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.
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.
Gout patients were identified, from among all NY Harbor VAMC patients ages 18100 (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 12 rheumatology visits were excluded. Mean serum UA for the two groups were compared using R statistical software (version 2.8.1).
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
|Mean UA among all patients||7.85 (7.65, 8.01) (n=474)||6.54 (6.12, 6.97) (n=85)||<0.0001|
|Mean UA among patients prescribed allopurinol||6.94 (6.56, 7.31) (n=142)||5.94 (5.49, 6.39) (n=57)||0.0004|
|Mean UA among patients prescribed HCTZ||7.85 (7.33, 8.37) (n=63)||6.22 (4.84, 7.60) (n=10)||0.0218|
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