We report an effective and well-received follow-up program delivered by telemedicine for medication adjustment and monitoring in the longitudinal management of gout.The goal SUA ≤6 mg/dl was achieved in >70% of patients, and 80% of the patient's achieved a more lenient SUA of ≤6.5 mg/dl with good clinical control of their symptoms. Additionally, the majority of patients were on appropriate prophylactic medications while adjusting the dose of ULT, thereby reducing the likelihood of gout flares. There were no hospitalizations and very few ER or urgent care visits during the observation period of the program. Some patients who did not achieve the goal were likely due to inadequate time in the telephone phase of the study before the study came to a close, inability to reach the patient via phone or other communication methods, and patient noncompliance with medication.
Our program was designed to overcome many obstacles in the longitudinal treatment of gout. Patients were monitored by a series of telephone calls, thus offering convenience to the patient. The provider reinforced medication adherence during the telephone calls and repeat SUA levels were performed regularly. Patient education was provided, which might have led to better compliance and more frequent achievement of SUA target. Medication refills were sent electronically with telephone encounters, and we used electronic medical record to contact the patient through messages in cases when phone calls were unavailable, an additional convenience to the patients.
Access to care remains a major issue in rheumatic diseases in the United States due to a nationwide shortage of practitioners. Our GDMP is an ideal way to limit bedside outpatient visit utilization and optimize regular follow-up with a focus on optimizing SUA, targeting a level of ≤6 mg/dl to reduce the likelihood of gouty attacks and long-term consequences of hyperuricemia. Gout is an ideal disease that lends itself to treatment algorithms and telephone-based care with application of available management recommendations.
The guidelines from the American College of Rheumatology and the American College of Physicians are available for gout treatment(2,3,4).Nevertheless, gout treatment remains suboptimal. The reason for this shortfallis likely multifactorial. The lack of symptoms between gout flares decreases patient adherence to chronic daily ULT medications. Additionally, the practitioner’s concern of medication toxicity can lead to using less optimum doses of medication.Furthermore, the frequent need to adjust the dose of medications and obtain SUA level (which typically requires multiple office visits) is an obstacle to many patients due to time constraints. Lastly, the treat-to-target approach, which is adopted by most rheumatologists as advocated by the ACR guidelines (2,3), is not necessarily embraced by primary care providers based on the prior 2017 ACP guidelines (4).
Similarly to our study, inthe RamP-UP study, patients were contacted directly by pharmacists(7). The SUA goal of ≤6 mg/dl was achieved in 30% of patients in the intervention group, in comparison to only 15% in the usual care group. Adherence was also higher in the intervention group. Intervention period was one year only. Our results differedfrom the RAmP-UP study in that we did not use an automatic voice response system;rather, wecalled the patients individually, which might have led to a more aggressive lowering of the SUA in our trial. Furthermore, our observation period was longer, and a rheumatology provider performedthe intervention.
In a study by Doherty et al. (8), a nurse-led intervention was successful in obtaining a goal SUA ≤6 mg/dl in 95% of the patients after 2 years. Of note, in that study, telephone contact could be substituted for face-to-face visits, and home visits were permitted.In our study, patients were mostly newly diagnosed, which requires frequent adjustments in medication doses and frequent encounters, while in the study byDoherty et al., patients were mainly established patients with a mean duration of disease of 11 years. Furthermore, the higher percentage of patients achieving target SUA in the Doherty et al. study as compared to ours could be related to our rheumatology providers doing the intervention as part of their clinic duty to mimic real-life situations, while the study by Doherty et al. had an educated nursing staff dedicated to this study.Additionally, after entry into the telephone phase of theprogram, we did not conduct any face-to-face or home-visits as in the study by Doherty et al., which could also have led to higher percentage of patients achieving target SUA in their study versus ours.
A study by Yokose et al. (9), in which an e-visit conducted in 62 patients with gout was compared to a matched historic cohort, showed that SUA target of ≤6 mg/dl was obtained in 63% of patients in the intervention group versus 33% in the historic matched group. Our results were superior, likely because the Yokose et al. study used email reminders and questionnaires, while we conducted phone calls in real-time with patients.
There are several strengths toour study. Patients were enrolled after a visit with their rheumatology provider, which makesgout less likely to be misdiagnosed. We used real-time phone calls instead of automated contacts with patients which might have increased the rate of patient compliance. After usual face-to-face office visits, the patients were entered into a novel telephone phase of the program. This was very convenient to patients, which in turn led to higher patient satisfaction. We were able to achieve a goal SUA level ≤6 mg/dl in the majority of patients, and the rate of hospitalizations, ER, or urgent care visits due to gout was very low. We included a large number of patients in our study, and providers continued to refer patients to our study. This study was the first of its kind to employ telephone-based, guidelines-directed management prospectively led by rheumatology providers.
One limitation of this study was reaching patients by phone.There wereincidences where patients were not available by phone, and wewere forced to use our electronic medical record and mailing system to try to contact such patients. Additionally, repeated SUA levels were not always done on time after adjusting the medication dosage due to patient factors.Furthermore, we did not have a control group in our study, and as such we cannot draw definitive conclusions about the efficacy of this program as compared to standard of care. Furthermore, we performed the telephone encounters free of charge, but this may not be plausible at all institutions.There is also a possibility of enrollment bias as our patients were included based on the discretion of the initial rheumatology provider. Finally, there was no time-related data at entry on prior healthcare utilization.
Our study demonstrated that a gout disease management program consisting of typical visits with a rheumatologist followed by a novel telephone-based follow-up phase has a high patient satisfaction rate, and it may lead to improvement in following clinical guidelines, thus leading to better management of disease and reduced healthcare costs. Such visits can reduce outpatient office visits, with a more abbreviated management strategy by phone, thus freeing time to provide access to patients requiring bedside encounters. While providers were not reimbursed for doing such calls, new COVID-19 related changes in reimbursement for telemedicine care may change this in the future.Futureworkwith a comparable group that can assess the effect on healthcare expenditure is warranted to further elucidate the benefits of a GDMP for gout management.