Background/Purpose: Gout is the most common inflammatory arthritis in adults worldwide. It can be managed by primary care physicians (PCPs), but complex cases often require rheumatology input. However, the average wait time for a first rheumatology clinic visit varies from 38 days to 47 weeks. By utilizing electronic consultation (e-consult) which allows two-way communications between referring and rheumatology physicians (pre-consult exchange), rheumatologists can decide whether patients can be managed by addressing the clinical questions electronically, or a face-to-face patient evaluation is necessary. We analyzed the effectiveness of gout management via e-consult compared to PCP and face-to-face rheumatology visits at the VA Medical Center in Long Beach.

Methods: A retrospective study of 133 VA gout patients from 2013 to 2014 was constructed and grouped by their management under rheumatology e-consults (n = 33), rheumatology clinic visits (n = 52), or PCP visits (n = 37). Electronic medical records were reviewed for a 24-month period from their initial gout flare or e-consult date. The effectiveness in management was measured by the change in frequency of gout flares and related emergency department (ED) visits, renal function and serum uric acid levels (sUA).

Results: Of the 48 gout e-consults, 33 cases were resolved electronically, and 15 were converted to rheumatology clinic visits. The wait time for recommendations from e-consult was 3.7 days. Face-to-face clinic visit took 20.3 days after pre-consult exchange (vs 71.3 days for direct clinic consult). Compared to PCP managed patients, both e-consult and rheumatology clinic patients have more gout attacks and related ED visits at baseline (p =0.08). They have fewer attacks in the first 12 months of management, with decreased sUA and improved renal function (p =0.06), (p =0.1), and are more likely to be treated with allopurinol, colchicine, febuxostat and corticosteroids than with NSAIDs alone (p <0.05). E-consult management was comparable but second to rheumatology clinical visits (p not significant), but beyond 12 months, disease activity was stable and similar in all groups.

Conclusion: More effective gout management can be achieved by referring patients with uncontrolled disease to direct rheumatology visits or e-consults in the first 12 months. Patients can be transitioned to PCP management after 12 months if disease is stable. Overall, e-consult serves as a reasonable alternative in managing gout. Clinical questions can be addressed electronically resulting in a shorter wait time and more efficient referrals to the rheumatology clinic.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-utility-of-electronic-consultation-in-the-management-of-gout-at-the-veterans-affairs-medical-center/