Illness perceptions in patients with gout and the relationship with progression of musculoskeletal disability

'Gout was like the boss'. A qualitative study exploring the impact of gout on employment

OBJECTIVE

Previous research has identified that gout impacts various domains of daily life. However, there have been no qualitative studies focusing on employment. This study aimed to understand the impact of gout on employment.

METHODS

Semistructured interviews were conducted in Spain and Aotearoa/New Zealand, in people with gout (according to the 2015 American College of Rheumatology/European Alliance of Associations for Rheumatology criteria) who had experienced a gout flare during their employment. The interviews were guided by questions exploring the impact on employment, job changes, disclosure and co-workers' reactions. Data were analysed thematically.

RESULTS

Eighteen participants were interviewed (89% male, mean age 52.9 years). Six themes were identified. The characteristics of the disease (pain intensity, tophi and joints affected) and the job itself (including physical job requirement and workplace flexibility) determined the experience of working with gout. The experiences were divided into physical (from total incapacity to working despite pain), emotional (feeling responsible, embarrassment, guilt and depression) and social (including disclosure responses and financial impact). Gout management strategies including rapid gout flare management and urate-lowering therapy reduced the number of flares and the intensity of pain, and allowed work attendance and participation.

CONCLUSION

Both gout and work characteristics influence the employment experience for people with gout. Effective management of gout led to improved work experiences in all its domains.

Patient factors and health outcomes associated with illness perceptions in people with gout

OBJECTIVE

Illness perceptions are views and beliefs formed in response to a health threat, and they may influence self-management behaviours and chronic disease outcomes. Despite effective medication, sub-optimal outcomes in gout are common. This study aimed to quantitatively investigate illness perceptions in gout to examine how illness perceptions relate to health outcomes.

METHODS

Data were obtained from a randomized controlled trial in which people with gout (n = 493) completed surveys measuring illness perceptions [Brief Illness Perception Questionnaire (B-IPQ)], gout flares, medication adherence, health-related quality of life, health-care utilization, and productivity, alongside serum urate blood tests at baseline, and at 6- and 12-month follow-ups. Multivariable linear regression identified patient factors independently associated with each B-IPQ item score. Logistic and linear regression, adjusted for age and sex, determined whether baseline B-IPQ items could predict current and future health outcomes.

RESULTS

Younger individuals and those with severe gout were more likely to experience pessimistic illness perceptions at baseline. Optimistic illness perceptions were associated with lower odds of having had at least one flare in the preceding 6 months. Every 1-point increase in B-IPQ treatment control, indicating an increasingly optimistic view that gout is treatable, decreased the odds of a recent flare prior to baseline by 33% [odds ratio (OR): 0.67; 95% CI: 0.53, 0.85; P < 0.001] and prior to the 12-month follow-up by 15% (OR: 0.85; 95% CI: 0.76,0.96; P = 0.01). Pessimistic illness perceptions also predicted poorer medication adherence, health-related quality of life, and productivity, but not serum urate levels.

CONCLUSION

Modifying pessimistic illness perceptions, including, but not limited to, patient education, may promote prudent self-management behaviours and better outcomes in gout.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; https://www.anzctr.org.au/, ACTRN12616000455460.

Knowledge, Attitudes, and Practices about Hyperuricemia and Gout in Community Health Workers and Patients with Diabetes

Hyperuricemia exhibits a high incidence among individuals with diabetes; however, the significance of hyperuricemia and gout is often underestimated. This study aimed to assess the knowledge, attitude, and practice of hyperuricemia and gout among community health workers and patients with diabetes. Two questionnaires were designed to investigate knowledge, attitudes, and practices of hyperuricemia and gout among community health workers and patients with diabetes in Chenghua District, Chengdu, from August 2021 to January 2022. A total of 709 community health workers were included, whose average score was 17.74/30. Approximately half of general practitioners (GPs) demonstrated knowledge regarding the target serum uric acid levels for hyperuricemia and gout. Only 11.2% of GPs were fully aware of the preferred medicine for acute gout. The majority of GPs (86.7%) demonstrated limited awareness regarding the contraindications associated with colchicine, while a significant proportion (65.1%) lacked knowledge about the specific classes of drugs that inhibit uric acid synthesis. Among the 508 patients with diabetes included in this survey, 32.3% demonstrated awareness of hyperuricemia, while 60.8% exhibited knowledge regarding gout. The average score attained by these individuals was recorded at 7.21 out of a total of 26 points. The majority of patients with diabetes (87.8%) held the mistaken belief that hyperuricemia definitely led to the development of gout. Almost 66% agreed that a massage or a hot compress could be used when acute gouty arthritis attacks. The knowledge rate of hyperuricemia and gout among community health workers was moderate, while it was low in patients with diabetes.

Limb salvage and systemic management of gouty tophi: Case series

INTRODUCTION

Gout is a chronic disease characterized by deposition of monosodium urate crystals. Tophi develop in some individuals with untreated or uncontrolled gout, which leads to ulcerations, cosmetic problems, mechanical obstruction of joint movement, joint damage and musculoskeletal disability. Currently, the treatment of gouty tophi is controversial and challenging. Both surgical and internal medical treatments have limitations and require further exploration in clinical practice.

PATIENT CONCERNS

In Case 1, we treated a patient with severe infection of diabetic foot ulcers with concomitant multiple gouty tophi in the same limb. A systematic management strategy was formulated to close the wound and save the limb. The ulcers healed successfully after half a year. In Case 2, a giant gouty tophi located in the first metatarsophalangeal joint of the left foot was removed by surgical treatment and vancomycin-loaded bone cement implantation. In Case 3, we present a case of gouty tophi that was resolved by standardized systemic medical management.

DIAGNOSIS

Three patients were all diagnosed with gout accompanied by gouty deposition, although there were other different comorbidities.

INTERVENTIONS

In case 1, we used debridement to gradually remove gouty tophi. In case 2, the giant gouty tophi was removed by surgical operation. In case 3, the gouty tophi disappeared after standardized treatment with medicine, diet and lifestyle management.

OUTCOMES

Three patients underwent different treatment therapies to remove gouty tophi based on their specific conditions.

LESSONS

We explored effective interventions for tophi in gout by surgical or other interventions in combination with pharmacotherapy.

Impact of Television Depictions of Gout on Perceptions of Illness: A Randomized Controlled Trial

OBJECTIVE

Gout is a chronic disease that can be effectively managed with long-term urate-lowering therapy. However, it is frequently portrayed on screen as an acute disease caused by a poor diet that should be managed with lifestyle changes. This study was undertaken to investigate the impact of a fictional television depiction of gout on perceptions of the disease and its management.

METHODS

In a randomized controlled single-blind study, 200 members of the public watched either a 19-minute commercial television comedy episode that depicted gout as an acute disease caused by poor diet and managed with lifestyle changes, or a control episode from the same television series that did not mention gout or other diseases. Participants completed a survey regarding their perceptions of gout, its likely causes, and management strategies.

RESULTS

Participants randomized to watch the gout-related episode believed gout had greater consequences (mean score of 7.1 versus 6.2 on an 11-point Likert scale; P < 0.001) and were more likely to rank the most important cause as poor eating habits compared to the control group (70% versus 38%; P < 0.001). They were also less likely to believe it is caused by genetic factors or chance. Participants watching the gout-related episode believed a change in diet would be a more effective management strategy (9.0 versus 8.4; P = 0.004) and long-term medication use would be less effective (6.9 versus 7.6; P = 0.007) compared to participants in the control group.

CONCLUSION

Television depictions of gout can perpetuate inaccurate beliefs regarding causes of the disease and underemphasize effective medical strategies required in chronic disease management.

Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care

OBJECTIVE

To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care.

METHODS

In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years.

RESULTS

A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05).

CONCLUSION

Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Urate-lowering therapy adherence and the association with medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concern in Chinese gout patients: a cross-sectional study

This study aims to assess urate-lowering therapy adherence and the relationship with medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concerns in Chinese gout patients during the COVID-19 outbreak. 101 gout patients receiving urate-lowering therapy were involved to evaluate adherence, medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concerns via a mobile app-based questionnaire. Statistical analysis was performed using SPSS 22.0. A total of 101 valid responses were included in the statistical analysis. The results showed that, the rate of adherence to urate-lowering therapy during the COVID-19 outbreak was 22.8% in Chinese patients with gout, higher than that in normal times (9.6%). Compared to the adherent group, non-adherent gout patients had shorter disease duration, lower self-efficacy, lower necessity about urate-lowering therapy score, higher concerns about urate-lowering therapy score, and smaller necessity-concerns differential. Depression and anxiety rates (3.0% and 5.0%, respectively) during the COVID-19 break were lower than that in normal times. Additionally, depression, anxiety, as well as COVID-19 pandemic-related concerns (27.7%) were not related to urate-lowering therapy adherence. In conclusion, adherence rate to urate-lowering therapy in Chinese gout patients during the COVID-19 outbreak was 22.8%, higher than normal times, but still very poor. Except for a little concern about being more susceptible to the virus, patients' mental state is relatively good. While the country puts great efforts into COVID-19 prevention and control, attention must also be paid to the medication management of patients with chronic diseases such as gout.

Gender differences in illness perceptions and disease management in patients with gout, results from a questionnaire study in Western Sweden

BACKGROUND

Aims were to examine gender differences in patients with gout with regard to a) self-reported gout severity, b) illness perceptions (IP), c) impact on daily activities and Quality of Life (QoL), d) advice from healthcare professionals, e) having changed dietary- or alcohol habits.

METHODS

Adult patients with gout identified in primary and secondary care in Sweden between 2015 and 2017 (n = 1589) were sent a questionnaire about demographics, gout disease severity, IP (using the Brief Illness Perception Questionnaire, (B-IPQ)) and disease management. T-tests, Chi square tests, ANalysis Of VAriance (ANOVA) and linear regression models were used for gender comparisons.

RESULTS

Eight hundred sixty-eight patients responded to the questionnaire. Women, n = 177 (20%), experienced more severe gout symptoms (p = 0.011), albeit similar frequencies of flares compared to men. Women experienced modest but significantly worse IP with regard to consequences, identity, concerns and emotional response (p < 0.05) as well as daily activities such as sleeping (p < 0.001) and walking (p = 0.042) and QoL (p = 0.004). Despite this and a higher frequency of obesity in women (38 vs 21%, P < 0.001) and alcohol consumption in men (p < 0.001), obese women had received significantly less advice regarding weight reduction (47 vs 65%, p = 0.041) compared to obese men. On the other hand, women reported having acted on dietary advice to a larger degree.

CONCLUSIONS

Despite only modestly worse gout severity and perception, women appear to have been given less information regarding self-management than men. These gender differences should be given attention and addressed in clinical care.

Why do patients with gout not take allopurinol?

Objective

The objectives of this study were to examine the reasons patients give for non-adherence to allopurinol and examine differences in intentional non-adherence for patients with and without serum urate at treatment target.

Methods

Sixty-nine men with gout attending rheumatology clinics, all prescribed allopurinol for at least six months, completed the Intentional Non-Adherence Scale (INAS). Differences in the types of intentional non-adherence were analysed between those with and without a serum urate (SU) at treatment target (<0.36mmol/L, 6mg/dL).

Results

Among most frequently endorsed reasons for not taking their urate lowering medication was because participants wanted to lead a normal life (23%) or think of themselves as a healthy person again (20%). Patients also reported not taking allopurinol as way of testing if they really needed it (22%). Participants with SU above target endorsed significantly more INAS items as reasons for not taking their medicine, had higher medicine-related concerns and were more likely to give testing treatment as a reason for non-adherence. Participants who were younger, single and non-NZ European also endorsed more reasons for not taking their allopurinol.

Conclusion

Major reasons behind the decision not to take allopurinol relate to wanting to lead a normal life and the strategy of testing treatment to see if patients could reduce the dose without getting symptoms. The results provide some potentially modifiable targets for adherence interventions and also some indications to clinicians about how urate-lowering treatment may be purposely framed for patients in order to improve adherence.

Illness perception and treatment experience in patients with gout: a descriptive qualitative study

OBJECTIVE

To explore the illness perception and treatment experience of gout patients in China.

METHODS

A descriptive qualitative approach was used. In-depth semi-structured individual interviews were conducted among 18 adults with gout between August 2020 and December 2020. The Common-Sense Model of Self-Regulation was used as the conceptual framework for developing interview guide and data analysis. Interviews were audio recorded, transcribed, independently coded, and analyzed for themes.

RESULTS

The 18 gout patients aged 23-77 years old, with 16 being male. Four themes were generated to reflect the experience of patients with gout: limited knowledge of gout, various but inadequate sources of gout knowledge, multifaceted influences of gout, and seeking for diversified disease treatment methods.

CONCLUSION

There is a gap between patients' anticipation and practical service that is closely linked with subsequent poor gout management among the participants. The findings indicate a need of strengthening health education about gout by considering building nurse-led support groups and developing mobile health applications, as well as addressing the long-term influence of the Chinese alcoholic drinking culture to promote patients' effective disease management.

KEY POINTS

• This qualitative study fills a knowledge gap on illness perception and treatment experience among Chinese gout patients, exploring how these patients perceived gout and manage gout. • The gout patients in this study reported disparity between personal anticipation and healthcare service that largely contributes to their poor gout management. • The Chinese alcoholic drinking culture embedded in personal, professional, and social activities posed extra difficulties and challenges on modifying lifestyle for gout patients that needs to be addressed for promoting gout management among this group.

A patient-centered gout information value chain: a scoping review

OBJECTIVE

To examine and identify the scope of research addressing health information requirements for gout patients using value chain analysis.

METHODS

Five electronic databases (PubMed, CINAHL, ERIC, PsycINFO, Embase, and Scopus) and grey literature (WorldCat) were searched in accordance with a published protocol. Only English language articles were included, with no limitations for date of publication. The findings of the 33 studies included for final analysis were subsequently divided into 6 groups according to the stages of the care delivery value chain their research most closely pertained to: screening/preventing (n = 2), diagnosing (n = 1), preparing (n = 7), intervening (n = 11), recovering/rehabilitating (n = 5), and monitoring/managing (n = 13).

RESULTS

The 33 studies focused on one or more of the following information phenotypes: 1) pathophysiology; 2) medical treatment; and 3) nonpharmaceutical interventions. Long term treatment adherence was a popular topic amongst studies that focused on gout patient education.

CONCLUSION

Based on the identified studies, gout patients are being told what to do, but are not being adequately educated regarding why recommended interventions are important or how to accomplish them.

PRACTICE IMPLICATIONS

This review provides a foundation to develop and evaluate personalized education materials using value chain analysis.

SToRytelling to Improve Disease outcomes in Gout (STRIDE-GO): a multicenter, randomized controlled trial in African American veterans with gout

BACKGROUND

Urate-lowering therapy (ULT) adherence is low in gout, and few, if any, effective, low-cost, interventions are available. Our objective was to assess if a culturally appropriate gout-storytelling intervention is superior to an attention control for improving gout outcomes in African-Americans (AAs).

METHODS

In a 1-year, multicenter, randomized controlled trial, AA veterans with gout were randomized to gout-storytelling intervention vs. a stress reduction video (attention control group; 1:1 ratio). The primary outcome was ULT adherence measured with MEMSCap™, an electronic monitoring system that objectively measured ULT medication adherence.

RESULTS

The 306 male AA veterans with gout who met the eligibility criteria were randomized to the gout-storytelling intervention (n = 152) or stress reduction video (n = 154); 261/306 (85%) completed the 1-year study. The mean age was 64 years, body mass index was 33 kg/m2, and gout disease duration was 3 years. ULT adherence was similar in the intervention vs. control groups: 3 months, 73% versus 70%; 6 months, 69% versus 69%; 9 months, 66% versus 67%; and 12 months, 61% versus 64% (p > 0.05 each). Secondary outcomes (gout flares, serum urate and gout-specific health-related quality of life [HRQOL]) in the intervention versus control groups were similar at all time points except intervention group outcomes were better for the following: (1) number of gout flares at 9 months were fewer, 0.7 versus 1.3 in the previous month (p = 0.03); (2) lower/better scores on two gout specific HRQOL subscales: gout medication side effects at 3 months, 32.8 vs. 39.6 (p = 0.02); and unmet gout treatment need at 3 months, 30.9 vs. 38.2 (p = 0.003), and 6 months, 29.5 vs. 34.5 (p = 0.03), respectively.

CONCLUSIONS

A culturally appropriate gout-storytelling intervention was not superior to attention control for improving gout outcomes in AAs with gout.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov NCT02741700.

An enquiry into the crippling gout affecting Pacific Islander and Māori men in Western Sydney

AIM

Despite the effectiveness and availability of urate-lowering therapies (ULT), we continue to see a number of advanced cases of tophaceous gout in the Pacific Islander and Māori population in Western Sydney. Although the high prevalence and increased severity of gout in this cohort has been well documented, there has been little qualitative research undertaken in Australia into the lived experience of this group of people. It is this gap in the research that our study aimed to address.

METHODS

Participants were recruited from the rheumatology clinics at Westmead and Blacktown Hospitals. Those eligible to participate were Pacific Islander and Māori patients with tophaceous gout currently living in the Western Sydney Local Health District (WSLHD). Data collection took the form of 10 semi-structured interviews, which were subsequently transcribed verbatim. A thematic analysis of the data was then performed.

RESULTS

Thematic analysis identified 6 key themes: lack of understanding of the disease and its potential effects; missed opportunities for intervention and disjointed care; chronic reliance upon corticosteroids; trivialization of gout as a nuisance illness; the substantial financial impact of chronic illness; and the all-consuming nature of severe gout.

CONCLUSION

The human cost of severe tophaceous gout in this cohort is immense. All 10 participants exemplified the disease's devastating social effects. We propose 4 key recommendations: improved education regarding diagnosis and management; immediate prescription of ULT at first presentation; a lower threshold for out-of-hospital rheumatologist referral; and improved follow-up through a nurse- and pharmacist-led collaborative gout management program.

Patient Perspectives and Preferences Regarding Gout and Gout Management: Impact on Adherence

BACKGROUND

Patient-centered management is becoming increasingly important in gout, but there are limited studies exploring patients' perspectives and preferences. We aimed to investigate patients' perspectives and preferences regarding gout and gout management, and their impacts on adherence to urate lowering therapy (ULT).

METHODS

A paper-based survey was performed in patients with gout seen at the rheumatology outpatient clinics of 16 tertiary hospitals. The survey included questions regarding demographics, comorbidities, gout attacks, current treatment and adherence, and patients' perspectives and preferences regarding gout and gout management. Multivariate regression analysis was performed to determine the factors associated with ULT adherence.

RESULTS

Of 809 surveyed patients with gout, 755 (94.5%) were using ULT. Among those using ULT, 89.1% had ≥ 80% adherence to ULT. Majority of the patients knew management strategies to some extent (94.8%), perceived gout as a life-long disease (91.2%), and were making efforts toward practicing at least one lifestyle modification (89.2%). Most patients (71.9%) obtained information about gout management during their clinic visits. Approximately half of the patients (53.6%) preferred managing their disease with both ULT and lifestyle modification, 28.4% preferred ULT only, and 17.4% preferred lifestyle modification only. Adherence was better in patients with older age (odds ratio [OR], 1.03), those with better knowledge of gout management strategies (OR, 3.56), and those who had preference for ULT (OR, 2.07).

CONCLUSION

Patients' perspectives and management preferences had high impacts on adherence to ULT in gout. Consideration of patients' perspectives and preferences is important for achieving the desired clinical outcome in gout.

Patient-Centered Outcomes and Key Study Procedure Finalization in the Pilot Feasibility Gout Randomized Trial: Comparative Feasibility Study in GOUt, CHerry Extract Versus Diet Modification (Mini-GOUCH)

OBJECTIVE

The aim of this study was to report patient-centered outcomes and finalization of key study procedures from a 9-month pilot internet randomized controlled trial of cherry extract versus diet modification.

METHODS

We randomized 84 people with physician-confirmed gout in an internet study to cherry extract (n = 41) or dietitian-assisted diet modification for gout (n = 43). All study outcomes were collected via internet and phone calls. We finalized key study procedures. We assessed acceptability and feasibility of the intervention and satisfaction with study website.

RESULTS

Study participant satisfaction with the intervention was high. The intervention was perceived as easy, enjoyable, understandable, and helpful (scores 65-88 for all; higher = better). The amount of time spent for the study was acceptable. Participant satisfaction with website interaction and content was very high; 85% or more were moderately to extremely satisfied. Significantly lower total calories, total carbohydrate, and saturated fat intake were noted at 6 months in the diet modification versus cherry extract group; differences were insignificant at 9 months. Six of the 8 Health Assessment Questionnaire sections/domains improved significantly from baseline to 9 months in cherry extract versus 2 Health Assessment Questionnaire sections/domains in the diet modification group. Key study procedures were finalized for a future trial, including an internet diet assessment tool, gout flare assessment, provider confirmation of gout diagnosis, patient reporting of classification criteria, and centralized laboratory-assisted serum urate testing.

CONCLUSIONS

High patient acceptability and feasibility of study/intervention and finalization of key study procedures indicate that hypothesis-testing internet gout trials of cherry extract and/or diet modification can be conducted in the future.

Markers of disease severity and positive family history are associated to significant risk perception in rheumatoid arthritis, while compliance with therapy is not: a cross-sectional study in 415 Mexican outpatients

BACKGROUND

Assessing risk perception (RP) helps explain how rheumatoid arthritis (RA) patients integrate their ideas concerning the disease and how this understanding affects their self-care management. Compliance with treatment impacts disease-related outcomes and could be associated with RP to variable degrees and at different levels. The primary objective was to determine a potential association between RP and compliance with therapy in RA outpatients and to identify additional factors. The secondary objective was to identify factors associated with judgment bias such as unrealistic RP.

PATIENTS AND METHODS

Between January 2018 and June 2019, 450 consecutive outpatients who received RA-related treatment were invited to a face-to-face interview to obtain socio-demographic data, RA-related information, comorbidities, and the following outcomes: adherence, persistence, and concordance with medications assessed with a questionnaire locally designed; RP with the RP questionnaire (RPQ); disease activity with the Routine Assessment of Patient Index Data-3 (RAPID-3); disability with the Health Assessment Questionnaire Disability Index (HAQ-DI); quality of life with Medical Outcomes Study Short Form-36 (SF-36) instrument; pain and overall disease with the respective visual analogue scale (VAS); and health literacy assessed with 3 questions. Significant RP was defined according to a cut-off based on the 75th percentile value of the sample in which the RPQ was validated. Unrealistic RP was defined based on the coincidence of the presence/absence of significant RP and less/more than 7 unfavorable medical criteria. Multiple logistic regression analysis was used. Patients provided written informed consent and the study received Internal Review Board approval.

RESULTS

There were 415 patients included, primarily middle-aged women with long-standing disease and moderate disease activity. Almost half of the patients were receiving corticosteroids and 15.9% intensive RA-related treatment. There were 44.1% of the patients concordant with treatment and 22.6% had significant RP. The patients' treatment behavior was not retained in the regression analysis; meanwhile, rheumatoid nodes, surgical joint replacement, family history of RA, and higher RAPID-3 score were associated with significant RP. There were 56 patients with unrealistic RP; significant RP and more unfavorable medical criteria were associated with unrealistic RP.

CONCLUSIONS

Compliance with therapy was not associated with significant RP in RA outpatients.

Which factors predict discordance between a patient and physician on a gout flare?

OBJECTIVE

To investigate the factors associated with discordance between patient and physician on the presence of a gout flare.

METHODS

Patients' self-reports of current gout flares were assessed with the question, 'Are you having a gout flare today?' which was then compared with a concurrent, blinded, physician's assessment. Based on agreement or disagreement with physicians on the presence of a gout flare, flares were divided into concordant and discordant groups, respectively. Within the discordant group, two subgroups-patient-reported flare but the physician disagreed and physician-reported flare but the patient disagreed-were identified. The factors associated with discordance were analysed with multivariable logistic regression analysis.

RESULTS

Of 268 gout flares, 81 (30.2%) flares were discordant, with either patient or physician disagreeing on the presence of a flare. Of the discordant flares, in 57 (70.4%) the patient reported a flare but the physician disagreed. In multivariable logistic regression analysis adjusted for demographics, disagreement among patients and physicians on the presence of a gout flare was associated with lower pain scores at rest [odds ratio (OR) for each point increase on 0-10 point pain scale 0.81 (95% Wald CI 0.73, 0.90), P < 0.0001] and less presence of joint swelling [OR 0.24 (95% CI 0.10, 0.61), P = 0.003] or joint warmth [OR 0.39 (95% CI 0.20, 0.75), P = 0.005].

CONCLUSION

Although patients and physicians generally agree about the presence of gout flare, discordance may occur in the setting of low pain scores and in the absence of swollen or warm joints.

Shared decision-making in gout treatment: a national study of rheumatology provider opinion and practice

To assess rheumatologists' views and practices related to shared decision-making (SDM) in gout treatment. We performed a cross-sectional electronic survey of rheumatologists at U.S. Veterans Affairs (VA) medical centers, assessing views and practices related to SDM in gout. Of the 154 VA rheumatology providers eligible, 90 responded (response rate, 58%). Fifty-eight percent were female, the mean age was 51 years (standard deviation, 9.6), 42% had > 20 years of experience in medical practice. Rheumatologists reported routinely offering a choice to their patients for (1) starting urate-lowering therapy (ULT) for gout vs. doing nothing (70%); (2) choosing NSAIDs, corticosteroids, or colchicine for the treatment of acute flares (67%); and (3) choosing NSAIDs, corticosteroids, or colchicine for anti-inflammatory prophylaxis when starting ULT (51%). Very few rheumatologists offered choice regarding (4) choosing allopurinol vs. febuxostat as the first ULT (16%) and (5) taking daily ULT long-term vs. intermittently (15%). Rheumatologists perceived that a large proportion of patients were often or sometimes unsure of the best choice for these five decisions, 34%, 76%, 76%, 52%, and 54%, respectively. Similar proportions of rheumatologists felt that patients were uninformed about both medication benefits and risks, unclear about the personal importance of the benefits and risks, and unsupported in decision-making. For the five decisions respectively, rheumatologists supported SDM with patients in 76%, 56%, 58%, 27%, and 25%. The majority of VA rheumatologists incorporated SDM in several gout treatment decisions. Rheumatologists also recognized that patients need better support to participate in SDM in gout. Key Points: • Rheumatologists offered shared decision-making to gout patients for 3 key treatment decisions. • Rheumatologists perceived that many patients were unsure of the best choice for these decisions. • Rheumatologists felt that patients were uninformed about medication benefits/risks and unsupported in decision-making.

"An apple pie a day does not keep the doctor away": Fictional depictions of gout in contemporary film and television

Background

Fictional portrayals of illness and medical management in film and television can reflect and perpetuate cultural stereotypes about illness. The aim of this study was to analyse fictional depictions of gout in contemporary film and television.

Methods

We conducted a search for English language depictions of gout in film and television since 1990 using the Internet Movie Database (IMDb), other internet media databases, and member suggestions from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). Film and television episodes with gout content were analysed for depictions of characters with gout, causal factors, and management strategies (n=44).

Results

Gout was used to denote royalty or nobility in historical settings, and as a plot device to explain the absence of characters from key events. The most commonly depicted causes of gout were overindulgence of food and alcohol (61%), and portrayals of biological causes were infrequent (12%). Common management strategies were change in diet (36%) and short-term pain relief (32%), with only one mention of urate-lowering therapy (5%). The majority of films and television episodes depicted gout as humorous (59%) and embarrassing (50%).

Conclusions

In contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-020-00174-z.

The comparative effect of exposure to various risk factors on the risk of hyperuricaemia: diet has a weak causal effect

BACKGROUND

Prevention of hyperuricaemia (HU) is critical to the prevention of gout. Understanding causal relationships and relative contributions of various risk factors to hyperuricemia is therefore important in the prevention of gout. Here, we use attributable fraction to compare the relative contribution of genetic, dietary, urate-lowering therapy (ULT) and other exposures to HU. We use Mendelian randomisation to test for the causality of diet in urate levels.

METHODS

Four European-ancestry sample sets, three from the general population (n = 419,060) and one of people with gout (n = 6781) were derived from the Database of Genotypes and Phenotypes (ARIC, FHS, CARDIA, CHS) and UK Biobank. Dichotomised exposures to diet, genetic risk variants, BMI, alcohol, diuretic treatment, sex and age were used to calculate adjusted population and average attributable fractions (PAF/AAF) for HU (≥0.42 mmol/L [≥7 mg/dL]). Exposure to ULT was also assessed in the gout cohort. Two sample Mendelian randomisation was done in the UK Biobank using dietary pattern-associated genetic variants as exposure and serum urate levels as outcome.

RESULTS

Adherence to dietary recommendations, BMI (< 25 kg/m²), and absence of the SLC2A9 rs12498742 urate-raising allele produced PAFs for HU of 20 to 24%, 59 to 69%, and 57 to 64%, respectively, in the three non-gout cohorts. In the gout cohort, diet, BMI, SLC2A9 rs12498742 and ULT PAFs for HU were 12%, 49%, 48%, and 63%, respectively. Mendelian randomisation demonstrated weak causal effects of four dietary habits on serum urate levels (e.g. preferentially drinking skim milk increased urate, β = 0.047 mmol/L, P = 3.78 × 10^-8). These effects were mediated by BMI, and they were not significant (P ≥ 0.06) in multivariable models assessing the BMI-independent effect of diet on urate.

CONCLUSIONS

Diet has a relatively minor role in determining serum urate levels and HU. In gout, the use of ULT was the largest attributable fraction tested for HU.

Gout flare severity from the patient perspective: a qualitative interview study

OBJECTIVE

The patient experience of a gout flare is multi-dimensional. To establish the most appropriate methods of flare measurement, there is a need to understand the complete experience of a flare. This qualitative study aimed to examine what factors contribute to the severity of a flare from the patient perspective.

METHODS

Face-to-face interviews were conducted with people with gout. Participants were asked to share their experience with their worst gout flare and contrast it to their experience of a less severe or mild flare. Interviews were audio-recorded and transcribed verbatim. Data was analysed using a reflexive thematic approach.

RESULTS

Twenty-two participants with gout (17 males, mean age 66.5 years) were interviewed at an academic centre in Auckland, New Zealand. Four key themes were identified as contributing to the severity of a flare: flare characteristics (pain intensity, joint swelling, redness and warmth, duration, and location), impact on function (including walking, activities of daily living, wearing footwear, and sleep), impact on family and social life (dependency on others, social connection, and work) and psychological impact (depression, anxiety, irritability, and sense of control).

CONCLUSION

A wide range of interconnecting factors contribute to the severity of a gout flare from the patient perspective. Capturing these domains in long-term gout studies would provide more meaningful and accurate representation of cumulative flare burden.

Rebranding Gout: Could a Name Change for Gout Improve Adherence to Urate-Lowering Therapy?

Gout is the most common form of inflammatory arthritis in men, yet both patients and the public often do not recognise gout as a form of arthritis. Instead, due to historical misconceptions, gout is typically seen as a lifestyle disease caused by poor diet. In reality, there are a number of risk factors that contribute to gout, including genetic factors. Views of gout as precipitated by lifestyle alone can lead to stigma, and maladaptive beliefs that it should be treated primarily through dietary changes. This is thought to contribute to poor uptake of, and adherence to, effective pharmaceutical treatments. Gout has some of the poorest medication adherence rates of any chronic disease, contributing to suboptimal health outcomes for patients. Recent research suggests that when gout is referred to as 'urate crystal arthritis' (a rarely used name for gout), the perception of the disease by members of the public was more accurate. It was viewed as being less under personal control (i.e. less appropriately managed by behaviours such as dietary intake), and more appropriately managed by long-term medical treatment. This finding raises the possibility that patients themselves might also benefit from gout being explicitly labelled as arthritis. Indeed, parallels can be drawn between this case and other diseases that have recently had their names changed to improve outcomes, namely primary biliary cirrhosis and schizophrenia. A movement away from the term gout may benefit those living with the disease by changing illness perceptions and increasing uptake of, and adherence to, guideline-recommended treatment(s).

Longitudinal evaluation of the effects of illness perceptions and beliefs about cardiac rehabilitation on quality of life of patients with coronary artery disease and their caregivers

BACKGROUND

Patients' negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients' and caregivers' perceptions of the patient's illness and beliefs about CR at baseline predict their own and their partner's quality of life at 6 months.

METHODS

In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient's illness and CR. The Short-Form 12 Health Survey was used to assess patients' and caregivers' perceived health status. Dyadic data were analysed using the Actor-Partner Interdependence Model.

RESULTS

Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient's illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers' poorer mental health at 6 months was predicted by the patient's perceptions of timeline and illness concern (i.e. partner effects). Patient's and caregiver's illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects).

CONCLUSIONS

Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes).

Distinct Distress Symptom Trajectories Over 3 Years Are Associated With Baseline Illness Perceptions in Individuals With Coronary Heart Disease

BACKGROUND

Depression and anxiety symptoms (termed distress) are common among coronary heart disease (CHD) patients and associated with poor outcomes. Illness perceptions predict distinct outcome trajectories in other long-term conditions, yet it is not known how they relate to distress trajectories in CHD.

PURPOSE

This study aimed to examine whether baseline illness perceptions are associated with distress symptom trajectories among primary care CHD patients.

METHODS

This is a secondary analysis of 803 CHD patients from the UPBEAT-UK study, who completed the Hospital Anxiety and Depression Scale every 6 months for 3 years. Baseline assessments included the Brief Illness Perception Questionnaire. Using latent class growth analysis, Palacios et al. (2018) identified five distinct distress symptom trajectories ("stable low," "chronic high," "improving," "worsening," and "fluctuating") in this cohort. Adjusted multinomial logistic regression analyses were used to test the association between baseline illness perceptions and distress symptom trajectories.

RESULTS

Compared with the stable low distress trajectory, stronger illness identity (odds ratio [OR] = 1.31, p < .01), higher perceived consequences (OR = 1.47, p < .01), illness-related emotion (OR = 1.66, p < .01), and illness concerns (OR = 1.36, p < .01) increased the odds of having chronic high distress. Stronger illness coherence (OR = 0.89, p < .05) and personal (OR = 0.77, p < .01) and treatment control (OR = 0.75, p < .01) reduced the odds of chronic high distress. Worsening distress symptoms were associated with weaker perceptions of treatment control, higher perceived consequences, and greater illness-related concerns and emotions.

CONCLUSIONS

Illness perceptions of CHD are associated with distress symptom trajectories. Therapeutically modifying unhelpful illness perceptions in CHD patients who experience high levels of distress could potentially improve mental health outcomes.

The impact of the illness label 'gout' on illness and treatment perceptions in Māori (Indigenous New Zealanders)

Background

Despite contemporary advances in understanding pathogenesis and effective management of gout, beliefs about the disease continue to be focused on gout as a self-inflicted illness. The illness label itself may contribute to inaccurate perceptions of the disease and its management. In Aotearoa/New Zealand, Māori (Indigenous New Zealanders) have high prevalence of severe gout. The aim of this study was to examine the impact of the illness label ‘gout’ on perceptions of the disease and its management for Māori.

Methods

Māori supermarket shoppers (n = 172) in rural and urban locations were recruited into a study examining the perceptions about arthritis. Participants were randomised 1:1 to complete a questionnaire examining the perceptions of the same illness description labelled as either ‘gout’ or ‘urate crystal arthritis’. Differences between the two illness labels were tested using independent sample t-tests.

Results

‘Gout’ was most likely to be viewed as caused by diet, whereas ‘urate crystal arthritis’ was most likely to be viewed as caused by aging. ‘Urate crystal arthritis’ was seen as having a wider range of factors responsible for the illness, including stress or worry, hereditary factors and chance. ‘Gout’ was less likely to be viewed as having a chronic timeline, and was perceived as being better understood. Dietary management strategies were seen as more helpful for management of the gout-labelled illness.

Conclusions

This study has demonstrated that for Māori, Indigenous New Zealanders who are disproportionately affected by gout, the illness label influences perceptions about gout and beliefs about management.

Patient perspectives in gout: a review

PURPOSE OF REVIEW

Recent studies have produced evidence regarding the patient perspectives in gout including from disease experience to disease outcomes. Therefore, an overview on the topic can help improve our understanding of the patient experience.

RECENT FINDINGS

This article explores several aspects of the patient perspective including the impact of gout on a patient's life, patient knowledge and beliefs regarding gout and its treatments, patient-perceived barriers to optimal medication adherence in gout and patient's perception of their gout. This article also summarizes any evidence of the association of patient perceptions to patient outcomes in gout.

SUMMARY

A recognition of patient perspectives in gout has the potential to positively impact clinical care for gout. Discussion of disease impact, misperceptions about benefits/harms of urate-lowering therapy (ULT), and patient values/preferences regarding pharmacological and nonpharmacological treatments can lead to a better shared decision-making and improved outcomes in gout. These findings emphasize the importance of inclusion of patient perspective not only in clinical care and quality improvement and research initiatives but also in the design and implementation of the research agenda in gout. Inclusion of patient-reported outcomes in clinical research is likely to improve its relevance to patients with gout.

Self-Reported Medication Adherence in Patients With Ankylosing Spondylitis: The Role of Illness Perception and Medication Beliefs

Objectives

This study aims to investigate medication adherence in Turkish patients with ankylosing spondylitis (AS) and analyze the related factors for non-adherence.

Patients and methods

Ninety-nine patients with AS (60 males, 39 females; mean age 41.3±8.4 years; range, 18 to 66 years) were included in the study. Sociodemographic and clinical data were collected. Disease activity (Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein, and erythrocyte sedimentation rate), functional status (Bath Ankylosing Spondylitis Functional Index), spinal pain and fatigue (visual analog scale), quality of life (Ankylosing Spondylitis Quality of Life), and depression and anxiety (Hospital Anxiety and Depression Scale) were evaluated. Adherence to anti-rheumatic drugs was elicited using the Compliance Questionnaire on Rheumatology (CQR). Medication beliefs were assessed using the Beliefs about Medicines Questionnaire (BMQ), and illness perception using the Brief Illness Perception Questionnaire (B-IPQ).

Results

Non-adherence was reported in 64 patients (64.6%). No significant relationship between demographic, clinical, or psychological factors and adherence was found, except for disease duration (p=0.031). High B-IPQ treatment follow-up, illness coherence, and BMQ-Specific necessity scores were associated with good adherence (p=0.007, p=0.039, and p=0.002, respectively). BMQ-General overuse and harm scores showed an inverse correlation with the CQR score (p=0.005 r=-0.278; p=0.029 r=-0.219, respectively). Longer disease duration [odds ratio (OR): 0.98, 95% confidence interval (CI): 0.97-0.99] and higher B-IPQ item-1 score regarding the effect of the illness on the individual's life (OR: 0.58, 95% CI: 0.42- 0.81) were important predictors of low adherence.

Conclusion

Nearly three out of five AS patients were identified as at risk for non-adherence with the CQR. Medication adherence is influenced by the patient’s beliefs about medicines and illness perceptions, and these may be key targets for future interventions to improve medication adherence.

Illness Perceptions in Chronic Lymphocytic Leukemia: Testing Leventhal's Self-regulatory Model

BACKGROUND

Leventhal's Self-regulatory Model proposes that somatic characteristics of a health threat (e.g., symptom severity), and prior experience with the threat (e.g., unsuccessful treatment), are determinants of illness perceptions. Chronic lymphocytic leukemia (CLL) is appropriate for test of these postulates, having three phases differing in symptom severity and prior treatment experiences: indolent disease requiring no treatment (active surveillance; AS), symptomatic disease requiring a first treatment (FT), and highly symptomatic disease in those who have relapsed and/or failed to respond to prior treatments (relapsed/refractory; RR).

PURPOSE

To test symptom severity and prior treatment experiences as determinants of illness perceptions, illness perceptions were characterized and contrasted between CLL groups.

METHODS

Three hundred and thirty CLL patients (AS, n = 100; FT, n = 78; RR, n = 152) provided illness perception data on one occasion during a surveillance visit (AS) or prior to beginning treatment (FT, RR).

RESULTS

Analysis of variance with planned comparisons revealed that consequences, identity, and concern were least favorable among RR patients, followed by FT, then AS (ps < .01). AS patients endorsed the lowest levels of coherence (ps < .01), and the most chronic illness timeline (ps < .01). FT patients endorsed the highest levels of personal and treatment control (ps < .01).

CONCLUSIONS

Data provide preliminary empirical support for Self-regulatory Model postulates that symptom severity and prior disease experiences influence illness perceptions. Unique knowledge needs for AS patients and elevated psychological/physical symptoms for later-stage CLL patients may warrant clinical attention.

Association Between User Engagement of a Mobile Health App for Gout and Improvements in Self-Care Behaviors: Randomized Controlled Trial

Background

Mobile health (mHealth) apps represent a promising approach for improving health outcomes in patients with chronic illness, but surprisingly few mHealth interventions have investigated the association between user engagement and health outcomes. We aimed to examine the efficacy of a recommended, commercially available gout self-management app for improving self-care behaviors and to assess self-reported user engagement of the app in a sample of adults with gout.

Objective

Our objective was to examine differences in self-reported user engagement between a recommended gout app (treatment group) and a dietary app (active control group) over 2 weeks as well as to examine any differences in self-care behaviors and illness perceptions.

Methods

Seventy-two adults with gout were recruited from the community and three primary and secondary clinics. Participants were randomized to use either Gout Central (n=36), a self-management app, or the Dietary Approaches to Stop Hypertension Diet Plan (n=36), an app based on a diet developed for hypertension, for 2 weeks. The user version of the Mobile Application Rating Scale (uMARS, scale: 1 to 5) was used after the 2 weeks to assess self-reported user engagement, which included an open-ended question. Participants also completed a self-report questionnaire on self-care behaviors (scale: 1-5 for medication adherence and diet and 0-7 for exercise) and illness perceptions (scale: 0-10) at baseline and after the 2-week trial. Independent samples t tests and analysis of covariance were used to examine differences between groups at baseline and postintervention.

Results

Participants rated the gout app as more engaging (mean difference –0.58, 95% CI –0.96 to –0.21) and more informative (mean difference –0.34, 95% CI –0.67 to –0.01) than the dietary app at the 2-week follow-up. The gout app group also reported a higher awareness of the importance of gout (mean difference –0.64, 95% CI –1.27 to –0.003) and higher knowledge/understanding of gout (mean difference –0.70, 95% CI –1.30 to –0.09) than the diet app group at follow-up. There were no significant differences in self-care behaviors between the two groups postintervention. The gout app group also demonstrated stronger negative beliefs regarding the impact of gout (mean difference –2.43, 95% CI –3.68 to –1.18), stronger beliefs regarding the severity of symptoms (mean difference –1.97, 95% CI –3.12 to –0.82), and a stronger emotional response to gout (mean difference –2.38, 95% CI –3.85 to –0.90) at follow-up. Participant feedback highlighted the importance of tracking health-related information, customizing to the target group/individual, providing more interactive features, and simplifying information.

Conclusions

Participants found the commercially available gout app more engaging. However, these findings did not translate into differences in self-care behaviors. The gout app group also demonstrated stronger negative illness perceptions at the follow-up. Overall, these findings suggest that the development of gout apps would benefit from a user-centered approach with a focus on daily, long-term self-care behaviors as well as modifying illness beliefs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12617001052325; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373217.

Illness perceptions and their association with 2 year functional status and change in patients with hand osteoarthritis

Objective

To investigate the association between illness perceptions and disability both cross-sectionally and over 2 years in patients with hand OA.

Methods

Illness perceptions and self-reported disability were assessed at baseline and after 2 years in 384 patients with primary hand OA (mean age 61 years, 84% women, n = 312 with follow-up) with the Illness Perception Questionnaire - Revised (IPQ-R), Functional Index for Hand OA, Australian/Canadian Hand OA Index and HAQ. Risk ratios for high disability (highest quartile) at both time points were estimated for tertiles of IPQ-R dimensions, using Poisson regression. The mean IPQ dimension change difference between patients with and without disability progression (change Functional Index for Hand OA ⩾ 1, Australian/Canadian Hand OA Index > 1.4, HAQ > 0.22) was estimated with linear regression. Analyses were adjusted for age, Doyle index and baseline score.

Results

At baseline, stronger negative illness perceptions were associated with high disability. Baseline illness perceptions were also associated with high disability after 2 years, although adjustment made apparent that these associations were confounded by baseline disability status. Most illness perceptions changed over 2 years; understanding increased, OA was regarded as more chronic and fewer emotions and consequences and less personal and treatment control were experienced. The 2 year change in disability was different between patients with and without progression for the illness perceptions of more perceived consequences, symptoms, treatment control and emotions.

Conclusion

Illness perceptions seemed to be implicated in disability and its progression. Our results suggest that interventions could focus on improving baseline disability, potentially using illness perceptions to accomplish this goal.

The clinically crucial predictors of depression in women with systemic autoimmune diseases

The researchers' aim of this study was to identify and quantify the useful, clinically crucial predictors of depression in Taiwanese women with systemic autoimmune diseases (SADs). We used a cross-sectional method. A total of 241 Taiwanese women with SADs between 21 and 85 years of age participated in the study. Analysis revealed that the strongest predictors of depression in participants were: perceived stress, fatigue, mental health, physical health, chronic-disease-related comorbidities, self-perceived SAD severity, and social support. The model used in the present study explained 70.9% of the variance in the depression.

Does seeing personal medical images change beliefs about illness and treatment in people with gout? A randomised controlled trial

Objective: To explore the effects of an educational intervention with embedded personal medical images on illness perceptions, medication beliefs and treatment understanding in patients with gout. Design: Sixty people with gout were recruited into the study with three arms. The participants viewed a 12-min presentation about gout with either personalised medical scans, generic scans or medical illustrations from a standard educational booklet on gout. Main Outcome Measures: Illness perceptions about gout and beliefs about treatment for gout were assessed at baseline and immediately after the intervention. Results: There were no significant time by group interaction effects. All groups showed an increase in treatment control beliefs (p = .002), medication necessity (p < .001), improved understanding of medicines for gout (p < .001) and reduced their perceived gout stigma (p = .004). The personalised intervention was rated as more interesting compared to one with medical illustrations (p = .026). Personal scans were found more helpful than generic scans (p = .023) and medical illustrations (p = .048). Conclusion: The brief educational intervention yielded positive changes in illness perceptions, medication beliefs and treatment understanding in all groups. Personal scans did not induce specific changes but made the information more interesting.

Implication of nurse intervention on engagement with urate-lowering drugs: A qualitative study of participants in a RCT of nurse led care

OBJECTIVES

To explore patient perception of the role of a nurse-led complex package of care in facilitating engagement with urate-lowering therapies (ULTs) in the management of gout.

METHODS

Thirty people who had participated in a randomised controlled trial investigating the effect of a nurse-led complex package of care for gout, were purposively sampled and interviewed between 18-26 months after the end of the trial. Interviews were recorded, transcribed and analysed using a modified grounded-theory approach. Data were managed using Nvivo. STATA v15 was used to describe summary statistics.

RESULTS

Participants described their views and experiences of engaging with a nurse-led intervention designed to provide holistic assessment, individualised patient education, and involvement in shared decision-making for the long-term management of gout. The analysis revealed key themes in how nurse-led intervention facilitated engagement with ULT, namely by proving improved knowledge and understanding of gout and its treatment, involvement of patients in decision-making about treatment, and increased confidence about benefits from treatment. However, some treatment uncertainty and concern remained and one participant free of gout flares discontinued ULT, while another halved the dose after the end of the trial.

CONCLUSIONS

This study reports data on patient experience of engaging with ULT to manage gout after receiving nurse-led care. It demonstrates that shared decision-making and the joint efforts of fully informed practitioners and patients persuades patients to engage with ULTs, and that experiencing the benefits of curative treatment motivates them to maintain adherence.

Evaluation of the diet wide contribution to serum urate levels: meta-analysis of population based cohorts

OBJECTIVE

To systematically test dietary components for association with serum urate levels and to evaluate the relative contributions of estimates of diet pattern and inherited genetic variants to population variance in serum urate levels.

DESIGN

Meta-analysis of cross sectional data from the United States.

DATA SOURCES

Five cohort studies.

REVIEW METHODS

16 760 individuals of European ancestry (8414 men and 8346 women) from the US were included in analyses. Eligible individuals were aged over 18, without kidney disease or gout, and not taking urate lowering or diuretic drugs. All participants had serum urate measurements, dietary survey data, information on potential confounders (sex, age, body mass index, average daily calorie intake, years of education, exercise levels, smoking status, and menopausal status), and genome wide genotypes. The main outcome measures were average serum urate levels and variance in serum urate levels. β values (95% confidence intervals) and Bonferroni corrected P values from multivariable linear regression analyses, along with regression partial R² values, were used to quantitate associations.

RESULTS

Seven foods were associated with raised serum urate levels (beer, liquor, wine, potato, poultry, soft drinks, and meat (beef, pork, or lamb)) and eight foods were associated with reduced serum urate levels (eggs, peanuts, cold cereal, skim milk, cheese, brown bread, margarine, and non-citrus fruits) in the male, female, or full cohorts. Three diet scores, constructed on the basis of healthy diet guidelines, were inversely associated with serum urate levels and a fourth, data driven diet pattern positively associated with raised serum urate levels, but each explained ≤0.3% of variance in serum urate. In comparison, 23.9% of variance in serum urate levels was explained by common, genome wide single nucleotide variation.

CONCLUSION

In contrast with genetic contributions, diet explains very little variation in serum urate levels in the general population.

The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients With Noncancer Musculoskeletal Pain: A Systematic Literature Review

BACKGROUND

In the literature, illness perceptions have been reported to be important psychological factors associated with pain intensity and physical function in individuals with musculoskeletal pain.

OBJECTIVE

To assess the relationship of illness perceptions with pain intensity and physical function in individuals with noncancer musculoskeletal pain.

METHODS

In this systematic review, relevant literature databases, including PubMed, Embase, PsycINFO, CINAHL, and SPORTDiscus, were searched from inception through December 12, 2017. Two authors (E.D.R. and H.W.) independently performed the search procedures, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the A MeaSurement Tool to Assess systematic Reviews guidelines, and the risk-of-bias assessment, using the QUality In Prognosis Studies tool. A qualitative best-evidence synthesis was performed.

RESULTS

A total of 26 articles were included in the review. There were 11 cross-sectional studies concerning associations of illness perceptions with pain intensity and 11 cross-sectional studies of associations of illness perceptions with physical function. For the prognosis of pain intensity by illness perceptions, the authors found 4 longitudinal studies, and for the prognosis of physical function by illness perceptions, the authors found 12 longitudinal studies. All studies except 1 had high risk of bias. Across 15 cross-sectional studies on 9 different musculoskeletal conditions, the researchers found limited to moderate evidence for a consistent direction of the relationship of illness perceptions with pain intensity and physical function. Higher maladaptive illness perceptions imply stronger pain intensity and more limitation in physical function. Evidence in longitudinal studies is lacking, especially on pain.

CONCLUSION

There is limited to moderate evidence for the cross-sectional relationship between illness perceptions and various musculoskeletal conditions. The prognostic value, however, remains unclear. Future research is recommended to investigate the longitudinal relationship between illness perception domains and outcomes in greater detail. J Orthop Sports Phys Ther 2018;48(10):789-800. Epub 10 May 2018. doi:10.2519/jospt.2018.8072.

Gout prevalence and predictors of urate-lowering therapy use: results from a population-based study

Background

Gout has an increasing global prevalence. Underutilization of urate-lowering therapy (ULT) is thought to be common, via both suboptimal dosing and poor medication adherence. The aims of this study were to determine the prevalence of self-reported gout and the key predictors of ULT use in those with gout in a representative population survey in South Australia.

Methods

Data were obtained from the Spring 2015 South Australian Health Omnibus Survey, a multilevel, systematic, survey in a representative population sample involving face-to-face interviews (n = 3005). This study analyzed responses from respondents aged ≥ 25 years (n = 2531) about self-reported gout, ULT use, sociodemographic factors, lifestyle factors, and comorbidities, using survey weighting. Univariate and subsequent adjusted logistic regression analyses on self-reported gout were performed. ULT use was divided into three categories (never use, prior use, and current use) and these data were analyzed using a multinomial logistic regression model.

Results

Self-reported gout prevalence was 6.8% (95% CI 5.8, 7.9). The mean age of respondents with gout was 64 years (standard deviation 16) and 82% were male. As expected, older age, male gender, lower socioeconomic status (SES), and higher body mass index (BMI) were associated with gout, as were high alcohol consumption, current smoking, other forms of arthritis, and hypertension or hypercholesterolemia medication, after adjustment for sociodemographic variables. Two thirds of respondents with gout reported ULT use (36% current; 29% previous) with only 55% continuing treatment. Predictors of ULT use included male gender, low SES, and concomitant cholesterol-lowering therapy. Respondents with gout with a higher BMI were more likely to remain on ULT.

Conclusions

Despite gout being a common, potentially disabling joint disease, only 55% of respondents with gout in this study adhered to ULT. Identification of key predictors of ULT use will provide guidance on prescribing strategy in clinical practice and on the quality of gout care in the community.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1633-9) contains supplementary material, which is available to authorized users.

Allopurinol Medication Adherence as a Mediator of Optimal Outcomes in Gout Management

BACKGROUND

Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes.

OBJECTIVES

The aim of this study was to examine associations of patient and provider factors with optimal gout management.

METHODS

Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement.

RESULTS

A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20-2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50-3.68) and dose escalation (OR, 2.48; 95% CI, 2.48-4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02-1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12-0.37).

CONCLUSIONS

Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.

A Qualitative Study Exploring Perceptions of Patients With Gout

Gout is a chronic disease that is on a rising trend and greatly affects one’s physical and psychosocial well-being. The aim of this study was to explore patients’ perceptions of living with gout. A descriptive qualitative study was conducted and 15 adults with gout were interviewed face-to-face between December 2014 and January 2015. Thematic analysis was used to analyze the transcribed data. The experiences of patients with gout were found to revolve around four themes: emotional experiences with gout, disruptions in daily lives, interactions with doctor, and coping with gout using internal and external resources. The in-depth understanding of the patients’ experiences indicates a need to provide holistic patient education and to involve family members to create nurse-led support groups and to raise public awareness regarding gout.

How Can We Improve Disease Education in People with Gout?

PURPOSE OF REVIEW

Gout management is currently suboptimal despite excellent available therapy. Gout patient education has been shown to enhance medication adherence and self-management, but needs improvement. We explored the literature on gout patient education including gaps in gout patient knowledge; use of written materials; in-person individual and group sessions; education via nurses, pharmacists, or multi-disciplinary groups; and use of phone, web-based, mobile health app, and text messaging educational efforts.

RECENT FINDINGS

Nurse-led interventions have shown significant improvement in reaching urate goals. Pharmacist-led programs have likewise succeeded, but to a lesser degree. A multi-disciplinary approach has shown feasibility. Needs-assessments, patient questionnaires, and psychosocial evaluations can enhance targeted education. An interactive and patient-centered approach can enhance gout educational interventions. Optimal programs will assess for and address educational needs related to knowledge gaps, health literacy, race, gender, socio-economic status, and level of social support.

Illness perception is significantly determined by depression and anxiety in systemic lupus erythematosus

Objectives Illness perception is a cognitive representation influencing physical and psychological functioning and adherence in patients with rheumatic disease. Studies exploring illness perception in systemic lupus erythematosus (SLE) are still scarce and none of them have investigated factors determining illness perception. We aimed to assess illness perception and to identify psychological, clinical and sociodemographic factors that might influence illness perception in SLE. Methods The study involved 80 patients with SLE (87.5% women, mean age 41.56 years). The Brief Illness Perception Questionnaire, State Trait Anxiety Inventory, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Visual Analogue Scale-Pain and Fatigue Severity Scale were used. Clinical and sociodemographic data were collected via structured interview and medical files review. Results Illness perception was significantly positively correlated with anxiety, depression, sleep quality, fatigue and pain while it was not related to age, education, steroid treatment, disease duration and activity (SLEDAI) or organ damage (SLICC/ACR). Regression analysis revealed that state anxiety and depression explained 43% of illness perception variance. Cluster analysis identified three patient groups among which the middle-aged group had the most negative illness perception, the highest levels of anxiety, depression, pain and fatigue, and the poorest sleep quality. Conclusions The study has proved a significant relationship between negative illness perception and anxiety and depression. Patients reporting fatigue, poor sleep and pain might have special needs in terms of psychological intervention focused on negative illness perception and distress symptoms. Multidisciplinary care in managing SLE seems to be of great importance.

Health-related quality of life in gout in primary care: Baseline findings from a cohort study

Objectives

To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout.

Methods

Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models.

Results

A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (≥5 attacks PF-10 β = −4.90, HAQ-DI β = 0.14, GIS subscales β = 8.94, 33.26), current attack (HAQ-DI β = 0.15, GIS β = −1.94, 18.89), oligo/polyarticular attacks (HAQ-DI β = 0.11, GIS β = 0.78, 7.86), body pain (PF-10 β = −10.68, HAQ-DI β = 0.29, GIS β = 2.61, 11.89), anxiety (PF-10 β = −1.81, HAQ-DI β = 0.06, GIS β = 0.38, 1.70), depression (PF-10 β = −1.98, HAQ-DI β = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 β = −16.10, HAQ-DI β = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS β = −13.05, −13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 β = −4.33, HAQ-DI β = 0.14), stroke (PF-10 β = −12.21, HAQ-DI β = 0.37), renal failure (PF-10 β = −9.43, HAQ-DI β = 0.21), myocardial infarction (HAQ-DI β = 0.17), female gender (PF-10 β = −17.26, HAQ-DI β = 0.43), deprivation (PF-10 β = −7.80, HAQ-DI β = 0.19), and body mass index ≥35 kg/m² (PF-10 β = −6.10, HAQ-DI β = 0.21).

Conclusions

HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout-specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments.

"I can't bend it and it hurts like mad": direct observation of gout consultations in routine primary health care

BACKGROUND

Gout is the most common form of inflammatory arthritis and is associated with considerable co-morbidity. It is usually managed in the primary care setting with a combination of lifestyle modification and pharmacological therapy. This study describes patterns of communication about gout observed in interactions between patients and primary care practitioners during routine consultations.

METHODS

Secondary analysis of video-recordings of individual healthcare consultations between patients and a range of primary care practitioners (including general practitioners, practice nurses, podiatrists and dietitians) from an archived database. Consultations that included any discussion about gout were eligible for inclusion (n = 31) and were not restricted to those where gout was the main presenting complaint. The consultation transcripts were analysed using a qualitative inductive approach from clinical and linguistic perspectives and supplemented with visual observation of the interactions.

RESULTS

Two main themes emerged from the data; the importance of gout and 'telling' versus 'listening' in consultations. The first theme had two distinct strands; gout as an incidental part of the consultation and the impact of gout on patients. A trend towards more didactic practitioner communication encompassed by the second theme occurred at many different consultation points including diagnosis, in more general post-diagnosis discussion, and when discussing biochemical test results and lifestyle advice. In contrast, when discussion about treatment with medicines occurred a tendency towards a greater degree of listening to patients was observed.

CONCLUSION

Our observation of the communication patterns in these consultations illustrates an inherent complexity of gout consultations in primary care. Gout may be more important to patients than is often apparent to practitioners in routine consultations. Consultation management needs to take into account the impact of the condition and the balance of information provided around lifestyle advice versus long-term management with medicines.