Priyanka Chandratre

Health-related quality of life in gout: a systematic review

Objectives. To identify the instruments that have been used to measure health-related quality of life (HRQOL) in gout and assess their clinimetric properties, determine the distribution of HRQOL in gout and identify factors associated with poor HRQOL. Methods. Medline, CINAHL, EMBASE and PsycINFO were searched from inception to October 2012. Search terms pertained to gout, health or functional status, clinimetric properties and HRQOL. Study data extraction and quality assessment were performed by two independent reviewers. Results. From 474 identified studies, 22 met the inclusion criteria. Health Assessment Questionnaire Disability Index (HAQ-DI) and Short Form 36 (SF-36) were most frequently used and highest rated due to robust construct and concurrent validity, despite high floor and ceiling effects. The Gout Impact Scale had good content validity. Gout had a greater impact on physical HRQOL compared to other domains. Both gout-specific features (attack frequency and intensity, intercritical pain and number of joints involved) and comorbid disease were associated with poor HRQOL. Evidence for objective features such as tophi and serum uric acid was less robust. Limitations of existing studies include cross-sectional design, recruitment from specialist clinic settings and frequent use of generic instruments. Conclusion. Most studies have used the generic HAQ-DI and SF-36. Gout-specific characteristics and comorbidities contribute to poor HRQOL. There is a need for a cohort study in primary care (where most patients with gout are treated) to determine which factors predict changes in HRQOL over time. This will enable those at risk of deterioration to be identified and better targeted for treatment.

Increased cardiovascular mortality associated with gout: a systematic review and meta-analysis

Background Hyperuricaemia, the biochemical precursor to gout, has been shown to be an independent risk factor for mortality from cardiovascular disease (CVD), although studies examining the clinical phenomenon of gout and risk of CVD mortality report conflicting results. This study aimed to produce a pooled estimate of risk of mortality from cardiovascular disease in patients with gout. Design Systematic review and meta-analysis. Methods Electronic bibliographic databases were searched from inception to November 2012, with results reviewed by two independent reviewers. Studies were included if they reported data on CVD mortality in adults with gout who were free of CVD at time of entry into the study. Pooled hazard ratios (HRs) for this association were calculated both unadjusted and adjusted for traditional vascular risk factors. Results Six papers, including 223,448 patients, were eligible for inclusion (all (CVD) mortality n = 4, coronary heart disease (CHD) mortality n = 3, and myocardial infarction mortality n = 3). Gout was associated with an excess risk of CVD mortality (unadjusted HR 1.51 (95% confidence interval, CI, 1.17–1.84)) and CHD mortality (unadjusted HR 1.59, 95% CI 1.25–1.94)). After adjusting for traditional vascular risk factors, the pooled HR for both CVD mortality (HR 1.29, 95% CI 1.14–1.44) and CHD mortality (HR 1.42, 95% CI 1.22–1.63) remained statistically significant, but none of the studies reported a significant association with myocardial infarction. Conclusions Gout increases the risk of mortality from CVD and CHD, but not myocardial infarction, independently of vascular risk factors.

Prospective observational cohort study of Health Related Quality of Life (HRQOL), chronic foot problems and their determinants in gout: a research protocol

BackgroundGout is the commonest inflammatory arthritis affecting around 1.4% of adults in Europe. It is predominantly managed in primary care and classically affects the joints of the foot, particularly the first metatarsophalangeal joint. Gout related factors (including disease characteristics and treatment) as well as comorbid chronic disease are associated with poor Health Related Quality of Life (HRQOL) yet to date there is limited evidence concerning gout in a community setting. Existing epidemiological studies are limited by their cross-sectional design, selection of secondary care patients with atypical disease and the use of generic tools to measure HRQOL. This 3 year primary care-based prospective observational cohort study will describe the spectrum of HRQOL in community dwelling patients with gout, associated factors, predictors of poor outcome, and prevalence and incidence of foot problems in gout patients.MethodsAdults aged ≥ 18 years diagnosed with gout or prescribed colchicine or allopurinol in the preceding 2 years will be identified through Read codes and mailed a series of self-completion postal questionnaires over a 3-year period. Consenting participants will have their general practice medical records reviewed.DiscussionThis is the first prospective cohort study of HRQOL in patients with gout in primary care in the UK. The combination of survey data and medical record review will allow an in-depth understanding of factors that are associated with and lead to poor HRQOL and foot problems in gout. Identification of these factors will improve the management of this prevalent, yet under-treated, condition in primary care.

Gout, anxiety, and depression in primary care: a matched retrospective cohort study

Co-morbidity is frequently experienced by gout patients (1) but psychological morbidity associated with gout remains poorly understood. Given the established association between musculoskeletal pain and mental health problems (2), it seems plausible that gout is associated with psychological co-morbidity, such as anxiety or depression. However, the incidence of these specific psychological co-morbidities in gout populations remains unknown. We conducted a matched retrospective cohort study to examine the association between gout and subsequent incident consultation for anxiety or depression in UK primary care. Consultation data were available from nine general practices in North Staffordshire, UK between 2000 and 2011 (3). Consulters aged > 18 years who had been diagnosed with gout between 2000 and 2008 were identified using Read codes and were frequency matched by age, gender, year of consultation, and general practice to four controls without gout. The outcome of interest was the first consultation with a diagnostic Read code for anxiety or depression subsequent to the first diagnostic Read code for gout. Gout patients or controls with a diagnosis of anxiety or depression before the matching dates were excluded. Key characteristics of the gout sample and the matched controls were examined. These included factors upon which the cohorts were matched and the neighbourhood level of deprivation, determined using the Indices of Multiple Deprivation (IMD) (4). Incident consultation rates (per 1000 person-years) for anxiety or depression were calculated for gout and non-gout controls. The proportions consulting for other selected co-morbidities were also described. Cox regression was used to model the time to first anxiety or depression consultation, adjusting initially for the matched factors and then further adjusting to include deprivation status and co-morbidities. Outcomes are reported as hazard ratios (HRs) with 95% confidence intervals (CIs) for gout cases vs. matched controls. In total, 1689 gout patients were identified and matched successfully to 6756 patients without gout. The mean age of gout patients was 63 years (sd 16); 76% were male. Deprivation status was similar between those with and without gout, gout patients were more likely to have all co-morbidities, other than smoking, than controls. The incidence rate of depression was 10.8 (95% CI 10.0–11.7) per 1000 person-years for gout cases and 10.0 (95% CI 8.5–11.8) for matched controls. The incidence rate of anxiety was 15.2 (95% CI 14.2–16.2) per 1000 person-years for the gout cases and 16.2 (95% CI 14.3–18.3) for matched controls (Table 1). Unadjusted HRs in the Cox regression model found no association between gout and time to consultation for either anxiety (1.09, 95% CI 0.95–1.25) or depression (0.92, 95% CI 0.77–1.10) compared to matched controls. Adjustment had little effect on these associations for anxiety (1.01, 95% CI 0.87–1.16) or depression (0.87, 95% CI 0.73–1.05) (Table 1). Table 1. Incidence rates and hazard ratios (HRs) for the risk of anxiety and depression in gout cases vs. matched controls. This is the first study of consultation incidence of psychological co-morbidities in gout. Using a large UK primary care consultation database, incident gout was not associated with subsequent consultation for anxiety or depression. Possible explanations are that the psychological burden of pain is lessened during the prolonged asymptomatic inter-critical periods between gout attacks in some patients, or that whereas gout predominantly affects men, women are more likely to consult primary care for anxiety or depression (5). As such, our study may simply reflect population norms of consulting behaviour (6). This study provides new evidence of a lack of an association between common mental health problems and gout. This was achieved through the use of a large primary care database with proven validity and used previously to examine gout patients (3). There are several limitations of our study: anxiety and depression are typically under-reported in primary care (7) and limitations of coding by general practitioners (GPs) are also highlighted in the low prevalence of other co-morbidities, such as smoking. However, there is no reason to suspect that any under-recording of any of these conditions would differ between those with and without gout. In conclusion, the rates of consultation for anxiety or depression in UK primary care gout patients were equivalent to their matched counterparts. Further research is needed using more patient-reported measures of anxiety and depression and considering gout severity and disease characteristics.

Patient related factors are also important in treating gout

The treatment of gout remains suboptimal—only 30% of primary care patients take urate lowering drugs.1 Lipworth and colleagues note that important reasons for this underuse include drug toxicity and poor patient adherence owing to the introduction of these drugs provoking gout attacks.2 However, the views and beliefs of patients about gout and urate lowering drugs also …

Health-related Quality of Life in Gout in Primary Care: Baseline Findings From a Cohort Study

Objectives To examine gout-related, comorbid, and sociodemographic characteristics associated with generic and disease-specific health-related quality of life (HRQOL) in gout. Methods Adults with gout from 20 general practices were mailed a questionnaire containing the Health Assessment Questionnaire-Disability Index (HAQ-DI), Short-Form-36 Physical Function subscale (PF-10), Gout Impact Scale (GIS), and questions about gout-specific, comorbid and sociodemographic characteristics. Variables associated with HRQOL were examined using multivariable linear regression models. Results A total of 1184 completed questionnaires were received (response 65.9%). Worse generic and gout-specific HRQOL was associated with frequent gout attacks (≥5 attacks PF-10 β = −4.90, HAQ-DI β = 0.14, GIS subscales β = 8.94, 33.26), current attack (HAQ-DI β = 0.15, GIS β = −1.94, 18.89), oligo/polyarticular attacks (HAQ-DI β = 0.11, GIS β = 0.78, 7.86), body pain (PF-10 β = −10.68, HAQ-DI β = 0.29, GIS β = 2.61, 11.89), anxiety (PF-10 β = −1.81, HAQ-DI β = 0.06, GIS β = 0.38, 1.70), depression (PF-10 β = −1.98, HAQ-DI β = 0.06, GIS 0.42, 1.47) and alcohol non-consumption (PF-10 β = −16.10, HAQ-DI β = 0.45). Gout-specific HRQOL was better in Caucasians than non-Caucasians (GIS β = −13.05, −13.48). Poorer generic HRQOL was associated with diabetes mellitus (PF-10 β = −4.33, HAQ-DI β = 0.14), stroke (PF-10 β = −12.21, HAQ-DI β = 0.37), renal failure (PF-10 β = −9.43, HAQ-DI β = 0.21), myocardial infarction (HAQ-DI β = 0.17), female gender (PF-10 β = −17.26, HAQ-DI β = 0.43), deprivation (PF-10 β = −7.80, HAQ-DI β = 0.19), and body mass index ≥35 kg/m2 (PF-10 β = −6.10, HAQ-DI β = 0.21). Conclusions HRQOL in gout is impaired by gout-specific, comorbid, and sociodemographic characteristics, highlighting the importance of comorbidity screening and early urate-lowering therapy. Both gout-specific and generic questionnaires identify the impact of disease-specific features on HRQOL but studies focusing on comorbidity should include generic instruments.