eHealth-supported decentralized multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics: proof-of-concept study

  • Alyssa Howren
  • Nicole W. Tsao
  • Hyon K. Choi
  • Kam Shojania
  • Alison Kydd
  • Russell Friesen
  • J. Antonio Avina-Zubieta
  • Mary A. De VeraEmail author
Original Article



To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian.


We conducted a 12-month proof-of-concept study. Gout patients with ≥ 1 flare in the past year and serum urate (SUA) ≥ 360 μmol/L within the previous 2 months were followed by participating community rheumatologists on an as-needed basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Healthcare professionals were not co-located but had shared access to the rheumatologists’ electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA < 360 μmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a subset of patients and applied constructivist grounded theory to gather patients’ perspectives.


Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA < 360 μmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: (1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares, and (2) practical considerations, including categories of optimizing timing of care and coordination and accessibility.


Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.

Key Points

We demonstrated the feasibility and impact of an eHealth-supported, decentralized collaborative care model for gout involving rheumatology, pharmacy, and dietetics

Although prior multi-disciplinary models of care for gout have been reported, the novelty of our model is that healthcare providers are not co-located, lending to potential efficiencies and outreach to patients in rural areas


Dietetics Gout Models of care Pharmacy Rheumatology 



The authors thank all participants in the study and our collaborators at Plexia Electronic Medical Systems for technical support provided for the study. The authors thank Drs. John Esdaile, Nicole Bauer, David Collins, and Shahin Jamal for their rheumatologic contributions to the study.

Funding information

Dr. Mary De Vera is a recipient of a Scholar Award from the Michael Smith Foundation for Health Research and holds a Tier 2 Canada Research Chair.

Ms. Howren was supported by a Master’s Award from the Canadian Institutes of Health Research—Canada Graduate Scholarships—Master’s (CGS-M) Program for her work related to this study.

Dr. Avina-Zubieta is a recipient of Scholar Award from the Michael Smith Foundation for Health Research and is the BC Lupus Research Scholar.

This study was supported by an operating grant from the Canadian Initiative for Outcomes in Rheumatology Care and a team grant titled, ‘PRECISION: Preventing Complications from Inflammatory Skin, Joint and Bowel Conditions’ (FRN#THC-135235) from the Canadian Institutes of Health Research.

Compliance with ethical standards

Ethics approval and consent to participate

This study was reviewed and approved by the University of British Columbia Clinical Research Ethics Board (H14-01465) and Behavioural Research Ethics Board (H16-02061). Written consent was received from all study participants.

Consent for publication

Not applicable.

Competing interests

HKC reports grants from AstraZeneca and consulting fees from Takeda, Selecta, and Horizon outside of the submitted work.

The other authors have disclosed no conflicts of interest.

Supplementary material

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ESM 1 (PNG 306 kb)


  1. 1.
    Kuo CF, Grainge MJ, Mallen C, Zhang W, Doherty M (2015) Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study. Ann Rheum Dis 74(4):661–667. CrossRefPubMedGoogle Scholar
  2. 2.
    Zhu Y, Pandya BJ, Choi HK (2012) Comorbidities of gout and hyperuricemia in the US general population: NHANES 2007-2008. Am J Med 125(7):679–687.e671. CrossRefPubMedGoogle Scholar
  3. 3.
    Rai SK, Avina-Zubieta JA, McCormick N, De Vera MA, Shojania K, Sayre EC, Choi HK (2017) The rising prevalence and incidence of gout in British Columbia, Canada: population-based trends from 2000 to 2012. Semin Arthritis Rheum 46(4):451–456. CrossRefPubMedGoogle Scholar
  4. 4.
    Edwards NL (2011) Quality of care in patients with gout: why is management suboptimal and what can be done about it? Curr Rheumatol Rep 13(2):154–159. CrossRefPubMedGoogle Scholar
  5. 5.
    Singh JA, Hodges JS, Toscano JP, Asch SM (2007) Quality of care for gout in the US needs improvement. Arthritis Rheum 57(5):822–829. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Nasser-Ghodsi N, Harrold LR (2015) Overcoming adherence issues and other barriers to optimal care in gout. Curr Opin Rheumatol 27(2):134–138. CrossRefPubMedGoogle Scholar
  7. 7.
    Cottrell E, Crabtree V, Edwards JJ, Roddy E (2013) Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice. BMC Fam Pract 14(1):1–11. CrossRefGoogle Scholar
  8. 8.
    Doherty M, Jansen TL, Nuki G, Pascual E, Perez-Ruiz F, Punzi L, So AK, Bardin T (2012) Gout: why is this curable disease so seldom cured? Ann Rheum Dis 71(11):1765–1770CrossRefGoogle Scholar
  9. 9.
    Rees F, Jenkins W, Doherty M (2012) Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study. Ann Rheum Dis 72(6):826–830. CrossRefPubMedGoogle Scholar
  10. 10.
    Doherty M, Jenkins W, Richardson H, Sarmanova A, Abhishek A, Ashton D, Barclay C, Doherty S, Duley L, Hatton R, Rees F, Stevenson M, Zhang W (2018) Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet 392(10156):1403–1412CrossRefGoogle Scholar
  11. 11.
    Goldfien RD, Ng MS, Yip G, Hwe A, Jacobson A, Pressman A, Avins AL (2014) Effectiveness of a pharmacist-based gout care management programme in a large integrated health plan: results from a pilot study. BMJ Open 4(1):e003627. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Goldfien R, Pressman A, Jacobson A, Ng M, Avins A (2016) A pharmacist-staffed, virtual gout management clinic for achieving target serum uric acid levels: a randomized clinical trial. Permanente J 20(3):18–23. CrossRefGoogle Scholar
  13. 13.
    Coburn BW, Cheetham TC, Rashid N, Chang JM, Levy GD, Kerimian A, Low KJ, Redden DT, Bridges SL Jr, Saag KG, Curtis JR, Mikuls TR (2016) Rationale and design of the randomized evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study. Contemp Clin Trials 50:106–115CrossRefGoogle Scholar
  14. 14.
    Mikuls TR, Cheetham TC, Levy GD, Rashid N, Low KJ, Coburn BW, Saag KG, Chen L, Curtis JR (2017) Improving Gout Outcomes: The Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-Up) Study. Paper presented at the American College of Rheumatology Conference, San Diego, CA, USAGoogle Scholar
  15. 15.
    Fields TR, Rifaat A, Yee AMF, Ashany D, Kim K, Tobin M, Oliva N, Fields K, Richey M, Kasturi S, Batterman A (2017) Pilot study of a multidisciplinary gout patient education and monitoring program. Semin Arthritis Rheum 46(5):601–608. CrossRefPubMedGoogle Scholar
  16. 16.
    Kataria S, Ravindran V (2018) Digital health: a new dimension in rheumatology patient care. Rheumatol Int 38(11):1949–1957. CrossRefPubMedGoogle Scholar
  17. 17.
    Roddy E, Choi HK (2014) Epidemiology of gout. Rheum Dis Clin N Am 40(2):155–175. CrossRefGoogle Scholar
  18. 18.
    Estrada A, Tsao NW, Howren A, Esdaile JM, Shojania K, De Vera MA (2018) Utility of electronic medical records in community rheumatology practice for assessing quality of care indicators for gout: a feasibility study. J Clin Rheumatol 24(2):75–79CrossRefGoogle Scholar
  19. 19.
    de Klerk E, van der Heijde D, Landewe R, van der Tempel H, van der Linden S (2003) The compliance-questionnaire-rheumatology compared with electronic medication event monitoring: a validation study. J Rheumatol 30(11):2469–2475PubMedGoogle Scholar
  20. 20.
    Hughes LD, Done J, Young A (2013) A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs. BMC Musculoskelet Disord 14:286CrossRefGoogle Scholar
  21. 21.
    Reilly MC, Zbrozek AS, Dukes EM (1993) The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics 4(5):353–365CrossRefGoogle Scholar
  22. 22.
    Bruce B, Fries JF (2003) The Stanford Health Assessment Questionnaire: a review of its history, issues, progress, and documentation. J Rheumatol 30(1):167–178PubMedGoogle Scholar
  23. 23.
    Fries JF, Spitz P, Kraines RG, Holman HR (1980) Measurement of patient outcome in arthritis. Arthritis Rheum 23(2):137–145CrossRefGoogle Scholar
  24. 24.
    EuroQol--a new facility for the measurement of health-related quality of life (1990) Health Policy 16 (3):199-208Google Scholar
  25. 25.
    Brooks R (1996) EuroQol: the current state of play. Health Policy 37(1):53–72CrossRefGoogle Scholar
  26. 26.
    Rabin R, Gudex C, Selai C, Herdman M (2014) From translation to version management: a history and review of methods for the cultural adaptation of the EuroQol five-dimensional questionnaire. Value Health 17(1):70–76. CrossRefPubMedGoogle Scholar
  27. 27.
    Howren A, Cox SM, Shojania K, Rai SK, Choi HK, De Vera MA (2018) How patients with gout become engaged in disease management: a constructivist grounded theory study. Arthritis Res Ther 20(1):110. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Charmaz K (2014) Constructing grounded theory, 2nd edn. SAGE Publications, LondonGoogle Scholar
  29. 29.
    Leese J, Kerr S, McKinnon A, Carruthers E, Backman C, Li L, Townsend A (2017) Evolving patient- researcher collaboration: an illustrative case study of a patient-led knowledge translation event. J Participatory Med 9(e13)CrossRefGoogle Scholar
  30. 30.
    Rai SK, Choi HK, Choi SHJ, Townsend AF, Shojania K, De Vera MA (2018) Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies. Rheumatology 17:17Google Scholar
  31. 31.
    Bearne LM, Byrne AM, Segrave H, White CM (2016) Multidisciplinary team care for people with rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol Int 36(3):311–324CrossRefGoogle Scholar
  32. 32.
    Burmester GR (2018) Response to: ‘digital health: a new dimension in rheumatology patient care’ by Kataria and Ravindran. Ann Rheum Dis 02:02Google Scholar
  33. 33.
    Singh JA (2014) Challenges faced by patients in gout treatment: a qualitative study. J Clin Rheumatol 20(3):172–174. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Singh JA (2014) The impact of gout on patient’s lives: a study of African-American and Caucasian men and women with gout. Arthritis Res Ther 16(3):R132. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lindsay K, Gow P, Vanderpyl J, Logo P, Dalbeth N (2011) The experience and impact of living with gout: a study of men with chronic gout using a qualitative grounded theory approach. J Clin Rheumatol 17(1):1–6. CrossRefPubMedGoogle Scholar
  36. 36.
    Latif ZP, Nakafero G, Jenkins W, Doherty M, Abhishek A (2018) Implication of nurse intervention on engagement with urate-lowering drugs: a qualitative study of participants in a RCT of nurse led care. Joint Bone Spine. CrossRefGoogle Scholar
  37. 37.
    Gaffo AL, Schumacher HR, Saag KG, Taylor WJ, Dinnella J, Outman R, Chen L, Dalbeth N, Sivera F, Vazquez-Mellado J, Chou CT, Zeng X, Perez-Ruiz F, Kowalski SC, Goldenstein-Schainberg C, Chen L, Bardin T, Singh JA (2012) Developing a provisional definition of flare in patients with established gout. Arthritis Rheum 64(5):1508–1517CrossRefGoogle Scholar

Copyright information

© International League of Associations for Rheumatology (ILAR) 2019

Authors and Affiliations

  1. 1.Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverCanada
  2. 2.Arthritis Research CanadaRichmondCanada
  3. 3.Collaboration for Outcomes Research and EvaluationVancouverCanada
  4. 4.Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical SchoolBostonUSA
  5. 5.Faculty of Medicine, Department of Medicine, Division of RheumatologyUniversity of British ColumbiaVancouverCanada
  6. 6.Providence HealthVancouverCanada

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