Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice

Abstract

BackgroundGout is estimated to affect 1.4% of adults in the UK. Appropriate and timely management is essential to reduce the risk of further flares, complications, and to reduce cardiovascular disease risk. The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) have published guidance regarding the management of gout, thereby providing standards against which performance can be measured. This audit was designed to assess the extent to which patients diagnosed with gout in one primary care medical practice in North Staffordshire, UK, are managed in accordance with current best practice guidelines, and to identify strategies for improvement where appropriate.MethodsAudit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. An electronic search of the practice records was performed to identify adults with a diagnosis of gout. Medical record review with a descriptive analysis was undertaken to assess the extent to which medical management adhered to the predefined standards.ResultsOf the total ≥18 year-old practice population (n = 8686), 305 (3%) patient records included a diagnosis of gout. Of these, 74% (n = 226) had an electronic record of serum uric acid (SUA), and 11% (n = 34) and 53% (n = 162) a measure of estimated glomerular filtration rate (eGFR) ever and serum glucose since diagnosis respectively. 34% (n = 105) of patients had ever taken urate-lowering therapy with 25% (n = 77) currently prescribed this at the time of data extraction. Dose adjustment and monitoring of treatment according to SUA was found to be inadequate. Provision of lifestyle advice and consideration of comorbidities was also lacking.ConclusionsThe primary care management of gout in this practice was not concordant with national and international guidance, a finding consistent with previous studies. This demonstrates that the provision of guidelines alone is not sufficient to improve the quality of gout management and we identify possible strategies to increase guideline adherence.

Poorly controlled gout: who is doing poorly?

“…Studies in the primary care setting in the United Kingdom showed that 20% of patients with tophaceous gout and 33% of patients with recurrent attacks were on allopurinol, and only 33% of patients on urate-lowering therapy attained the SUA treatment target. (12,13) Similar results were seen locally: an audit of the rheumatology clinic in a restructured hospital found that only 25% of patients started on allopurinol had achieved their target SUA levels at one-year follow-up. (3) …”

Improvement in Diagnosis and Treat-to-Target Management of Hyperuricemia in Gout: Results from the GEMA-2 Transversal Study on Practice

“…Audits more accurately reflect real practice, despite all the limitations regarding the retrospective nature of the design. Management of gout may differ widely from average [2] to outstanding specialized practices [4]. It is far from the authors' intention to cast blame or praise any particular setting, but rather to suggest that if a particular specialist's practice is suboptimal, this can result in errors used by general practitioners for their own benchmarking purposes.…”

“…Recommendations for diagnosis and management are based on the best evidence and expertise available to obtain the best possible outcomes. Adherence to recommendations, such as prescription rates of uratelowering medications, is reportedly low in general practice [2], even worsening over time in terms of controlling serum urate (sUA) levels [3]. It remains unknown whether such recommendations have a true impact on gout.…”

An Observational Study of Gout Prevalence and Quality of Care in a National Australian General Practice Population

“…The British Society for Rheumatology recommends a lower target of 0.30 mmol/l 20 . Similar quality measures have been used in other quality-of-care studies 11 .…”

“…There is international evidence that gout is inadequately treated and that adherence to urate-lowering therapies is low 9,10 . For example, in a recent quality-of-care assessment in the United Kingdom, there were low levels of allopurinol prescription, infrequent serum urate and renal function testing, and very low rates of achievement of target serum urate levels documented 11 . Similar findings have been observed in North America and Europe 12,13 .…”