional Review Board and all of the investigations were conducted in conformity with ethical principles of research.
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 (see Supplementary Appendix A, available in the online version of this article at http://www3.interscience.wiley.com/journal/77005015/home). We asked the VA rheumatologists to grade each QI on 3 aspects on a 0–10 scale (where 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) the likelihood of improving 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 given an opportunity at the end of the survey to provide their comments in a free-text box.
Responders also provided their demographics, including age, sex, 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 3 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 e-mail request received 2 reminder e-mails to complete the survey. Physicians who chose not to participate were given the alternative to “opt-out” in their survey response.
The survey included all 10 QIs described for gout by Mikuls et al (1) (see Supplementary Appendix A, available in the online version of this article at http://www3.interscience.wiley.com/journal/77005015/home). 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 the use of antiinflammatory therapy in acute flares and during the initiation of urate-lowering therapy, and lifestyle modifications.
Sample characteristics were described as the mean ± SD or the proportion. For each QI, the scores (range 0–10) were averaged for all valid responses from survey responders and presented as the mean ± SD. For the top 3 QIs chosen by each responder, we calculated the percent votes for each of the 10 QIs. We also calculated the total votes for the top 3 QIs and aggregated them as a single sum to find out which QI was the most often recommended among the top 3 QIs.
Of the 147 unique e-mail addresses for VA rheumatologists, 139 rheumatologists with valid e-mail addresses were eligible to participate (n = 6 not at the VA or not rheumatologists, n = 2 invalid e-mail addresses). Of these, 34 (25%) were nonresponders and 6 (4%) opted out, resulting in a 71% response rate (n = 99). No demographics were available on the nonresponders.
The VA rheumatologists who responded to the survey had a mean ± SD age of 51.3 ± 10.3 years. Sixty-five percent of the respondents were men; 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 to high: 9% saw <4 patients per month, 38% saw 4–14 patients per month, 35% saw 15–24 patients per month, and 18% saw ≥25 patients per month. The 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.
The survey responders ranked all 10 QIs with a score of 8.2 or higher with regard to relevance to veterans (Table 1). QIs concerning 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 (score of 9 for each).
|Relevance to veterans†||Likelihood of improving care‡||Ease of electronic capture‡|
|QI 1: renal dose adjustment of allopurinol dose at new initiation||8.7 ± 1.8||7.6 ± 2.7||8.7 ± 2.1|
|QI 2: dose adjustment of azathioprine/6-MP when used concurrently with allopurinol||8.2 ± 2.3||8.7 ± 1.9||8.6 ± 2.1|
|QI 3: recommendation of the use of antiinflammatory prophylaxis when initiating urate-lowering therapy||8.8 ± 1.8||8.6 ± 1.9||7.8 ± 2.4|
|QI 4: no treatment of hyperuricemia with urate-lowering therapy in the absence of gouty arthritis, gouty nephropathy, or malignancy||8.5 ± 1.8||7.5 ± 2.5||7.2 ± 2.7|
|QI 5: preference for xanthine oxidase inhibitor as initial therapy over uricosurics in gout patients with renal insufficiency or renal stones||8.8 ± 1.7||8.3 ± 1.9||7.7 ± 2.5|
|QI 6: urate-lowering therapy should be offered to patients with gouty arthritis with frequent attacks, radiographic changes, or tophaceous deposits||9.2 ± 1.2||9.0 ± 1.4||7.3 ± 2.7|
|QI 7: serum urate level should be monitored within 6 months of initiation of xanthine oxidase inhibitor prescription||9.3 ± 1.1||9.0 ± 1.4||8.8 ± 1.9|
|QI 8: counseling patients with gout regarding reduction in weight and alcohol use||8.9 ± 1.6||7.7 ± 2.4||5.9 ± 3.0|
|QI 9: treatment of acute gouty arthritis with an antiinflammatory agent in the absence of contraindications||9.0 ± 1.4||8.6 ± 1.7||7.4 ± 2.5|
|QI 10: monitoring CBC and CK levels in gout patients receiving long-term colchicine||8.5 ± 1.7||7.8 ± 2.3||8.0 ± 2.2|
With regard to the likelihood of improving 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 (QI 7), 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 the highest (≥8.6).
We asked the physicians to select the top 3 QIs 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 = 30 [33%]; QI 1), followed by recommendation to start urate-lowering therapy in gout patients with frequent attacks, radiographic changes, or tophaceous deposits (n = 24 [26%]; QI 6). Monitoring serum urate levels after allopurinol initiation (n = 15 [16%]; QI 7) was ranked third (Table 2). If all of the votes for the top 3 QIs recommended were aggregated, the top 3 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).
|Top choice for QI (n = 91)||Second choice for QI (n = 89)||Third choice for QI (n = 89)||Choice as one of top 3 QIs (n = 269 votes)|
|QI 1: renal dose adjustment of allopurinol dose at new initiation||30 (33)||45 (17)|
|QI 3: recommendation of the use of antiinflammatory prophylaxis when initiating urate-lowering therapy||21 (24)||14 (16)|
|QI 4: no treatment of hyperuricemia with urate-lowering therapy in the absence of gouty arthritis, gouty nephropathy, or malignancy||14 (16)|
|QI 6: urate-lowering therapy should be offered to patients with gouty arthritis with frequent attacks, radiographic changes, or tophaceous deposits||24 (26)||11 (12)||47 (17)|
|QI 7: serum urate level should be monitored within 6 months of initiation of xanthine oxidase inhibitor prescription||15 (16)||24 (27)||17 (19)||56 (21)|
The survey responders made several comments related to QIs 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 QI 1) and the need for titrating allopurinol dose to reduce uric acid level below 6.8 mg/dl to reduce gout symptoms and flares (related to QI 7).
|Pharmacy services are usually very apt, ensuring that allopurinol dosage is adjusted appropriately in both renal failure based on the patient's GFR and also based on drug interactions.|
|Evidence not good to adjust allopurinol dose for renal failure, weight loss advice rarely effective <10%.|
|We should not under dose patients who need allopurinol when it can be used safely in many patients with some renal insufficiency.|
|Emphasize that allopurinol should be started at a low dose of 100 mg every day in all patients– those with normal serum creatinine too, and that it should be titrated to lower serum uric acid levels to less than 6.0. Most patients with serum creatinine higher than 2.0 would also tolerate 100 mg qday as a starter. Key would be to adequately lower serum uric acid to prevent gout attacks and individualize therapy to lower serum uric acid levels.|
|Re “use of antiinflammatory…,” incomplete re-contraindications to colchicine and NSAID. Also, some may feel that NSAIDs inadvisable with creatinine level of 1.5–2. Concern re “Not treating asymptomatic…” because some recommend treating for very high uric acid levels (for example, >13).|
|The QI regarding use of antiinflammatory prophylaxis when starting uric acid–lowering therapy does not indicate an appropriate duration of antiinflammatory therapy and thus implies chronic therapy. That should be changed.|
|People need to learn that if you don't reduce uric acid into an acceptable range, the patient is still making tophi.|
|Level of uric acid should be below the equilibrium level to be effective treatment (<6.8).|
|Should probably not use allopurinol or febuxostat with azathioprine/6-MP.|
|Allopurinol/probenecid should be titrated to serum uric acid and symptom frequency and duration.|
|Renal dose adjustment at initial allopurinol initiation|
|The first indicator, “allopurinol dose adjustment in renal failure,” should be removed. The EBM data to support this is highly questionable and contrary to much recent research.|
|No patient should be on long-term colchicine treatment. Gout should always be treated with urate-lowering treatment.|
|I feel that the initial dose of allopurinol needs to be adjusted in the setting of CRF, but then the dose should be adjusted to get uric acid below 6 mg/dl with careful monitoring for toxicity.|
|Allopurinol and azathioprine: existing programs/pharmacy will catch almost nobody uses uricosurics weight loss alcohol counseling we do anyway everyone knows the prescription of gout acutely colchicine toxicity seems an infrequent risk from what I have seen.|
|Consider reevaluating allopurinol dose adjustment in renal failure. Conservative (i.e., low-dose) initial therapy is ok, but many patients with chronic kidney injury require higher doses of allopurinol than those recommended in the initial guidelines by Hande.|
|Did not address the issue of dose escalation with allopurinol. All too often, PC practitioners will not exceed 300 mg.|
|Listed recommendation does not deal with most common cause of flare, compliance.|
|It will be difficult to gather electronic data on diagnosis of gout, especially acute gout. I think impossible to gather data on diagnosis of asymptomatic hyperuricemia. Otherwise, the electronic data gathering is very doable.|
|Disagree that the data are that strong for dose adjustment in renal failure (related to hypersensitivity).|
|I would not use colchicine in the setting of renal insufficiency, even with checking CBC or CK. Patients can get neurotoxicity and this would not be manifested in the blood work.|
In this national survey of VA rheumatologists, we assessed 10 QIs for gout (1). All 10 QIs were rated highly in terms of their relevance to US veterans, with urate monitoring, treatment of acute gouty arthritis with antiinflammatory agents, and treatment of symptomatic gout with urate-lowering agents ranked as most relevant to veterans with gout. Similarly, most QIs were regarded as very significant with regard to the likelihood of improving the care of gout in veteran patients. The use of urate-lowering therapy in patients with symptomatic gout (QI 6), serum urate level monitoring in patients receiving urate-lowering therapy (QI 7), and adjustment of initial allopurinol dose in patients with renal failure (QI 1) were rated as the top 3 QIs for implementation. The use of antiinflammatory 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 policymakers during future implementation of gout QIs in the VA health care system. An advanced completely electronic medical record 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 rankings, 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 patients with gout receiving serum urate monitoring started on a urate-lowering therapy (3–5, 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 level 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. Furthermore, 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 the target serum urate level 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% of 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 QIs by all of the 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 believed to be very important. To our knowledge, there are currently no data available with regard to physician noncompliance with this QI, since the 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 the interpretation of this QI among responders.
The use of antiinflammatory prophylaxis at initiation and titration of urate-lowering therapy to decrease acute flares received attention from responders. Low adherence to this QI of 48% has previously been reported (12). Furthermore, 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 antiinflammatory 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 noncompliance. Nonresponse bias limits generalization. The aim of this study was to assess gout QIs with regard to US veterans with gout, and therefore our findings may not be applicable to nonveterans and may 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 QIs may also be revisited. However, most QIs related to available gout therapies are still applicable, and in the absence of additional data from randomized controlled trials, are 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 a response rate of 71%, a rate higher than the 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 QIs rather than expert opinion only.
In patients with multiple medical diseases, it is impractical to capture and implement all QIs 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 QIs for gout. Implementation of prioritized QIs as performance measures may serve as an incentive to practitioners to improve adherence, which we believe will improve patient outcomes in gout.
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Singh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study conception and design. Singh, Alpert, Kerr.
Acquisition of data. Singh, Alpert, Kerr.
Analysis and interpretation of data. Singh, Alpert, Kerr.
We would like to acknowledge all members of the VARC for their continued dedication to the care of veterans with rheumatic diseases.