Improved Gout Outcomes in Primary Care Using a Novel Disease Management Program: A Pilot Study

The Impact of mHealth-Based Continuous Care on Disease Knowledge, Treatment Compliance, and Serum Uric Acid Levels in Chinese Patients With Gout: Randomized Controlled Trial

Background

In patients with gout, suboptimal management refers to a lack of disease knowledge, low treatment compliance, and inadequate control of serum uric acid (SUA) levels. Several studies have shown that continuous care is recommended for disease management in patients with gout. However, in China, the continuous care model commonly used for patients with gout requires significant labor and time costs, and its efficiency and coverage remain low. Mobile health (mHealth) may be able to address these issues.

Objective

This study aimed to explore the impact of mHealth-based continuous care on improving gout knowledge and treatment compliance and reducing SUA levels.

Methods

This study was a single-center, single-blind, and parallel-group randomized controlled trial. Participants were recruited at the West China Hospital of Sichuan University in Chengdu, China, between February 2021 and July 2021 and were randomly assigned to the intervention and control groups. The intervention group received continuous care via an mHealth app, which includes modules for health records, 24 weeks of gout-related health education materials, and interactive support. The control group received routine continuous care, including face-to-face health education, paper-based health education materials consistent with the content for the intervention group, and telephone consultations initiated by the patient. Follow-up was conducted at 6 months. Participants' gout knowledge levels and treatment compliance were measured at baseline and the 12th and 24th weeks, and participants' SUA levels were measured at baseline and the 24th week. The intention-to-treat principle and a generalized estimating equation model were used to test the effect of the intervention.

Results

Overall, 258 potential participants underwent eligibility assessments, and 120 were recruited and randomized into the intervention (n=60, 50%) and control (n=60, 50%) groups. Of the 120 participants, 93 (77.5%) completed the 24-week study. The 2 groups had no significant differences in sociodemographic or clinical characteristics, and the baseline measurements were comparable (all P>.05). Compared with the control group, the intervention group exhibited a significant improvement in gout knowledge levels over time (β=0.617, 95% CI 0.104-1.129; P=.02 and β=1.300, 95% CI 0.669-1.931; P<.001 at the 12th and 24th weeks, respectively). There was no significant difference in treatment adherence between the 2 groups at the 12th week (β=1.667, 95% CI -3.283 to 6.617; P=.51), while a statistical difference was observed at the 24th week (β=6.287, 95% CI 1.357-11.216; P=.01). At the 24th week, SUA levels in both the intervention and control groups were below baseline, but there was no significant difference in SUA changes between the 2 groups (P=.43).

Conclusions

Continuous care based on the mHealth app improved knowledge levels and treatment compliance among patients with gout. We suggest incorporating this intervention modality into standard continuous care for patients with gout.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Changing paradigms in the management of gout

The incidence and prevalence of gout have increased, as have comorbid obesity, diabetes mellitus, hypertension, chronic kidney and cardiovascular disease. Gout is now the commonest type of inflammatory arthritis despite availability of safe, effective and potentially 'curative' urate-lowering drugs. Modern imaging studies show that gout is a chronic inflammatory crystal deposition disorder even at the first acute attack and they illuminate the need to eliminate urate crystals by continuing reduction of the serum urate below its solubility threshold. Clinical outcomes, adherence to therapy and quality of gout care in primary care and hospital practice can be greatly improved by better use of allopurinol and flare prophylaxis, greater patient engagement, education and follow-up, and by nurse-led models of care that employ a 'treat-to-target' principle (SUA< 360 or 300µmol/l). Advances in understanding the physiology and genetic control of urate transport in the kidney and gut have led to novel, more selective uricosuric drugs, and basic research on mediators of urate crystal-induced inflammation has pointed to alternative therapeutic targets for treating and preventing gout flares. Current guidelines for the management of gout and indications for the use of some more recently introduced drugs; febuxostat, lesinurad, pegloticase and interleukin-1 antagonists are also briefly reviewed.

Gout Flare Burden, Diagnosis, and Management: Navigating Care in Older Patients with Comorbidity

Gout is the most common form of inflammatory arthritis, and its incidence is highest in middle-aged and older patients. Adding to the diagnostic complexity, up to 50% of patients aged > 65 years present atypically, with subacute oligo- or polyarticular flares. Comorbidity and polypharmacy, common in older populations, affect real-world treatment decisions in gout management, and no specific guidelines are available to address these issues in these at-risk groups. Despite the growing public health burden posed by gout, suboptimal management has led to increased morbidity and substantial healthcare utilization and cost burden, as reflected by an increased incidence of emergency department visits and hospitalizations in recent years. Colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) should be considered as first-line agents for gout flare management. Urate-lowering therapy, with the goal of lowering and maintaining serum urate concentrations at < 6 mg/dL (< 360 μmol/L), is recommended to achieve optimal outcomes, including regression of tophi, reduction (or elimination) of flares, and reductions in total urate burden. In this review, we summarize the current burden posed by gout and discuss best practices in its diagnosis and management, focusing on best practices in the context of gout flare in older patients with comorbid conditions.

Gender and Ethnic Inequities in Gout Burden and Management

Although effective and low-cost urate-lowering therapy has been available for decades, inequities in gout management exist. Despite high impact of disease, rates of urate-lowering therapy prescription are low in women, in African-Americans in the United States, in Māori (Indigenous New Zealanders), and in Pacific peoples living in Aotearoa/New Zealand. Social determinants of health, barriers to accessing the health care system, health literacy demands, stigmatization, and bias contribute to inequities in gout burden and management. Approaches that focus on building health literacy and delivering culturally safe care lead to improved outcomes in gout, and offer important solutions to achieve health equity.

Interventions to improve uptake of urate-lowering therapy in patients with gout: a systematic review

BACKGROUND

Gout treatment is suboptimal despite available therapy, with low levels of initiation and persistence of urate-lowering therapy (ULT) in many patients.

AIM

To identify all interventions that have attempted to improve the uptake of ULT and analyse the clinical outcomes.

DESIGN & SETTING

A systematic review of international articles published in English.

METHOD

A systematic search was conducted through MEDLINE, Embase, CINAHL Plus, and Scopus databases to identify all studies on relevant interventions for gout. Interventions were included if they aimed to address patient adherence with serum urate (SU) level as an outcome. This included patient education, practitioner monitoring, medication titration, SU monitoring, and ongoing patient engagement and follow-up. Follow-up studies to original interventions and those with only an abstract available were included.

RESULTS

Twenty articles met the inclusion criteria, describing outcomes of 18 interventions conducted in primary care settings: six nurse-led, five pharmacist-led, and seven multidisciplinary, multifaceted interventions. Improvement in SU levels was observed in all interventions. Nurse-led interventions were effective at empowering patients as they addressed illness perceptions and provided education, advice, and telephone follow-up. Pharmacist-led interventions primarily aimed to monitor patients, alter medication dosage, and provide automated telephone follow-up. Various multifaceted programmes involving a range of providers resulted in increased sustained use of urate-lowering medication.

CONCLUSION

A nurse-led approach focusing on patient understanding about gout is the most effective in achieving improved patient adherence, and lowered SU levels among patients. An intervention should include patient education and follow-up components.

Using electronic visits (E-visits) to achieve goal serum urate levels in patients with gout in a rheumatology practice: A pilot study

OBJECTIVE

Achieving goal serum urate levels in patients with gout remains difficult in primary care and rheumatology practices. This study measured the ability of an asynchronous electronic visit (E-visit) program to facilitate achieving a goal serum urate (SU) of less than 6.0 mg/dL.

METHODS

We performed a retrospective cohort study in a large academic medical center rheumatology practice between April 1, 2017 and May 31, 2018. Patients with gout and SU levels over 6.0 mg/dL were enrolled in an E-visit program and were compared with historical controls who received usual care, matched 1:1 for age and sex. The primary outcome of interest was the proportion of patients achieving SU target of less than 6.0 mg/dL at six months.

RESULTS

Sixty-two patients were enrolled by their rheumatologist in the gout asynchronous E-visit program and were compared to 62 historical controls who were seen within one year prior to E-visit program initiation. Baseline characteristics including age, sex, body mass index, renal function, and initial SU were similar among patients enrolled in the E-visit program and controls. At six months, a significantly higher proportion of patients in the E-visit program achieved goal SU of less than 6.0 mg/dL compared to controls (63.8% vs 33.9%, respectively, p < 0.01), and the E-visit patients had a lower mean SU level than historical controls (5.5 mg/dL versus 6.7 mg/dL, respectively, p < 0.01).

CONCLUSION

A physician-initiated E-visit program led to a substantial improvement in the rate of achieving goal SU among patients with gout within an academic rheumatology practice.

Making the right thing the easy thing to do: strategies to improve outcomes in gout

The burden of gout is increasing worldwide. Although urate-lower ing drugs have been available for more than half a century, the initiation and persistence of urate-lowering therapy remain low. Health-care system, practitioner, and patient barriers contribute to the clinical inertia in gout management. Pervasive beliefs about gout as a disease of an indulgent lifestyle that should be managed primarily with dietary modification are key barriers that prevent patients from receiving effective therapy. In light of safety concerns about newer urate-lowering medications, allopurinol, an inexpensive generic medication, is likely to remain the first-line urate-lowering therapy for the foreseeable future. Ensuring that allopurinol is optimally and persistently prescribed is a priority for improved gout management. A health literacy approach that focuses on patient understanding of gout as a chronic disease that requires behaviour change to take long term urate-lowering therapy is important. This approach provides a clear rationale for long-term urate-lowering therapy that is able to dissolve the monosodium urate crystals and ultimately prevent the symptoms of gout. Patient-centred models that use the skills of nurses and pharmacists to facilitate patient understanding can lead to major improvements in gout care. Additionally, systematic quality improvement approaches within practices, while reducing inconvenience and cost to patients, should be a priority.

Gout

Gout is a chronic disease caused by monosodium urate (MSU) crystal deposition. Gout typically presents as an acute, self-limiting inflammatory monoarthritis that affects the joints of the lower limb. Elevated serum urate level (hyperuricaemia) is the major risk factor for MSU crystal deposition and development of gout. Although traditionally considered a disorder of purine metabolism, altered urate transport, both in the gut and the kidneys, has a key role in the pathogenesis of hyperuricaemia. Anti-inflammatory agents, such corticosteroids, NSAIDs and colchicine, are widely used for the treatment of gout flare; recognition of the importance of NLRP3 inflammasome activation and bioactive IL-1β release in initiation of the gout flare has led to the development of anti-IL-1β biological therapy for gout flares. Sustained reduction in serum urate levels using urate-lowering therapy is vital in the long-term management of gout, which aims to dissolve MSU crystals, suppress gout flares and resolve tophi. Allopurinol is the first-line urate-lowering therapy and should be started at a low dose, with gradual dose escalation. Low-dose anti-inflammatory therapies can reduce gout flares during initiation of urate-lowering therapy. Models of care, such as nurse-led strategies that focus on patient engagement and education, substantially improve clinical outcomes and now represent best practice for gout management.

Management of complex gout in clinical practice: Update on therapeutic approaches

Increasing therapeutic options are available for gout management. Anti-inflammatory agents are used in the acute management of gout flares, and interleukin-1 inhibitors are effective for those unable to take conventional anti-inflammatory treatments. Lowering of serum urate remains the cornerstone of effective long-term management. Allopurinol is the first-line urate-lowering therapy, and a gradual dose-escalation strategy to serum urate target is recommended. Febuxostat and lesinurad have been approved more recently. In a large cardiovascular outcomes trial, higher all-cause and cardiovascular mortality was observed with febuxostat than with allopurinol. Lesinurad should be co-prescribed with a xanthine oxidase inhibitor, and close monitoring of kidney function is required. Evidence for non-pharmacological management is limited, but personalised lifestyle modification may reduce associated cardiovascular risk. In this review, we discuss current principles in the gout management paradigm, consider strategies for managing complex, clinical scenarios, and review emerging therapies.

Effectiveness of healthcare educational and behavioral interventions to improve gout outcomes: a systematic review and meta-analysis

BACKGROUND

We aimed to systematically review the effectiveness of healthcare behavioral and education interventions for gout patients on clinical outcomes.

METHODS

We searched multiple databases to identify trials or observational studies of educational or behavioral interventions in gout. Risk of bias was assessed with the Cochrane tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale for observational studies. We estimated odds ratios (ORs) for categorical and standardized mean difference (SMD) for continuous measures using a random-effects model.

RESULTS

Overall, eight (five RCTs and three observational) studies met the inclusion criteria and examined pharmacist-led interventions (n = 3), nurse-led interventions (n = 3) and primary care provider interventions (n = 2). Compared with the control intervention (usual care in most cases), a higher proportion of those in the educational/behavioral intervention arm achieved serum urate (SU) levels <6 mg/dl, 47.2% versus 23.8%, the OR was 4.86 [95% confidence interval (CI), 1.48, 15.97; 4 RCTs] with moderate quality evidence. Compared with the control intervention, a higher proportion of those in the educational/behavioral intervention arm were adherent to allopurinol, achieved at least a 2 mg/dl decrease in SU, achieved an SU < 5 mg/dl, had a reduction in the presence of tophi at 2 years, had improved quality of life as assessed with SF-36 physical component scores, had a higher knowledge about gout and higher patient satisfaction (moderate-low quality evidence).

CONCLUSION

Educational and behavioral interventions can improve gout outcomes in the short-intermediate term. Randomized trials are needed to assess its impact on long-term gout outcomes.