Arthritis & Rheumatism, Volume 60,
October 2009 Abstract Supplement

The 2009 ACR/ARHP Annual Scientific Meeting
Philadelphia October 16-21, 2009.


Gout Management in Primary Care Vs. Rheumatology: Evidence for Suboptimal Treatment

Keenan1,  Robert T., Lehman2,  Robert A., O'Brien3,  William R., Crittenden1,  Daria B., Lee1,  Kristen H., Pillinger4,  Michael H.

NYU-HJD, New York, NY
NYU Hospital for Joint Diseases, New York, NY
New York University, New York, NY
NYU Langone Medical Center/NYU Hospital for Joint Diseases, New York, NY

Purpose:

Primary care physicians (PCPs) manage most gout patients, but several studies suggest that the quality of PCP gout management may differ from that of rheumatologists. To prevent acute gouty attacks, a serum uric acid (UA) of <= 6 is the consensus UA lowering target. We compared the achievement of UA <= 6 in patients managed by PCPs vs. rheumatologists.

Methods:

Gout patients were identified, from among all NY Harbor VAMC patients ages 18–100 (n-33,000) as having any 1 of 7 ICD codes for gout. Gout patients were defined as managed by their PCP if they had not seen a rheumatologist during the study period (7/07-6/09), or treated by a rheumatologist if they had seen a rheumatologist >=3 times during the interval. Patients with 1–2 rheumatology visits were excluded. Mean serum UA for the two groups were compared using R statistical software (version 2.8.1).

Results:

Prevalence of gout in the overall population was 2.5% (34% African-American, 49% White, 8% Hispanic, 2.5% South East Asian, 1% Pacific Islander, 0.5% Native American and 5% unknown). All subjects were male; average age was 72 years. Among 575 patients meeting ICD-9 diagnosis for gout, 474 had been treated for gout only in primary care, whereas 85 had been managed by a rheumatologist. 5.3% in the PCP cohort vs. 14.1% in the rheumatology cohort had a crystal confirmation of their disease. Patients receiving allopurinol achieved UA <=6 in the rheumatology- but not the PCP-treated group. Among 191 patients prescribed allopurinol in the PCP cohort, 25.7% had no UA measurement during the study period; in contrast, 100% of the 57 rheumatology patients receiving allopurinol had >=1 UA measurement. Average allopurinol dose in the PCP and rheumatology cohorts were 196 mg and 182 mg, respectively. Among patients with gout and hypertension, 16.7% were prescribed hydrochlorothiazide (HCTZ) in the PCP cohort vs. 11.8% in the rheumatology cohort.

Uric acid outcomes in gout subjects by treatment setting

 PCPRheumatologyP-valuea=0.05
Mean UA among all patients7.85 (7.65, 8.01) (n=474)6.54 (6.12, 6.97) (n=85)<0.0001
Mean UA among patients prescribed allopurinol6.94 (6.56, 7.31) (n=142)5.94 (5.49, 6.39) (n=57)0.0004
Mean UA among patients prescribed HCTZ7.85 (7.33, 8.37) (n=63)6.22 (4.84, 7.60) (n=10)0.0218

Conclusion:

Our analyses suggest that gout patients cared for by PCPs may be undertreated. Compared with rheumatologists, PCPs are more likely to under dose, and/or inadequately monitor the results of, UA-lowering therapy. PCPs may also be more likely than rheumatologists to eschew crystal diagnosis, and to fail to account for the UA-raising properties of anti-hypertensive diuretics. To ensure proper clinical care, rheumatologists may need to assume a greater role in treating gout patients, and/or better educate PCPs in appropriate gout management.

To cite this abstract, please use the following information:
Keenan, Robert T., Lehman, Robert A., O'Brien, William R., Crittenden, Daria B., Lee, Kristen H., Pillinger, Michael H.; Gout Management in Primary Care Vs. Rheumatology: Evidence for Suboptimal Treatment [abstract]. Arthritis Rheum 2009;60 Suppl 10 :1110
DOI: 10.1002/art.26185

Abstract Supplement

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