Abstract
Objective:
Achieving goal serum urate levels in patients with gout remains difficult in primary care and rheumatology practices. This study measured the ability of an asynchronous electronic visit (E-visit) program to facilitate achieving a goal serum urate (SU) of less than 6.0 mg/dL.
Methods:
We performed a retrospective cohort study in a large academic medical center rheumatology practice between April 1, 2017 and May 31, 2018. Patients with gout and SU levels over 6.0 mg/dL were enrolled in an E-visit program and were compared with historical controls who received usual care, matched 1:1 for age and sex. The primary outcome of interest was the proportion of patients achieving SU target of less than 6.0 mg/dL at six months.
Results:
Sixty-two patients were enrolled by their rheumatologist in the gout asynchronous E-visit program and were compared to 62 historical controls who were seen within one year prior to E-visit program initiation. Baseline characteristics including age, sex, body mass index, renal function, and initial SU were similar among patients enrolled in the E-visit program and controls. At six months, a significantly higher proportion of patients in the E-visit program achieved goal SU of less than 6.0 mg/dL compared to controls (63.8% vs 33.9%, respectively, p<0.01), and the E-visit patients had a lower mean SU level than historical controls (5.5 mg/dL versus 6.7 mg/dL, respectively, p <0.01).
Conclusion:
A physician-initiated E-visit program led to a substantial improvement in the rate of achieving goal SU among patients with gout within an academic rheumatology practice.
Keywords: gout, electronic visits
INTRODUCTION
As the most common inflammatory arthritis affecting nearly 4% of the US general population (1), gout has a significant impact on quality of life, productivity, and health care costs (2, 3). Despite the well-understood pathophysiology of gout and widely available, safe, and effective urate-lowering therapy (ULT), gout care remains suboptimal for many patients. The 2012 American College of Rheumatology (ACR) gout management guidelines recommend a “treat-to-target” approach in gout management, targeting a serum urate (SU) level <6.0 mg/dL in most patients with gout on ULT and <5.0 mg/dL in those with subcutaneous tophi (4). However, only 13 to 30% of patients who receive usual care for gout achieve this SU target, as has been consistently shown in a variety of practice settings, including rheumatology community practices, academic centers, and large managed care organizations (5-8). Failing to reach goal SU levels may result in a higher frequency of gout flares, development of subcutaneous tophi and permanent joint destruction and disability, as well as possible worsening of cardiovascular and renal comorbidities. Such suboptimal care has contributed to the rising global burden of gout (9), especially among the elderly (10). Indeed, hospitalizations for gout now surpass both frequency and cost of hospitalizations for rheumatoid arthritis (11, 12).
There are multiple factors that contribute to poor adherence to the “treat-to-target” approach, including lack of patient understanding of the disease and its treatment, patient-perceived ineffectiveness of treatment, insufficient time during visits for educational discussion, infrequent visits for gout care, failure by the provider or patient to obtain serial SU levels, and failure by the provider to titrate ULT dose based on SU levels (13). To this end, digital health tools may provide a unique way to alleviate many of these barriers. One such digital health tool is an electronic visit (E-visit), which represents a patient-provider interaction by which information is exchanged electronically. Patients report a strong desire to be able to communicate with their providers electronically; up to 71% of patients express interest in electronically communicating with physicians, while only 6-19% of patients actually do so (14). Numerous practices across the country are beginning to use electronic communications between providers and patients, such as E-visits, for a variety of acute and chronic health problems (15). Additional potential benefits of E-visits include facilitating provider-patient communication between office visits and opportunities for electronic patient education. To our knowledge, there have been no published studies regarding the efficacy of E-visits for gout management in rheumatology or primary care practices.
Thus, the objective of this study was to determine whether the proportion of patients with gout on ULT achieving goal SU levels could be improved with the implementation of an asynchronous E-visit program.
METHODS
Population and Study Design
We developed and implemented a gout asynchronous E-visit program in a large academic rheumatology practice at Massachusetts General Hospital, Boston, Massachusetts. An asynchronous visit is defined as one in which the provider and the patient submit their electronic communications at separate times; the communication is not occurring in real-time. All patients eligible for study entry had a clinical or crystal-proven diagnosis of gout made by a rheumatologist and at least one ICD-10 diagnostic code for gout associated with an outpatient rheumatology encounter. Patients with a SU greater than 6.0 mg/dL at the onset of study follow-up who were prescribed ULT were eligible to enroll in the E-visit program between April 1, 2017 and May 31, 2018. All patients who were enrolled in the E-visit program were included in the intervention group, even if they did not ultimately complete any E-visits (Figure 1).
Figure 1.
Enrollment Timeline for Gout E-visit Program and Historical Controls.
Historical controls were selected among all patients with gout meeting the same inclusion criteria who were seen in the rheumatology clinic during the one-year prior to availability of E-visits for gout, from April 1, 2016 through May 31, 2017. Control subjects were matched 1:1 based on age (± 1 year) and sex to the intervention group. Additionally, all historical control patients were required to have an email address listed in their patient profiles, as this was a requirement for E-visit participation in the intervention group. The E-visit patients were followed for 6 months starting from the time of E-visit enrollment. The historical control patients were followed for 6 months starting from earliest clinic visit during the time period from April 1, 2016, to May 31, 2017.
Intervention
The E-visit interface was built for Massachusetts General Hospital using the custom platform Healthcare 360 developed by Active Frequency, and a specific E-visit template was developed for patients with gout. Patients were enrolled in the gout E-visit program at the discretion of their rheumatologist during office-based encounters. Choice of ULT was also left to provider discretion. Once enrolled, patients received email reminders from the E-visit program team to access a confidential patient portal to complete E-visits at regular intervals as determined by the provider (typically monthly). The E-visit included a patient questionnaire regarding medication compliance and recent symptoms of gout, and also provided educational information on dietary triggers, medications, and the treat-to-target approach for gout management (Supplemental Figure 1). The E-visit also served as a reminder to the patient to have laboratory testing performed, as recommended by his/her physician. Once the E-visit was completed by the patient, the treating physician was notified to review the patient’s responses and to recommend further action (including adjustment of ULT dose), communicating with the patient electronically through the E-visit portal or by phone call. Completed E-visits were integrated into the electronic health record (EHR). If the patient did not respond to the E-visit within seven days, the physician could decide whether to cancel the E-visit request or to have an E-visit liaison send a reminder email or call the patient. The patients were not billed for E-visits; however, the providers did receive a small internally funded stipend for reviewing completed E-visit responses and communicating with the patient on the appropriate next steps in gout management.
Primary Endpoint and Covariates
The primary endpoint was the proportion of patients achieving a target SU level of less than 6 mg/dL in the 6 months. We also investigated the mean SU level between E-visit participants and historical controls at the end of the study period. Baseline SU was defined as SU at time of study initiation or within one year prior to study initiation based on chart review. The final SU level prior to the end of the 6-month study period was determined for each patient. If the patient did not have a follow-up SU level checked during the study period, the baseline SU level was carried forward. ULT was considered to be a continuation of therapy if the patient was already on ULT at the time of the initial visit; it was otherwise considered a new start. For the E-visit group, we determined the number of E-visits that patients completed within a 6-month time period after enrollment. For all patients, we also determined the number of office visits, not including the initial visit, that took place during the ensuing 6-month period. Demographic factors, other comorbidities such as presence of chronic kidney disease (CKD), and laboratory values such as serum creatinine were ascertained by chart review.
Sensitivity Analyses
Multiple sensitivity analyses were performed including a “per-protocol” analysis among E-visit patients who completed at least one E-visit, an analysis restricted to patients newly initiating ULT, and an analysis excluding patients without a follow-up SU level available. Due to the limited pool available for controls, sex-matched controls were not available for 3 cases. Therefore, we also performed an analysis excluding cases without sex-matched controls.
Statistical Analysis
Outcomes were compared using a two-sample t-test for continuous normally distributed variables, Wilcoxon rank sum test for continuous non-normally distributed variables, and chi-square test comparing two proportions or Fischer’s exact test (for variables with low cell sizes) for categorical variables (SAS University Edition). The level of significance was set as a two-tailed p <0.05.
RESULTS
Patient Characteristics
Sixty-two patients were enrolled in the gout E-visit program and were compared to 62 historical controls. Baseline characteristics including age, sex, body mass index, renal function, and new initiation of ULT were similar in both groups (Table 1). Enrollment in the study (i.e., index date) occurred at the time of the initial clinic visit in our rheumatology practice for 33.9% of E-visits patients and 45.2% of historical controls. At least one E-visit was completed by 69.4% of patients enrolled in the gout E-visit program, and enrolled patients completed an average of 1.6 (SD 1.5) E-visits over the 6-month study period (Table 2). A similar proportion of patients were cared for by attending physicians (80.6% in the E-visit group and 87.1% in the control group) and rheumatology fellows-in-training.
Table 1.
Baseline Characteristics of Patients with Gout Enrolled in E-visits and Historical Controls
| E-visit Program (n=62) | Controls (n=62) | |
|---|---|---|
| Age, years (mean, SD)1 | 58.0 (12.6) | 58.6 (11.3) |
| Male sex (n, %) | 52 (83.9%) | 49 (79.0%) |
| White (n, %) | 57 (91.9%) | 52 (83.9%) |
| Black (n, %) | 0 | 2 (3.2%) |
| Asian (n, %) | 3 (4.8%) | 4 (6.4%) |
| Other (n, %) | 2 (3.2%) | 4 (6.4%) |
| Hispanic (n, %) | 3 (4.8%) | 1 (1%) |
| Weight, kg (mean, SD)1 | 95.6 (18.9) | 98.7 (20.7) |
| Height, cm (mean, SD)1 | 172.5 (10.8) | 174.3 (10.6) |
| Body mass index, kg/m2 (mean, SD)1 | 32.3 (6.7) | 32.4 (6.3) |
| Creatinine, mg/dL (mean, SD)1 | 1.1 (0.3) | 1.2 (0.4) |
| Mean glomerular filtration rate (mL/min/1.73m2)1-2 |
103.4 (38.5) | 99.0 (36.5) |
| Stage 3, 4, or 5 chronic kidney disease (n, %)3 |
11 (17.7) | 10 (16.1) |
| New start of urate lowering therapy (n, %) |
37 (59.7) | 37 (59.7) |
| New to rheumatology practice (n, %) | 21 (33.9) | 28 (45.2) |
Mean values are reported with standard deviation in parentheses
Calculated by Cockroft-Gault Equation
Stage 3 or worse chronic kidney disease defined as estimated glomerular filtration rate <60 mL/min/1.73m2
Table 2.
Comparison of Treat-to-Target in Gout Patients Enrolled in E-visits Compared to Historical Controls
| E-visit Program (n=62) |
Controls (n=62) |
P- value |
|
|---|---|---|---|
| Mean number of office visits in 6 months* | 0.8 (0.8) | 1.1 (1.0) | 0.08 |
| Mean number of E-visits in 6 months* | 1.6 (1.5) | N/A | N/A |
| Completed at least one E-visit (n,%) | 43 (69.4) | N/A | N/A |
| Mean initial serum urate (mg/dL)* | 8.3 (1.5) | 8.2 (1.8) | 0.73 |
| Mean number of follow up serum urate | 1.8 (1.4) | 1.3 (1.3) | 0.03 |
| checks in study period* | |||
| Mean serum urate at 6 months (mg/dL)* | 5.5 (1.5) | 6.7 (1.6) | <0.01 |
| Allopurinol (n,%) | 56 (90.3) | 55 (88.7) | 0.77 |
| Febuxostat (n,%) | 4 (6.5) | 5 (8.1) | 0.73 |
| Probenecid (n,%) | 0 | 1 (1.6) | 0.32 |
| Pegloticase (n,%) | 1 (1.6) | 0 | 0.32 |
| Mean allopurinol dose at 6 months (mg)* | 273.5 (97.6) | 261.7 (109.8) | 0.56 |
| Dose change/escalation over 6 months (n,%)** | 45 (72.6) | 43 (70.5) | 0.70 |
| Achieved goal serum urate (n,%)*** | 37 (63.8) | 21 (33.9) | <0.01 |
All mean values are reported with standard deviation in parentheses unless otherwise indicated
Includes change in dose of ULT or switch to another medication
Goal serum urate defined as <6 mg/dL
N/A: not applicable
Serum Urate Levels at Baseline and Six-Month Follow-Up
The mean SU at enrollment was similar between the E-visit patients and historical controls (8.3 mg/dL versus 8.2 mg/dL, respectively, p = 0.73). The proportion of patients achieving a goal SU of less than 6.0 mg/dL at the end of 6 months was higher in the E-visit group compared to historical controls (63.8% versus 33.9%, respectively, p <0.01). Furthermore, the E-visit intervention patients had a lower mean SU at the end of 6 months compared to historical controls (5.5 mg/dL versus 6.7 mg/dL, respectively, p <0.01) (Table 2). Patients in the E-visit group had SU levels checked more frequently during the study period (mean 1.8 vs. 1.3 times, p=0.03). In both groups, the majority of patients (90.3% in the E-visit group and 88.7% in the control group) were treated with allopurinol, with only a small number of patients receiving febuxostat, probenecid, or pegloticase. There were 72.6% and 70.5% of patients in the E-visit and control groups, respectively, who underwent dose escalation of ULT or switch to another ULT medication during the study period. The mean prescribed allopurinol dose at 6 months was similar between the E-visit patients and control subjects (273.5 mg versus 261.7 mg, respectively, p = 0.56).
Sensitivity Analyses
In a “per-protocol” analysis of patients who completed at least one E-visit (n= 43 patients), goal SU was achieved by 70.7% compared to 33.9% of the control group (p<0.01) (Supplemental Table 1). Among patients who were newly initiated on ULT at the time of study enrollment, a similar trend was observed in achieving goal SU (55.6% compared to 35.1% among E-visits and control patients, respectively, p=0.08) (Supplemental Table 2). Among patients who had at least one follow-up SU value during the study period (85.5% of E-visit patients and 91.9% of control patients), the goal SU was achieved in 69.8% of the E-visit group compared to 36.8% of the control group (p<0.01) (Supplemental Table 3). Excluding cases without sex-matched controls, there was no significant change in the results (Supplemental Table 4).
DISCUSSION
In this retrospective cohort study conducted at a single large academic rheumatology practice, we found that the use of asynchronous E-visits by patients with gout undergoing titration of ULT resulted in a significantly higher proportion of patients achieving the target SU level of less than 6.0 mg/dL, as compared to those receiving usual care. Although the baseline mean SU level was comparable between the two groups, the patients in the E-visit group had a mean SU level at the end of 6 months that was 1.2 mg/dL lower than the historical control group. Only one-third of historical controls achieved treat-to-target goals, which is consistent with what has been reported in the literature as part of routine care in a wide range of practice settings (5-8).
The doubling of the treat-to-target achievement rate within 6 months with the E-visit intervention is a statistically and clinically significant improvement compared to historical controls. However, this rate is still lower than that achieved with nurse-led gout care in the United Kingdom (UK) in a recent clinical trial by Doherty and colleagues (16). In this study, nurse-led care resulted in 95% of patients achieving target SU levels compared to 30% with standard general practitioner care; patients in the nurse-led care group also experienced less frequent gout flares, reductions in tophi, and improved quality-of-life metrics at 2 years (16). The nurses were specifically recruited and trained for the UK clinical trial to provide individualized yet highly comprehensive care, including holistic assessments of the patient, discussions regarding illness perceptions, extensive gout education, and engagement in shared decision making. While our E-visits were designed to emulate many facets of this comprehensive care approach, the lower proportion of patients achieving goal SU levels in our study likely reflects persistent barriers which could not be fully overcome by E-visits, such as patients or providers declining to engage in E-visits or time constraints for more complicated discussions that could not be addressed with E-visits alone. Another notable difference of the UK study was that it was conducted as a clinical trial with dedicated research nurses, whereas our study was carried out as a part of routine clinical care, reflecting a “real world” practice setting.
Notably, the mean allopurinol dose at the end of the 6-month period in our study did not differ substantially between the two groups despite the difference in primary outcome. The mean daily allopurinol dose was under 300 mg for both groups, which is a dose lower than expected to achieve goal SU for many patients (17, 18). Though we do not have data on the number or rates of prescription filling, it may suggest improved adherence to the prescribed ULT in the E-visit group, and adherence may have contributed to the differences in achieving SU levels between the two groups. Alternatively, as this study relied on retrospective chart review, it is possible that the dose of allopurinol indicated in the medical record did not accurately reflect the most recent dose that the patient was taking based on undocumented communication with their providers.
Other unmeasured factors, such as a reduction in alcohol use or other lifestyle changes in response to the educational component of the E-visits, could have also accounted for the difference in the proportion of patients reaching goal.
Nevertheless, E-visits served as a scheduled, easy-to-use virtual platform for provider-patient communication between clinic visits to assess for symptoms and flare occurrences while encouraging medication adherence. They also served as a mechanism to reinforce patient education, remind patients to obtain labs, and prompt providers to titrate the ULT dose.
Therefore, E-visits likely helped overcome several barriers to achieving goal SU levels for patients with gout primarily through efficient yet personalized communication. However, other modes of facilitating patient-provider communication such as e-mail, text messages, or use of mobile phone applications may accomplish similar goals in achieving treat-to-target in gout management. Future studies to examine the effectiveness and cost of different methods of communication in various healthcare settings are warranted.
There are several strengths and limitations of this study. This retrospective study is the first of its kind to employ and evaluate a physician led E-visit program with the goal of achieving target SU levels among gout patients. As patients with gout were identified by a rheumatologist’s assessment, misclassification of a gout diagnosis is likely to be minimal. However, patients were enrolled in the E-visit program at the providers’ discretion; thus, there may have been selection bias. To minimize this, historical controls were used as the comparison group instead of using patients who did not choose to enroll in E-visits during the time period in which this intervention was evaluated. Additionally, possessing an active email address was included in the inclusion criteria for both groups to ensure similarity with respect to technology access and the potential to enable E-visit use. Nevertheless, the patients who chose to participate in E-visits may have had unmeasured inherent differences that affected the outcome. We were unable to quantify whether patient-provider interactions increased in general with enrollment in the E-visits, as phone calls may be inconsistently documented in the EHR. Further studies could assess the optimal frequency of electronic patient interactions to achieve the SU goals. Furthermore, although we used a standardized E-visit questionnaire that included patient education material, other aspects of the E-visit intervention were left to the providers’ discretion, including ULT agent and dose titration, frequency of E-visits, and any additional counseling. Thus, there may have been differences in the practice patterns of individual providers which could have affected both the patients’ decisions to participate in the E-visit program and the primary outcome. This flexibility was incorporated into the intervention to facilitate its integration with routine clinical practice, allowing physicians to utilize the gout E-visit program while providing individualized treatment for patients. However, this heterogeneity may limit its incorporation into future treatment models and additional studies are needed to investigate a more uniform intervention that utilizes E-visits. Additionally, gout flare frequency, presence of tophi, and other patient-reported outcome measures were not assessed in this study. However, we evaluated the guideline-driven outcome of achieving SU <6.0mg/dL (4). Lastly, as computer-associated physician burnout continues to be a significant problem, E-visits will need to be incorporated into clinical practice in a way that is sustainable for providers. We did not evaluate the impact of the E-visit program on workflow or provider satisfaction. In this pilot study, the patients were not billed for E-visits but the providers did receive a small internally funded stipend to review the E-visit responses; future studies could investigate the feasibility of provider payment for these types of interventions using a telemedicine code, which may help partially mitigate physician burnout.
Based on the results of our study, E-visits could enhance achievement of goal SU levels, providing more flexibility for patients and providers, more frequent contact for patients with their provider’s office, and less financial burden for both patients and the healthcare system. E-visits conducted by nurse practitioners or physician assistants or by primary care physicians rather than rheumatologist physicians, could additionally be studied. The incorporation of E-visits as opposed to in-person visits could facilitate improved access to care and availability of appointments for other patients. However, it remains important to assess the cost-effectiveness of E-visits as well as its impact on patient-reported outcomes.
In conclusion, this study suggests that E-visits may be a useful tool for optimizing achievement of target SU levels among gout patients. Further studies are required to identify subpopulations of patients who are most likely to benefit from this type of intervention and to assess the generalizability and cost effectiveness of an E-visit program in other practice settings.
Supplementary Material
Acknowledgments
Funding/Support: CY, AJ, KD, NSB, and MN are supported by the National Institutes of Health Ruth L. Kirschstein Institutional National Research Service Award [T32-AR-007258]. AJ is supported by the Rheumatology Research Foundation Scientist Development Award.
Footnotes
Financial Disclosures: No authors report conflicts of interest.
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