VBCR - October 2012, Volume 1, No 5 - Gout

By Neil Canavan

Cincinnati, OH—Results of a new study suggest that despite the availability of urate-lowering treatments (ULTs) and the newly published American College of Rheumatology (ACR) guidelines for the treatment of gout, which were initially introduced at last year’s ACR annual meeting, no more than 50% of physicians are currently following these recommendations.

“The take-home message here is that adherence to the guidelines is not very good for any physician type,” lead investigator Robert J. Morlock, PhD, Head of Global Market Access and Health Economics Consultant, Ardea Biosciences, San Diego, CA, and Adjunct Faculty at Henry Ford Hospital, Detroit, MI, told Value-Based Care in Rheumatology. “Rheumatol­ogists are slightly better than primary care providers, but neither group is treating enough of their patients to the guidelines.”

The study was presented at the October 2012 meeting of the Academy of Managed Care Pharmacy. In their study, Dr Morlock and colleagues conducted a retrospective chart review of patients who were diagnosed with gout and were being seen by a rheumatologist or by a primary care physician (PCP).

To be included in the study, patients had to be initiated with gout treatment with 1 of 2 xanthine oxidase inhibitors (or ULTs)—allopurinol (Zyloprim; n = 621) or febuxostat (Uloric; n = 237)—and have had 1 year of follow-up.

All treating physicians had to have at least 50 patients with a diagnosis of gout in their practice within the past year. There were 125 rheumatology practices (500 patients) and 124 PCPs (358 patients) included in the analysis. Chart reviews were performed on the last 5 patients treated within a given practice.

The patient cohort was assessed for adherence to the ACR guidelines according to the following criteria: timely prophylaxis with a ULT, titration to a target serum uric acid level of <6 mg/dL, and the number of assessments of serum uric acid in 12 months.

Results of the analysis were striking. A key component of the guidelines—frequent monitoring of the patient—was routinely ignored. After an initial baseline measurement of serum uric acid, only 68% of rheumatologists, and 53% of PCPs performed a second assessment within the first 12 months after initiating treatment.

“After 2 or more gout episodes in a year, the guidelines recommend treating with a ULT,” explained Dr Morlock. “That’s step 1. Step 2 asks that you then follow urate levels—but if [physicians] aren’t taking another laboratory value for a year or more, how can they say if the drug is optimally working or not?”

Reflecting the lack of recommended follow-up, the majority of patients in this cohort did not achieve the suggested serum uric acid treatment goal of <6 mg/dL; only 50% of patients in rheumatology practices reached this target versus 36% of patients being treated by a PCP.

The cut-off point is not arbitrary—the goal of long-term ULT is to reduce serum uric acid levels below the saturation point of monosodium urate so that new crystals do not form and so existing crystals are dissolved. Yet, lacking the data for serum uric acid levels, in this study 32% of rheumatologists and 57% of PCPs did not adjust their patients’ ULT dose to this treatment goal.

Given the evidence that it takes several years for physicians to incorporate national guidelines into their daily practice, what can be done to improve guideline adherence sooner in face of the significant disease burden on patients?

“What I’d like to see managed care do is put metrics in place to measure or grade clinicians on following the guideline,” Dr Morlock suggested. Lacking that, he advised physicians to simply do a bit more testing. “If you have the laboratory assessments, you can adjust the treatment accordingly.”

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