Improving gout outcomes and achieving equity

Gout is inextricably linked with other major long-term conditions such as diabetes, and cardiovascular and renal disease. Take the opportunity to screen for these comorbidities in your patients with gout.¹

With a single-medication regimen, gout is more easily treatable compared with other long-term conditions, and the incidence of gout flares is helpful as a primary care quality indicator.¹

Identifying patients with gout and providing successful treatment can relieve its debilitating physical, painful, social, psychological and spiritual effects, and restore wellbeing.

In te ao Māori, a holistic view of health and wellbeing, hauora, is paramount. Encouraging people to take a long-term management approach to their gout makes it possible to address their health in a more holistic manner.

As well as improved overall outcomes for gout, equitable outcomes are long overdue. Māori and Pacific peoples in Aotearoa New Zealand:

• have a much higher burden of gout than non-Māori, non-Pacific populations
• develop gout at a much earlier age and with greater severity
• start urate-lowering therapy (ULT) at a younger age (but perhaps not soon enough)
• have poorer outcomes and greater rates of hospitalisations for gout (see table below).^2,3

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Inequities in gout and its treatment ^1-4

In 2021, Pharmac published Gout Insights – Impact on Māori, a baseline report which concluded an estimated 10,400 more Māori need to be started on preventive gout medicine each year to achieve equity. The corresponding 2022 report into Pacific peoples found that number to be 8700 more people to achieve equity of access to medicines.^2,3

While gout is most commonly seen in men, Māori and Pacific women remain disproportionately affected compared with non-Māori, non-Pacific women.^1,4 Early-onset gout is also much more prevalent in Māori and Pacific peoples; over the period 2016 to 2020, these groups started preventive gout medicine on average 10 to 13 years earlier than non-Māori, non-Pacific peoples.^1,5 While this is highly indicative of the higher and earlier disease burden, Māori and Pacific peoples should perhaps be starting their gout preventive treatments even sooner to achieve equitable care.^2,3

In June 2023, the Gout Guide was launched, following a project funded by Te Whatu Ora Long-Term Conditions directorate. The website is supported by Health literacy NZ and Health Navigator Charitable Trust and builds on findings from several gout programmes across Aotearoa, providing practical tools and insights for a fresh take on gout management.⁶

The guide is a toolkit of modules, exercises, resources, examples, case studies and links to further education for your team. Its aim is to help all involved in healthcare provision to build – from the ground up if necessary – a more effective and equitable approach to gout care, or to join with other providers already farther down this path. A brief overview of the component modules follows.

Gout education for your team

Identifies and expands on seven key areas of clinical knowledge and provides a pre- and post-education quiz to assess the impact of the module on your team. Best practice treatment and management have changed in recent years, as has the messaging around causation. Your level of knowledge for gout should ideally be as up to date and complete as your knowledge of diabetes.

Building your team

Gives a list of clinical and non-clinical roles you may need within your team. Remember, many of the conversations between your team and your whānau Māori and Pacific peoples don’t require a health professional until the talk turns to prescribing medication. Gout champions, kaiāwhina, health improvement practitioners and health coaches can achieve a great deal by talking with people about their beliefs and helping them think about the value and role of long-term medicines.

Medicines and prescribing

Pulls out the key points about ULT and links to treatment guidelines through HealthPathways. Additional resources include a form developed by the ProCare Gout Collaborative (helps you to coordinate gout care as well as find key laboratory results, medicines prescribed and pathway advice all in one place), a sample gout standing order from a community pharmacy group and an example prescribing regimen developed by the Whanganui GOUT STOP Programme.

Data

Presents stepwise advice beginning with deciding who to prioritise, and then refining the data to select target groups, creating a baseline (identifying the issue and its size), and using the data to drive the programme and monitor and track progress. Examples and suggestions are provided. Methods used to explore your prescribing further include PMS data queries, PHO queries, Dr Info, EPiC Gout dashboard and EPiC Reflect Gout.⁷

Point-of-care testing

Introduces the utility of point-of-care testing (POCT) for uric acid and includes a “how-to-use” video demonstration of the BeneCheck 3-in-1 Multi-Monitoring Meter for blood glucose, total cholesterol and uric acid. Also includes scripted talking points for explaining POCT and uric acid results to patients. Testing can be made much more accessible if a non-clinical staff member is trained to use the meter, overcoming many barriers for whānau Māori and Pacific peoples.

Better conversations about gout

Explains and promotes use of the three-step process in every health discussion to identify prior knowledge, thoughts and feelings, particularly in conversations with whānau Māori and Pacific peoples. Sometimes, erroneous beliefs about gout (through experience or passed on by trusted whānau and friends) have been reinforced by the health sector. The multilingual resources contain extensive discussion points and example patient responses to help address anxieties, uncertainty, common concerns and beliefs, and treatment inertia.

Care pathways and workflows

Presents examples of planning models and tools that may work for your team and your gout project goals. New pathways and workflows may be needed, and this module outlines key opportunities including the health coach role, proactive contact, partnering with community pharmacy, monitoring, POCT, titration and avoiding interruptions to medicine supply.

Equity

Highlights outcomes-focussed actions and goals needed to move towards equity for whānau Māori and Pacific peoples with gout. Resources in this module include links to Pharmac gout data insights (Māori and Pacific peoples), and gout-specific equity webinars, videos, articles and case studies.

Patient and whānau resources

The patient booklet Change your life – stop the pain of gout by bringing your uric acid levels down is available in English, te reo Māori, Samoan and Tongan. This module links to eight short videos on living well with gout that explain key topics, as well as practice posters and postcards with key messages for Māori and Pacific peoples.

Gout and young men

Explains the higher prevalence of gout in young Māori and Pacific men and guides you in addressing the general reluctance of this group to take daily medication. Contains practical ideas for engagement, and gentle persistence, in a similar way to facilitating smoking cessation (a useful parallel), and links to a He Ako Hiringa podcast on the psychological effects of initiating new medicines.

Removing barriers

Stresses the need to recognise and remove barriers for whānau Māori and Pacific peoples with gout, including addressing self-blame and stigma, improving access to medicines and clinical support (long term), and the big two: patient cost and time. Provides helpful messaging, solutions and summaries of real-world barriers and initiatives from the Whanganui GOUT STOP Programme evaluation report and a marae primary health clinic.⁸

Funding

Explores what you and your practice can do to address the barrier of patient cost, providing action points and suggesting funding opportunities through Care Plus, via PHOs or engaging with pharmacy, or innovation funding and grants for quality improvement projects. This module encourages you to pursue all potential avenues for financial resourcing to enhance gout management and improve outcomes.

Partnering with community pharmacy

Promotes the well-established models available through the Community Pharmacy Gout Management Service where pharmacists undertake initiation and titration of allopurinol, and related POCT, to support patients to reach treatment goals. Cites a full example standing order for use in community pharmacy and describes the considerations and benefits of partnering.

Involving whānau Māori and Pacific peoples with gout

Reminds practitioners of the benefits of respectful engagement at the beginning of any community gout initiative, positioning it as a joint enterprise.

Raising awareness in the community

Provides ideas on changing the narrative and understanding around gout by being out in the community. Includes how to respectfully engage to develop a new understanding among whānau Māori and Pacific peoples who may have misunderstandings about gout and unresolved concerns about Western medicine: both barriers to improving gout outcomes.

Shared medical appointments and group visits

Invites you to consider the practical considerations, appropriateness, benefits and facilitation requirements of shared medical appointments. For Māori and Pacific peoples with gout in the same workplace, it can be mutually beneficial to address gout in this way.

Setting up a collaborative with other practices

Uses ProCare’s structured, evidence-based "Better Together Collaboratives" quality improvement methodology as an example of general practice teams working together to improve services to patients. Outlines the preparation, project aims, brainstorming and collaboration ideas, and review phases involved.

Continuous quality improvement activities

Participation in a project such as those described in the Gout Guide is evidence you can use for continuing professional development, and Cornerstone CQI and Equity projects. This module links to the free He Ako Hiringa CQI Toolkit (for antimicrobial stewardship) which has templates, examples and guided support you can adapt for your gout project.⁹

Gout initiatives in New Zealand

The Gout Guide is informed by 20 years of gout improvement and research projects, details of which are provided in this module. It is useful to direct locum or virtual prescribers, who usually live outside of your area, to this section to learn about local gout programmes.

Improving gout care and achieving equity for whānau Māori and Pacific peoples requires barriers to be addressed. It is fundamental to examine community beliefs about gout and to counter stigma and misinformation by reinforcing accurate and helpful messages at every possible opportunity (by non-clinical team members as well, and outside of the healthcare setting). If people are unwilling to engage and consider the benefits of ULT, successes will be hard to come by. Unhelpful beliefs include:

• “Gout is caused by overindulgence.” The cause of gout is 90 per cent genetic, predisposing whānau Māori and Pacific peoples to reduced renal excretion of uric acid. The unhelpful belief about diet and alcohol as primary causes, with self-blame and associated whakamā (shame), is perpetuated in workplaces, the media and sometimes the healthcare sector.
• “Gout is intermittent and when the pain is gone, the gout is gone.” This idea supports a belief that periodic pain relief (eg, NSAIDs) is sufficient, but a kōrero about the wider implications of uncontrolled serum urate levels may help change this.
• “Gout is something to be endured.” The genetic component means it is likely those with gout have seen whānau endure the pain of gout and see this as normal.
• “Being on medication is a sign you are unhealthy.” This a particular barrier in younger men but promoting the view that taking a long-term medicine is not as bad as having gout may help, especially if delivered by a health coach or kaiāwhina.

More beliefs and building new understandings about gout are worked through as part of the Gout Guide.¹⁰

Addressing gout inequity needs an approach akin to that for smoking cessation. Keep mentioning it if there is no immediate breakthrough (including reminders by phone or text) rather than labelling the person as non-compliant.

The Change Your Life booklet (available via the Gout Guide) is a useful resource on which to base your conversations (with gout education, case examples and decision aids), as are the two-part He Ako Hiringa podcasts Initiating New Medicines and Let’s Talk Gout. ^11–14

Long-term gout management requires ULT, with allopurinol first line. There are barriers to the uptake, titration and continuation of allopurinol, and these may be addressed as follows.

• Most people present when they are having an acute flare. While allopurinol should be discussed at a first flare, cognitively this may not always be a good time. Schedule a follow-up and discuss ULT at each appointment.
• Patients may be treatment-naive or have already tried ULT and still experience gout flares. Education should be provided about what allopurinol does, how symptoms are affected by serum urate levels, the reason for allopurinol titration (to reduce the risk of flares and drug reactions), the role of anti-inflammatory prophylaxis (ie, colchicine, prednisone or NSAID) while up-titrating, why it is important to continue allopurinol even if flares occur and not let supply or usage lapse. In time and at a sufficient dose, allopurinol will lower serum urate enough to control flares.
• Titration can require repeat visits, a barrier for many due to cost, time or transport. Look for ways to offer gout appointments using solutions suggested in the Gout Guide. This can involve community pharmacy: eg, the Midland Region HealthPathways describes pharmacies that may have funding for patient education on ULT (initiated by annotating “for pharmacist education” on the prescription).
• Patients sometimes stop taking their allopurinol because they run out, think they do not need it because they have had no flares, or cannot get to the clinic/pharmacy. Serum urate returns to pretreatment levels within about two weeks after stopping allopurinol, and recommencement thereafter requires re-titration (and anti-inflammatory prophylaxis). Patients should understand that treatment needs to be consistent, or flares will recur. Standing orders and other ways to facilitate patient access to medication are suggested in the Gout Guide.