Quality of care indicators for gout management

Abstract

Objective. Despite the significant health impact of gout, there is no consensus on management standards. To guide physician practice, we sought to develop quality of care indicators for gout management.Methods. A systematic literature review of gout therapy was performed using the Medline database. Two abstractors independently reviewed each of the articles for relevance and satisfaction of minimal inclusion criteria. Based on the review of the literature, 11 preliminary quality indicators were developed and then reviewed and refined by an initial feasibility panel of community and academic rheumatologists. A twelfth indicator was added at the request of the first panel. Using a modification of the RAND/University of California at Los Angeles appropriateness method (bridging teleconference and white-board Internet technology were added), a second expert panel rated each of the proposed indicators for validity using a 9-point scale, in which ratings of 1-3, 4-6, and 7-9 were considered "invalid," "indeterminate," and "highly valid," respectively. Indicators were considered valid if the median panel rating was >7 and there was no evidence of panel disagreement (defined to occur when 2 of 6 panelists provided a validity rating of 1-3 and 2 panelists provided a validity rating of 7-9).Results. Ten of the 12 draft indicators were rated to be valid by our second expert panel. Validated indicators pertained to 1) the use of urate-lowering medications in chronic gout, 2) the use of antiinflammatory drugs, and 3) counseling on lifestyle modifications.Conclusion. Using a combination of evidence and expert opinion, 10 indicators for quality of gout care were developed. These indicators represent an important initial step in quality improvement initiatives for gout care.Preliminary evidence suggests that medical errors in the treatment of gout are common. An older age at onset of gout and the presence of serious comorbid conditions render patients vulnerable to medicationrelated errors and substandard quality of care. Indomethacin, a nonsteroidal antiinflammatory drug (NSAID) routinely used in gout treatment, is among the most commonly prescribed inappropriate medications among the elderly (1). In a prospective investigation involving a large cohort of elderly patients who presented to an emergency room (1), gout was among the treatment indications most commonly associated with selection of inappropriate medications. Such medication-related errors have been reported as a complication in more than one-fourth of all orders for intravenous colchicine administered to inpatients (2) and approximately one-half of orders for administration of allopurinol (3), both of which are drugs that are commonly used in the treatment of gout.Although gout has a substantial health impact and although its treatment appears to be characterized by preventable medical errors, quality of care in gout has not been well studied. A barrier to such research has been a lack of consensus regarding the standards of care in gout therapy. To address this is...

Quality of Care in Patients with Gout: Why is Management Suboptimal and What Can Be Done About It?

“…The widespread inappropriate dosing and timing of ULT is a result of poor understanding of the therapeutic objectives in reducing serum urate levels [14][15][16][17]. For years, physicians have been confused by the way "normal ranges" for serum uric acid are reported by their clinical laboratories.…”

Understanding Gout Beyond Doubt

“…COX-2 inhibitors such as celecoxib (Celebrex) can also be used for patients with gastrointestinal concerns but their use for acute gout has not been specifically reported yet. On the basis of two studies of rigorous design and adequate size, etoricoxib is as efficacious as indomethacin for gout 19 , with fewer adverse events. Etodolac 600 mg daily was found to be as effective as naproxen (500 mg twice or three times a day) in the treatment of acute gout.…”

Quality of care for gout in the US needs improvement

“…Published gout treatment QIs have been linked to outcomes based on retrospective and prospective studies (15). Of the 10 QIs described by Mikuls et al (15), 7 pertain to uric acid-lowering therapy (allopurinol and probenecid), 2 to antiinflammatory medications (colchicine and nonsteroidal antiinflammatory drugs [NSAIDs]), and 1 to lifestyle modification. We focused on QIs related to medication management.…”

“…Mikuls et al recently published evidence-based quality of care indicators for gout management (15). These quality indicators (QIs) are minimum acceptable standards of care that have been directly or indirectly linked to outcomes in published clinical studies, and that are believed by the experts to produce good outcomes.…”