Technology, COVID-19, and approaching the insoluble problems of gout care

Gout is the most common inflammatory arthritis and has effective treatments; it can be cured by attaining serum urate targets with titration of urate-lowering therapy. However, it remains unclear why treatment outcomes for people with gout are consistently suboptimal. It seems reasonable to assume that the disruptions caused by the COVID-19 pandemic could have further worsened gout outcomes. In The Lancet Rheumatology, Mark D Russell and colleagues1Russell MD Massey J Roddy E et al.Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELY.Lancet Rheumatol. 2023; (published online Aug 31.)https://doi.org/10.1016/S2665-9913(23)00206-0Crossref Google Scholar have leveraged the digital infrastructure of the UK National Health Service to report on gout care during the past 5 years in England, including the COVID-19 pandemic. The OpenSAFELY data analytics platform enables analysis of pseudonymised patient records for a large proportion of the UK population. OpenSAFELY was kickstarted by the pandemic and quickly reported on risk factors for poor outcomes from COVID-19, influencing health care and policy globally.2Williamson EJ Walker AJ Bhaskaran K et al.Factors associated with COVID-19-related death using OpenSAFELY.Nature. 2020; 584: 430-436Crossref PubMed Scopus (3631) Google Scholar What then can be learnt from OpenSAFELY about routine gout health care, including testing our assumptions about the impact of the COVID-19 pandemic? The OpenSAFELY analysis reported a 30·9% decline in newly recorded gout diagnoses in primary care records and a 30·1% reduction in hospitalisations for gout in the year beginning March, 2020 (ie, the start of the first COVID-19 lockdown in England), compared with the year preceding the pandemic.1Russell MD Massey J Roddy E et al.Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELY.Lancet Rheumatol. 2023; (published online Aug 31.)https://doi.org/10.1016/S2665-9913(23)00206-0Crossref Google Scholar The number of newly recorded gout diagnoses increased slightly in 2021 and 2022, but remained below pre-pandemic levels. Because these data are from actual patient records, these reductions probably represent a decrease in people with gout flares presenting for care during the COVID-19 pandemic. These findings put a spotlight on the ongoing challenges in gout care—the underestimation of gout and its consequences for people with undiagnosed gout, and the barriers to accessing health care. It does not matter how effective the treatment strategy is if people with gout do not get medical attention in the first place. Many personal and societal factors affect health-care access for people with gout. Misperceptions regarding the nature of gout and its treatment can affect health-care-seeking behaviour and are common even among people already diagnosed with gout.3Dalbeth N Petrie KJ House M et al.Illness perceptions in patients with gout and the relationship with progression of musculoskeletal disability.Arthritis Care Res (Hoboken). 2011; 63: 1605-1612Crossref PubMed Scopus (101) Google Scholar During the early phase of the disease, gout flares can be easily suppressed by over-the-counter anti-inflammatory medications, creating a false sense of control over a disease perceived as self-limiting and not serious.4Te Karu L Kenealy T Bryant L Arroll B Harwood M The long shadow of inequity for Māori with gout.MAI Journal. 2020; 9: 152-165Crossref Scopus (6) Google Scholar The widely held misperceptions that gout is self-inflicted, due to an inappropriate diet or overconsumption, might also reduce health-care-seeking behaviours.5Doherty M Jansen TL Nuki G et al.Gout: why is this curable disease so seldom cured?.Ann Rheum Dis. 2012; 71: 1765-1770Crossref PubMed Scopus (222) Google Scholar During the COVID-19 pandemic, the disruption of the lockdowns might have exacerbated the known barriers to health care for people with gout, including time, transport, and direct costs of care,4Te Karu L Kenealy T Bryant L Arroll B Harwood M The long shadow of inequity for Māori with gout.MAI Journal. 2020; 9: 152-165Crossref Scopus (6) Google Scholar thus resulting in reduced access to health care for people with gout. Actions at societal and systems levels will be required to enhance gout care by addressing gout myths and improving health-care access. The study by Russell and colleagues1Russell MD Massey J Roddy E et al.Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELY.Lancet Rheumatol. 2023; (published online Aug 31.)https://doi.org/10.1016/S2665-9913(23)00206-0Crossref Google Scholar has nonetheless shown the remarkable resilience of the health-care system. Between 2015 and 2022, despite a very gradual increase in gout prevalence, there was a modest increase in the proportion of people with new gout diagnoses who started urate-lowering therapy within 6 months of diagnosis.1Russell MD Massey J Roddy E et al.Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELY.Lancet Rheumatol. 2023; (published online Aug 31.)https://doi.org/10.1016/S2665-9913(23)00206-0Crossref Google Scholar Despite the impact of the pandemic, once a gout diagnosis was made, gout treatment rates were sustained and even improved. Rapid implementation of telemedicine and involvement of nurses or pharmacists for patient education and telephone-based or internet-based monitoring could have contributed to the positive outcomes.6Bateman J Cleaton N Managing patients using telerheumatology: lessons from a pandemic.Best Pract Res Clin Rheumatol. 2021; 35101662 Crossref PubMed Scopus (20) Google Scholar These interventions improve adherence to urate-lowering therapy and have gained interest in the past decade.7Gill I Dalbeth N 'Ofanoa M Goodyear-Smith F Interventions to improve uptake of urate-lowering therapy in patients with gout: a systematic review.BJGP Open. 2020; 4 (bjgpopen20X101051)Crossref PubMed Scopus (22) Google Scholar Although remote consultations might not be appropriate for gout diagnosis, particularly where joint aspiration is indicated, optimisation of urate-lowering therapy seems perfectly suited for telemedicine. Models of care that reduce barriers for patients must be further explored and, where possible, adopted permanently. Although the insights to gout care from the study by Russell and colleagues suggest that more work is needed to attain positive outcomes for all people with gout, this study has bigger implications: it further confirms that routinely collected health data can be used to report on indicators of care quality. The Rheumatology Informatic System for Effectiveness (RISE) registry in the USA also uses routinely collected health-care data, although specifically from rheumatology practice, to report on and inform quality improvement initiatives and provide a rich dataset for research. In a recent RISE registry analysis including 9560 people with gout and at least 12 months of urate-lowering therapy, 5332 (55·8%) had serum urate measured in a 1-year period in 2018–19. Of those, 3933 (73·8%) had attained serum urate targets.8Hammam N Li J Kay J Izadi Z Yazdany J Schmajuk G Monitoring and achievement of target serum urate among gout patients receiving long-term urate-lowering therapy in the American College of Rheumatology RISE registry.Arthritis Care Res (Hoboken). 2023; 75: 1544-1552Crossref PubMed Scopus (1) Google Scholar These studies using OpenSAFELY and RISE give hope for gout care. Interventions at the system level, alongside implementation science and quality improvement initiatives, supported by technology that analyses routinely collected health data, might ultimately improve gout care at scale. That would be a remarkable achievement. For OpenSAFELY see https://www.opensafely.org/ For OpenSAFELY see https://www.opensafely.org/ We declare no competing interests. Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELYUsing gout as an exemplar disease, we showed the complexity of how health care was impacted during the COVID-19 pandemic. We observed a reduction in gout diagnoses but no effect on treatment metrics. We showed how country-wide, routinely collected data can be used to map disease epidemiology and monitor care quality. Full-Text PDF Open Access