Gout is the most common chronic inflammatory arthropathy with its incidence growing. The urate crystal deposition is not only responsible for the typical monoarticular flares, but also decreases quality of life and increases mortalityCitation1,Citation2. A urate lowering treating to target strategy has proved to decrease not just the number of flares but also mortalityCitation3. Although most gouty patients are not difficult to treatCitation4, they are poorly managed by general practitioners (GPs) and also by specialists, including rheumatologists. There are several published studies trying to understand why such a prevalent (in adults – UK: 2.5%; US: 3.9%; France: 0.9%; Spain 2.4%)Citation5 and easy to manage disease is so poorly treatedCitation6. Most gout patients are managed by GPs.
The objective of our study was to identify areas of improvement in the management of patients with gout in primary healthcare. We first conducted a search on PubMed to identify the main barriers described in the management of gout patients. The terms used were: “gout”, “primary healthcare” and “education”. Then a Google Form knowledge questionnaire was designed considering what is described in the literature (https://docs.google.com/forms/d/e/1FAIpQLScMWng8hws_2NpddO8oxlytsSP7nnbVskVq6sdOaJuNFG3cXA/viewform?vc=0&c=0&w=1). Main concerns were as follows. Who is in charge of gout patients’ management? Is there a rheumatologist available for crystal diagnosis or difficult to treat patients? Are guidelines or recommendations adequate or available? Is there correct physician, nurse or patient education? After that GPs were invited to answer it by mail and social media through different GP associations. Two hundred twenty-six GPs from 14 of the 17 Spanish autonomous communities (representing about 90% of the population) answered the questionnaire. Seventy per cent were women; and 80% had ten years or more of professional experience. The most relevant answers to the questionnaire were as follows. Only 29% recognized the target for the urate lowering therapies (ULT). Sixty-three per cent still thought that changes in diet and lifestyle were the principal treatment instead of ULT and a treat to target strategy. Only 37% answered that they step up ULT dose. That means that an important percentage of patients will receive a subtherapeutical dose of ULT therapy. All but one made a gout diagnosis just with clinical issues (and 17% without a blood test). Of GPs who answered the questionnaire, 59% reported that they do not follow any reference guide and 55.8% had not completed any gout update course in the last 5 years. As it is an internet Google Form questionnaire an age and interest bias could be found. Just 20.5% of the GPs who answered the questionnaire had 10 years of experience or less. If PCPs interested in gout are more expected to answer the questionnaire, then the real management of this arthritis would be even worse.
Among the several reasons to explain the deficient management of gout the most repeated are: discrepancies between different societies’ guidelines, lack of recommendations or guidelines from GP associations, perception of acute instead of chronic illness or the believe of a self-inflicted diseaseCitation6,Citation7. In our questionnaire PCPs could choose between five different guidelines, three from rheumatology (Spanish, European and American associations) and two from primary healthcare (one from a Spanish Association and the one from ACP). Our results demonstrate that it is not a problem of disagreement between guidelines or recommendationsCitation8. Most GPs just do not use them. GPs have growing multiple responsibilities in the management of different chronic illness such as diabetes, hypertension, dyslipidemia, osteoporosis and chronic obstructive pulmonary disease, and have been shown to do it correctly. Outcomes of most chronic diseases are included in contract agreements with national or local health providers. Gout outcomes should also be consistently included. This would be the first step to take on the long and winding road we need to begin to walk to treat correctly gout patients.
Gout is a prevalent and poorly managed disease.
General practitioners do not usually follow any guidelines or receive any specific gout education.
Including gout outcomes in contract agreements with national or local health providers can improve its management.
Key messages
Transparency
Declaration of funding
There was no funding.
Declaration of financial/other relationships
No potential conflict of interest was reported by the authors. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Author contributions
All the authors contributed to the design and acquisition of data. MAP and CDT contributed to the analysis and writing of the letter. Each of the authors has read and concurs with the content in the final letter.
Acknowledgements
None.
References
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