University Medicine Cluster, Division of Rheumatology, National University Health System, 1E Kent Ridge Road, Singapore.
Scand J Rheumatol. 2012;41(6):450-7. doi: 10.3109/03009742.2012.689325. Epub 2012 Jul 28.
Gout care is suboptimal because of lack of translation of knowledge into real-world practice, despite evidence-based guidelines. We have developed processes to ensure systematic care for gout patients and determined the predictors for achievement of a target serum uric acid (SUA) concentration of < 360 μmol/L in a prospective cohort of Asian gout patients requiring allopurinol therapy.
A 1-year clinical practice improvement project was undertaken using evidence-based guidelines and quality planning tools. Interventions included comprehensive patient education, enhanced telephone access, reappointments and refills, upward titration of allopurinol with no limitation specified by renal function, and increased frequency of visits until the target SUA concentration was achieved. The primary outcome was the time to achieve an SUA level of <360 μmol/L.
We recruited 126 gout patients. The median time to achieving the target SUA concentration was 36.9 weeks [95% confidence interval (CI) 29.3-44.4]. Based on survival analysis, the proportion of patients achieving the target was 8.1% (95% CI 3.2-13.0), 40.6% (95% CI 31.4-50.8), and 72.0% (95% CI 61.2-82.8) at 3, 6, and 12 months, respectively. On average, our patients who achieved the target were seen once every 2 months and achieved the target after a mean of 2.5 (SD = 1.1) visits. Frequency of follow-up visits and older patients not taking aspirin were independent predictors associated with achieving the target outcome, regardless of renal function.
Optimization of control of SUA is achievable, even in the setting of renal impairment, by redesigning and implementing processes involving changes in physician prescribing habits, enhanced nursing interventions, and patient empowerment and education.
尽管有循证指南，但由于缺乏将知识转化为实际实践，痛风护理仍不理想。我们已经制定了流程，以确保为痛风患者提供系统的护理，并确定了需要别嘌醇治疗的亚洲痛风患者队列中实现血清尿酸（SUA）浓度<360μmol/L 目标的预测因子。
使用循证指南和质量规划工具进行了为期 1 年的临床实践改进项目。干预措施包括对患者进行全面的教育、增强电话访问、重新预约和续药、根据肾功能不限制别嘌呤醇的剂量进行递增滴定，以及增加就诊次数，直到达到目标 SUA 浓度。主要结果是达到<360μmol/L 的 SUA 水平所需的时间。
我们招募了 126 名痛风患者。达到目标 SUA 浓度的中位数时间为 36.9 周[95%置信区间（CI）29.3-44.4]。根据生存分析，达到目标的患者比例分别为 8.1%（95%CI 3.2-13.0）、40.6%（95%CI 31.4-50.8）和 72.0%（95%CI 61.2-82.8）在 3、6 和 12 个月时。平均而言，我们达到目标的患者每 2 个月就诊一次，平均就诊 2.5（SD=1.1）次后达到目标。就诊频率和不服用阿司匹林的老年患者是与达到目标结果相关的独立预测因素，与肾功能无关。
通过重新设计和实施涉及改变医生处方习惯、增强护理干预以及赋予患者权力和教育的流程，可以实现 SUA 控制的优化，即使在肾功能受损的情况下也是如此。
