Background/Purpose: Gout is the most common chronic inflammatory arthritis. Gout prevalence has been rising over the past several decades, and gout is associated with significant health and financial burden. Numerous guidelines including 2012 American College of Rheumatology (ACR) guidelines have been published for management of gout. However, compliance with these practice guidelines remains poor. To promote adherence to management guidelines and improve quality of care for gout, ACR has developed a set of quality measures. We evaluated the performance of these quality measures at our university practice group.

Methods: We established a registry of patients receiving care for gout at our university practice group since 6/2013 using electronic medical record (EMR) and administrative database (ICD-9 codes 274.XX). Using a subset of this population being followed for gout over the past 12 months, we tested the three quality measures developed by ACR including: (1) Treat to Target: percentage of patients aged 18 and older with a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months whose most recent serum urate result is less than 6.8mg/dL; (2) ULT indications for therapy: percentage of patients aged 18 and older with a diagnosis of gout and either tophus/tophi or at least two gout flares (attacks) in the past year who have a serum urate level >6.0mg/dL, who are prescribed ULT; (3) serum urate monitoring: percentage of patients aged 18 and older with a diagnosis of gout who were either started on ULT or whose dose of ULT was changed in the year prior to the measurement period and who had their serum urate level measured within 6 months.

Results: From the university practice, 4988 patients were identified, 18 years of age or older with a diagnosis of gout. For the Treat to Target measure, 1183 (47.7%) of 2478 patients on ULT met the serum urate target of <6.8mg/dL. For the ULT indications measure, 329 (70.9%) of 464 patients with tophaceous gout or recurrent flares and serum urate level >6.0mg/dL were appropriately prescribed ULT. For the serum urate monitoring measure, 1259 (35.8%) of 3517 patients with new start or modification of ULT had serum urate level measured within 6 months. Several potential challenges in implementation were identified in our evaluation of the ACR quality measures. The Treat to Target measure appeared to be the most straightforward measure to implement, but outside labs not captured by the EMR posed a problem. For the ULT therapy measure, we encountered difficulties with establishing reliable criteria for capturing gout flares. Accurate recognition of modification of ULT dose was the primary challenge for the serum urate monitoring measure.

Conclusion: Analysis of gout patients at our university practice using the ACR quality measures confirms suboptimal adherence to available practice guidelines. Our analysis also identifies potential challenges in implementation of the ACR quality measures. Some of these challenges are practice specific (higher prevalence of outside labs at university referral practice), and others (identification of flares and medication changes) are amenable to modification of specifications to best match varying structures and available data from different EMR systems. Ability to accurately assess quality measures using EMR is an essential step in promoting adherence to practice guidelines. Continued efforts at optimizing quality measure assessments will help provide the foundation for design and implementation of future quality improvement projects.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/assessment-of-american-college-of-rheumatology-gout-quality-measures-at-a-university-practice-plan/