An estimated three million Americans are afflicted with gout, the result of a higher-than-normal level of uric acid in the body. The acid builds up in the joints, forming crystals, which cause the joint to swell and become inflamed. The acute form of the condition typically affects only one joint—usually the big toe. The chronic form is characterized by repeated episodes of pain and inflammation and can involve multiple joints.
The cause of the condition is unknown. However, it is more common in males, post-menopausal women, alcohol users and people who are overweight. Treatment usually includes nonsteroidal anti-inflammatories (NSAIDs) for occasional flare-ups. Daily use of allopurinol or probenecid can decrease uric acid levels in the blood, as can certain lifestyle changes. Patients with gout are instructed to avoid alcohol and fatty foods, as well as meat and some fish. With proper treatment, symptoms of the disease can be managed, though acute gout can progress to chronic gout.
Although gout is not that rare, only in the last 10 years have researchers compiled a set list of quality indicators (QIs)—metrics by which to judge how well a patient is being treated for the disease. Even more recently that researchers began formally asking whether those QIs apply as well to the VA population as they do to the civilian population.
Determining Quality Indicators
Jasvinder Singh, MD, a staff rheumatologist at the Birmingham VA, has worked with veterans for most of his medical career. He treated them in clinics and medical centers during his residency at the University of New York, Syracuse, and during fellowship training at Washington University in St. Louis. During that time, he saw a lot of gout, estimating the prevalence of the disease at 5 percent of all patients treated at the facility. Singh came to this figure by looking at ICD-9 codes for gout recorded in the electronic health record but noted that this only represented a single facility during a short period of time.
“I saw so much of it in the inpatient and outpatient setting,” Singh said, especially after he came to the Minneapolis VA after finishing medical school. “During my fellowship, I became interested in doing research using the national data systems within VA,” he added. “It provides a unique opportunity that no other health care system has. And with gout, there were lots of opportunities to look at care patterns, and see how we could look at the impact of improving care.”
Singh began his first research in 2002-2003, looking at patterns of health care use in the Minneapolis VA—seeing if patients were using VA care to treat gout, and to see if physicians were monitoring blood tests. “I wanted to see if physicians were tracking things that are now considered quality indicators. I started looking at this nine years ago, and while we were in the process of compiling that data, researchers from Birmingham and UCLA published quality indicators for gout.”
That study—Quality of Care Indicators for Gout Management, published in Arthritis & Rheumatism in March, 2003—looked at 10 QIs for gout that all ranked above a 7.5 on a 10-point scale. Singh began looking at which of those indicators could be tracked in the VA database at the hospital and Veterans Integrated Service Network level.
“We were interested in looking at medication use, treatment patterns, and looking at whether treatment patterns met quality standards,” Singh said. “And we looked at whether if quality standards aren’t being met, what that predicts.”
In research first published in 2008, Singh and his cohorts found that there were significant variations in how gout was treated in veterans, especially in terms of medication use. Of the 643 gout patients receiving a new allopurinol prescription, only 46% had continuous allopurinol prescription, 10% received colchicine prophylaxis and 20% reached target uric acid of ≤6 mg/dl. During episodes of renal insufficiency, appropriate dose reduction or discontinuation of probenecid was done in 77% episodes and of colchicine in 69%.
It was clear to Singh and his fellow researchers that a concerted effort was needed to improve gout care in VA.
What Works for Veterans?
At the time, there was still the question of whether these QIs applied equally to the VA population. “There’s not a big body of scientific work on gout,” Singh said. “It’s not the highest priority [condition].”
However, many experts in VA—rheumatologists who have spent years treating veterans with gout—and who have firsthand knowledge of which quality indicators are relevant. Singh polled the members of the VA Rheumatology Consortium, which is made up of about 140 VA rheumatologists and meets twice yearly.
The survey asked those rheumatologists which of the quality indicators for gout published in 2004 made sense to use as QIs for veterans being treated in the VA system. “If the VA Central Office was going to pick one or two quality indicators, could the group give their collective wisdom as to which make the most sense in terms of impacting the care and in terms capturing the essence of quality of care,” Singh said. “And also we wanted them to look at these and determine whether some of them are not relevant to veterans.”
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 anti-inflammatory agents were considered most likely to improve gout care, with the first two QIs also felt to be most relevant.
Adjustment of initial allopurinol dosing in patients with renal impairment and in those receiving concurrent azathioprine/6-mercaptopurine were considered by those surveyed 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.
“The results did not surprise me. I think we, as a group, had heard from our peers and colleagues several times. But that all of these scored so highly, and all were considered relevant—that was reassuring,” Singh said. “I don’t know if we knew that before the survey.”
The survey also indicated that, while weight loss and alcohol use are captured electronically, other behavioral changes are less likely to be captured, making for incomplete data when it comes to tracking a gout patient’s health.
Since those QIs were created, new drugs approved for gout have entered the market. Determining how those drugs compare to existing treatments and how they will have an impact on the quality indicators is at the top of the list of future research priorities, Singh said. “We have to determine if they are helping us improve the care of our veterans with gout.”
There is also the matter of how to take the information gleaned from the survey and use it to improve VA care. “How can we implement the findings from our study?” Singh said. “What can we do to help our system and our providers meet those goals and improve care even further.”
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