Eltharoni K.1, Melia B.2, Owen D. 2 , Thomson C. 3, Walker S. 3, Riches P.L.1
1 Rheumatic Disease Unit, IGMM, Edinburgh, UK. 2 Primary Care Pharmacy, Astley Ainslie Hospital, Edinburgh, UK. 3 Biochemistry Department, NHS Lothian, Edinburgh, UK
Objectives: This study assessed two interventions within the Edinburgh region aimed at improving the care of gout. The first an automatically generated biochemistry comment on uric acid test results and the second a gout audit tool that could be adopted on a voluntary, but incentivised, basis by general practitioners.
Methods: A change in reporting of urate results was introduced in September 2014 with a comment added to all results ≥ 0.36mmol/L stating ‘In patients with clinically confirmed gout the target for serum urate levels is < 0.36mmol/L”. This replaced the reporting of a high result only in patients with urate levels outwith a normal range of 0.12 to 0.42mmol/L. Urate test requests and community prescriptions of allopurinol and febuxostat were obtained between Jan 2014 and Aug 2015. A gout audit tool was developed for use in primary care in Lothian in 2015 which could be adopted as part of the Quality Outcome Framework agreement. Two sided student T test were used to compare continuous results and CHI-SQR test categorical variables.
Results: There was no significant increase in the number of urate requests per month which rose from 1032 ± 97 to 1095 ± 12. However the number of tests at target rose from 491 ± 30 per month to 592 ± 85 per month (p<0.005) and the percentage of repeat tests performed rose modestly from 1594/9287 (17%) to 2410/12050 (20%) (p<0.001). At the same time total prescriptions of allopurinol rose from 48,500,000mg/month ± 2,900,000 to 52,100,000mg/month ± 3,100,000 (p<0.05) and febuxostat increased from 320,000mg/month ± 40,000 to 400,000mg/month ± 40,000 (p<0.005). The gout audit was adopted as a General Medical Services action by 22 practices within Edinburgh and surrounding regions. Data from a completed audit cycle was obtained from 10 of these practices with 3 to 4 months spanning cycles 1 and 2. The percentage of patients with a urate level measured increased from 325/698 (43%) to 379/681 (56%) (p<0.005). The percentage of patients with a urate level <0.36 rose from 181/698 (26%) to 252/681 (37%) (p<0.001).
Conclusion: Improvement in the care of gout patients is possible with simple targeted interventions, however even in practices that elected to take part in gout audit, substantial shortcomings in care remain.