Patient and provider barriers to effective management of gout in general practice: a qualitative study

University of Nottingham, Department of Academic Rheumatology, Academic Rheumatology Clinical Sciences Building City Hospital, Nottingham NG5 1PB, UK.
Annals of the rheumatic diseases (Impact Factor: 10.38). 03/2012; 71(9):1490-5. DOI: 10.1136/annrheumdis-2011-200801
Source: PubMed


To explore patient and provider illness perceptions and barriers to effective management of gout in general practice.
A qualitative study involving semistructured face-to-face interviews with patients and health professionals from 25 Nottinghamshire general practices and one central National Health Service hospital.
Twenty gout sufferers and 18 health professionals (six general practitioners, five hospital physicians, seven practice nurses).
A number of key themes emerged suggesting that several factors impact on patients' access to recommended treatments. The main barriers were patient experiences and lay beliefs of their condition which affected seeking advice and adherence to treatment. There was universal lack of knowledge and understanding of the causes and consequences of gout and that it can be treated effectively by lifestyle change and use of urate lowering therapy (ULT). All participants associated gout with negative stereotypical images portrayed in Victorian cartoons. Many viewed it as self-inflicted or part of ageing and only focused on managing acute attacks rather than treating the underlying cause. The main provider barriers that emerged related to health professionals' lack of knowledge of gout and management guidelines, reflected in the suboptimal information they gave patients and their reluctance to offer ULT as a 'curative' long-term management strategy.
There are widespread misconceptions and lack of knowledge among both patients and health professionals concerning the nature of gout and its recommended management, which leads to suboptimal care of the most common inflammatory joint disease and the only one for which we have 'curative' treatment.

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    • "In a qualitative study of 26 Caucasian patients with gout, during the phone interviews, gout patients cited financial concerns, forgetfulness, worsening of gout, potential side effects, lack of information and doubts about the length of treatment, as reasons [15]. In another study of 20 UK gout patients (15 men, 5 women), during the semi-structured interviews with gout patients that covered a wide array of topics, patients reported non-adherence often due to concern about the side-effects or the belief that gout did not warrant any long-term treatment [16]. Our study design did not allow us to compare the barriers to gout medication adherence by gender. "
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    ABSTRACT: Limited literature exists for qualitative studies of medication adherence in gout, especially in African-Americans. The aim of this study was to examine the facilitators and barriers to adherence to urate-lowering therapy (ULT) in African-Americans with gout. In this study, nine nominal groups lasting 1 to 1.5 hours each were conducted in African-Americans with gout, six with low ULT and three with high ULT adherence (medication possession ratios of <0.80 or >=0.80, respectively). Patients presented, discussed, combined and rank ordered their concerns. A qualitative analysis was performed. This study included 43 patients with mean age 63.9 years (standard deviation, 9.9), 67% men, who participated in nine nominal groups (seven in men, two in women): African-American men (n = 30); African-American women (n = 13). The main facilitators to ULT adherence (three groups) were the recognition of the need to take ULT regularly to prevent gout flares, prevent pain from becoming chronic/severe and to have less dietary restriction; the lack of side effects from ULT; trust in physicians; and avoiding the need to seek emergent/urgent care for flares. Patients achieved high ULT adherence by organizing their pills using the pillbox and the incorporation of ULT intake into their routine to prevent forgetting. The main barriers to optimal ULT adherence were (six groups): doubts about effectiveness of ULT, concerns about cost and side effects, concomitant medications, forgetfulness, refilling the prescriptions on time, pill size and difficulty in swallowing, competing priorities, patient preference for alternative medicines (that is, cherry juice) and frequent travel. Identification of facilitators and barriers to high ULT adherence in African-Americans with gout in this study lays the foundation for designing interventions to improve ULT adherence in racial minorities.
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    • "Persistent stress related to challenging working environments with cancer patients often leads to burnout and poor quality of care [7] as well as low morale and distress to the healthcare professionals. Likewise, lack of knowledge, misconceptions about disease and lack of skills in management of a disease among health professionals may lead to suboptimal care [8]. "
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    • "Collectively, these findings provide further support for a treat-to-SU-target approach to long term allopurinol dosing [19]. A recent qualitative study of health care providers has identified barriers to effective gout management which include lack of knowledge about gout and reluctance to offer ULT as a long-term management strategy [20]. Furthermore, a ‘package of care’ intervention with close monitoring by nurse practitioners aimed to achieve serum urate target has shown excellent results in patients with gout [21]. "
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    ABSTRACT: Background Long term serum urate (SU) lowering to a target of <0.36 mmol/l (6 mg/dl) is recommended for effective gout management. However, many studies have reported low achievement of SU targets. The aim of this cross-sectional study was to examine the clinical and psychological factors associated with SU targets in patients with gout. Methods Patients with gout for <10 years were recruited from primary and secondary care settings. SU target was defined as SU concentration <0.36 mmol/L at the time of the study visit. Both clinical and psychological factors associated with SU target were analysed. The relationship between SU target and measures of gout activity such as flare frequency, tophi, work absences, and Health Assessment Questionnaire-II was also analysed. Results Of the 273 patients enrolled into the study, 89 (32.6%) had SU concentration <0.36 mmol/L. Urate-lowering therapy (ULT) use was strongly associated with SU target (p < 0.001). In those patients prescribed ULT (n = 181), allopurinol dose, patient confidence to keep SU under control, female sex, and ethnicity were independently associated with SU target. Other patient psychological measures and health-related behaviours, including adherence scores, were not independently associated with SU target in those taking ULT. Creatinine clearance, diuretic use, age, and body mass index were not associated with SU target. Patients at SU target reported lower gout flare frequency, compared with those not at target (p = 0.03). Conclusions ULT prescription and dosing are key modifiable factors associated with achieving SU target. These data support interventions focusing on improved use of ULT to optimise outcomes in patients with gout.
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