Background Gout is a common condition in NewZealand, being found in 10% of Maori men and 15 of Pacific men over the age of 20.It is commonly associated with comorbidities such as the metabolic syndrome, cardiovascular disease and diabetes. It has been suggested that an acute attack of gout might be used as a sentinel event to identify these comorbidities and manage them more effectively. Optimal management of gout includes the use of urate lowering therapy (ULT), with regular urate monitoring, to reach a target level of less than 0.36 mmol/L (6.0 mg/dL).
Objectives To determine the general health status (smoking, diabetes, cholesterol and cardiovascular risk) and current quality of care among patients with gout at two general practice (GP) settings in Manukau, Auckland NZ.
Methods Within a total population of 5337 patients with a diagnosis of gout, 200 were randomly sampled from the two GP centres, 100 from Practice A and 100 from Practice B. GP and hospital electronic notes and laboratory records were examined and relevant information recorded.
Results Among the 200 patients 76% were male, 35% were Samoan, and 20% were Maori. 19% of patients had eGFR <60ml/min/1.73m2 . 29% of patients were smokers. Diabetes is present in 34.5% of patients, with 37 of these 69 patients having suboptimal diabetes control with an HbA1c >60 mmol/mol. Systolic blood pressue (BP) is >130 in 36.5% of people, and a BP of over 130/85 is present in 17.5% of people. 40% of people had Total Cholesterol/HDL of >4.5. Only 33% of patients have a 5 year cardiovscular risk of <10%18.5% of patient have a 5 year CVD risk of >20%. Over the previous 12 months there were 58 patients with hospital admissions or emergency department visits of more than 3 hours, of which only 3 were primarily gout related.
Overall,54% of patients had an attack of gout in the previous 12 months though 27.5% of the 200 patients had not had a serum urate measurement within the previous year. 51.2% of patients are currently not on allopurinol or other urate lowering therapy (URT) and 70.5% of patients had a urate level ≥0.36mmol/L. Only 17% of patients in practice A and 11% in practice B not on allopurinol have their serum urate below 0.36 compared to 32% of patients in practice A and 38% of those in practice B who are on 300mg daily.
Conclusions The results have revealed areas in the management of gout and its comorbidities that will need to be addressed to achieve better patient outcomes. Predominantly this involves the lack of ULT use and insufficient dose escalation to achieve urate levels of <0.36mmol/L, and suboptimal control of diabetes, blood pressure, and hypercholesterolemia, all of which, with smoking, contribute to a high cardiovascular risk among this population.
This audit is the initial stage of a project aimed at implementing an integrated multidisciplinary health care programme enabled by health information technology and attention to health literacy, following which improvements are anticipated in the outcomes of both gout and its comorbidities.
Acknowledgements The cooperation of the general practitioners in the practices which were audited is gratefully acknowledged.
Disclosure of Interest None declared