Background
Gout is recognised as the most common form of inflammatory arthritis and is often associated with substantial co-morbidity [
1]. This condition, usually managed in primary care, is closely linked with diabetes and chronic kidney disease and is an independent risk factor for cardiovascular mortality [
2]. The clinical and economic burden of the disease is substantial [
3,
4].
Some aspects of gout management appear straightforward and there is a plethora of management reviews and treatment guidelines in existence globally [
1,
5‐
9]. Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the main medicine groups used for the management of acute flares, with colchicine and steroids providing alternative treatment options. A target serum uric acid level of less than 0.36 mmol/L is aimed for and allopurinol and other urate-lowering therapies are indicated for the chronic management of gout.
The burden of the disease is rising, [
3] and aspects of management remain challenging. Differences in primary care management strategies have been widely noted between routine practice and both reported management and recommended guidelines [
10‐
15].
Differing patient and physician perceptions of gout have been identified as one of the challenges to management in primary care [
16]. Issues identified include patients experiencing difficulty in obtaining information they perceive as directly relevant to them, [
17] self-diagnosis and treatment by patients, [
18] a lack of patient knowledge about gout medicines, [
19‐
22] a lack of practitioner knowledge about treatment guidelines and recommendations [
21] and a reluctance on the part of some practitioners to offer preventive medicines as a long-term solution, with some making an assumption that patients would prefer to be treated for an acute flare rather than take long-term medication [
21].
While some previous studies have attempted to address views about gout treatment from both patient and practitioner perspectives, [
21,
23] there is no research that investigates directly observed conversations in primary care consultations. Existing findings therefore rely on people’s abstract perceptions or retrospective reports of healthcare encounters. We describe communication between patients and primary care practitioners about gout medicines and treatment in the context of routine consultations. We identify how patient and practitioner perceptions are brought into play in the course of natural interactions between them. The prevalence of gout, due to its association with cardio-vascular disease and diabetes, is likely to increase further. A greater understanding of the communication process will help determine how the management of this condition can be improved.
Methods
Data source
Data were derived from the Applied Research on Communication in Health (ARCH) Corpus at the University of Otago, Wellington, New Zealand [
24]. This comprises a searchable digital collection of healthcare interactions and related data for use in interactional and narrative analysis. The data in the Corpus has been collected in the course of a series of funded projects since 2003. These studies include the ‘Interaction Study’ (IS), a study exploring clinical decision-making when rationing is explicit; the Tracking Study (TS), a study exploring communication processes throughout a single complete episode of care of patients referred from primary to secondary care; the Diabetes Study (DS), a longitudinal study tracking the contact of newly diagnosed patients with Type 2 diabetes with healthcare professionals over a six-month period. Data are permanently archived for use by authorised researchers.
As the data contained in the Corpus has been collected on a project-by-project basis it does not claim to be ‘representative’ in the statistical sense. It is, however, representative in the sense that the video-recordings were made in the course of ‘practice as usual’. They are therefore typical of routine interactions occurring in the New Zealand healthcare setting.
Logging of data in the ARCH Corpus
The digital video-recording for each consultation is logged by a trained research nurse onto a template summarising key clinical content (e.g. presenting problem, other clinical issues discussed, treatment with medicines) and a time-coded sequence of key events and topics discussed. Each consultation is subsequently transcribed in full using linguistic transcription conventions to capture both the words spoken and selected non-verbal cues (e.g. typing of notes on the computer) to assist in interpretation of the transcribed speech. The Corpus has a custom-designed information management system.
Search strategy for identifying gout consultations
When sampled, the Corpus included 418 video-recorded interactions between patients and practitioners recorded between 2004 and 2011. Consultations occurring in primary care and consultations where patients had given consent for secondary analysis of their data were included, resulting in a subset of 337 eligible consultations. These comprised 247 individual patients, 30 general practitioners (GPs), 31 nurses and 15 other practitioners.
A query was then run on the information held within the database using the keyword “gout”. A second search incorporating a list of key gout-related medicines was run, but did not yield any additional consultations.
Consultations included in the analysis
The search identified 31 consultations, 27 of which were included in the final analysis.
The majority of consultations identified came from those archived as part of the DS (n = 20). Gout was not, therefore, the primary focus of these encounters; many gout-related conversations stemmed from enquiries made by practitioners that resulted directly from application of the nationally agreed protocol for diabetes care. Despite this, discussion about gout medicines of varying length and complexity was a feature in the majority of these consultations (n = 16). In the remaining four, there was no mention of medicines in the context of gout; these consultations were therefore excluded from further analysis. As this study tracked patients over a six-month time-frame, the same patient was sometimes involved in more than one consultation in the sample and potentially more likely to discuss gout medicines with a practitioner if they had talked about them in a healthcare encounter in the recent past.
Contextual information about the 11 GP consultations derived from the IS study (
n = 5) and the TS study (
n = 6) is provided in Table
1.
Table 1
GP consultations that were not part of the DS (n = 11)
Gout was the patient’s presenting complaint | 2 |
Gout was the presenting complaint in the patient’s previous consultation (not part of the Corpus archive) and was followed up by the GP on this occasion | 2 |
Gout discussed in the context of a medicine that had been previously prescribed for this condition | 7 |
Patient and practitioner demographic characteristics
The final dataset of 27 consultations used for analysis encompassed 17 individual patients (male n = 12, female n = 5; age-range 36 to 67 years) consulting with 15 different practitioners. The number of consultations per patient ranged from one to eight, with the majority of patients (14/17) having only one included consultation. Patients interacted with a diverse range of professionals (GPs n = 9, nurses n = 3, podiatrists n = 2, dietitian n = 1).
Data analysis
This was an exploratory descriptive study based on direct observation of gout-related interactions from both clinical and linguistic viewpoints. Our aim was to identify and report on the range of patient-practitioner models of engagement around medicines use as these emerged from the data, with no preconceived assumptions.
Themes identified from the overall dataset were derived via an iterative process of inductive qualitative analysis [
25] of the medicine-related gout conversations between patients and practitioners, with visual observation of these interactions complementing the textual analysis of the transcripts. CM identified and coded all mentions or sequences of talk relating to the use of medicines in the management of gout in the transcripts. Video-recordings of consultations were then viewed to confirm and enrich the content analysis of the transcripts. Initial coding included the location within the consultation, who (patient or practitioner) initiated the conversation, the types and names of medicines discussed, the context in which that discussion took place and any significant non-verbal interactions. The video-recordings and transcripts were then re-reviewed to identify any other medicine-related conversation to help provide additional insights and context for the gout-related medicines communication. CM and AD reviewed and discussed the initial themes derived from data analysis and interpretation of data from their clinical perspectives (pharmacy and general practice), with disagreements resolved by consensus. LM and MS subsequently reviewed the data and themes derived from a linguistic and interactional perspective. All authors reviewed and agreed the final themes.
Discussion
Our study is the first to describe communication about medicines for gout treatment in the context of routine consultations in primary care. We identified three overarching themes from the data; level of patient knowledge about gout medicines, patients’ attitudes towards medicines, and the attributes of practitioner communication. Each of these inter-linking themes has the potential to impact either positively or adversely on the successful management of gout. Optimising the manner, and avenues, by which information is shared with patients has the potential to improve patient knowledge and understanding, and promote clinician-patient agreement. A link between good communication and positive health outcomes has been previously described in the literature [
26].
The strength of our study is that it enabled us to see, hear and review the interaction between patients and their practitioner in real encounters, rather than relying on the abstract views or retrospective opinions of each party. As some of the included consultations formed part of a longitudinal study we were also able to review encounters with a range of practitioners and gain insight into how patients’ knowledge and attitudes may alter over time. Although data were drawn from an archived database rather than a study specifically related to gout, the use of a video-recorder may have introduced an artificial bias, with participants behaving differently from ‘normal’ due to its presence. However, although all parties appear cognisant of a camera’s presence early on in a consultation, this effect can be observed to wane as the business of the consultation progresses [
27].
It was concerning that some patients lacked basic knowledge about the main medicines used for gout treatment. This has clear implications for the quality and safety of medicines use. In line with earlier work, [
19,
20] this study revealed lack of knowledge related to the appropriate NSAID dosing for an acute gout flare and confusion around NSAID generic and brand names. Some patients also lacked a clear understanding of the specific and unusual issues around the initiation of allopurinol therapy; an area which has been previously identified as a source of patient confusion [
19,
20,
28].
It was evident on following a single patient through a series of consultations that information may need repeated explanation to ensure that understanding remains consistent over time. Information that appeared to be unproblematic when initially given became less clearly understood by the patient as time progressed and other experiences intervened. All healthcare professionals that may interact with patients, including community pharmacists, have a potentially valuable role to play in facilitating patient understanding and hence the safe and effective use of medicines.
The level of knowledge about gout treatment may impinge on patients’ attitudes towards gout medicines and the likelihood of patient-practitioner concordance [
29]. There were examples in the present study of patients taking medicines ‘differently’ to the way the practitioner expected and a reticence expressed, by some, to taking preventive medicines long-term. To be considered for preventive treatment patients will have been previously symptomatic, although the level of pain experienced by an individual may vary widely. It is therefore not surprising that here, and in previous studies, [
19,
23] patients have admitted to failing to take medicines both unintentionally (they were unaware of how it should be taken or simply forgot) and intentionally (they had no desire to take a medicine every day) [
19,
23]. It is notable that one patient continued to take a medicine to treat gout despite the fact that it exacerbated a co-morbid condition, identifying that patient values and judgments around medicine side-effects may differ from their practitioner’s.
Communicating in an open way and engaging the patient in a discussion about treatment options is likely to increase patient knowledge about the rationale behind their treatment and potentially promote agreement and adherence to a treatment plan that takes account of the patient’s beliefs and wishes [
29]. Although some patients may ultimately choose to defer a treatment decision to their healthcare professional, the majority desire some level of involvement in the decision-making process [
30]. Patients are only able to make an informed and evaluated decision on how they personally wish to engage with medicine taking or sign-up to a suggested treatment plan if they have appropriate and accurate information on which to base their decision. It is therefore of note that gout patients have previously identified that they did not always understand the information that GPs provided and have suggested that practitioners should explicitly confirm their understanding [
19]. Furthermore, as in our study, potentially important mismatches in perceptions between patients and healthcare providers (including doctors, nurses, podiatrists) about the effectiveness and place of specific medicines in gout management and the adequacy of information provided have been shown to exist [
23].
The present study reviewed consultations with a range of different primary care health professionals. It was notable that medicines were a feature of consultations across all professional groups, although, not surprisingly, medicines-related talk occurred to a greater extent with GPs who are the prescriber of medicines. It is, however, vital that all practitioners engaging with gout patients are knowledgeable about the up-to-date management of this condition and provide clear, consistent and accurate messages to avoid the potential for misleading or confusing patients.
While our findings potentially have relevance to other musculoskeletal conditions, it is possible that communication between patients and practitioners about gout treatment may differ from, for example, osteoarthritis [
31]. In contrast to this condition, gout can be effectively managed using preventive therapy and is far less likely to be perceived as a normal part of getting old.
Our study was undertaken in the context of routine clinical practice. It thus allowed us to view the communication process within the real time constraints under which practitioners undertake their daily work. Furthermore, consultations were not solely for gout providing, for the first time, an indication of how this issue is routinely raised in primary care practice. Overall, there were many examples of good communication; practitioners often use open questions, are supportive of their patients’ medicines-related preferences and seize opportunities that present to discuss gout and its treatment.
The difficulty of managing patients with gout and its associated co-morbidities in a short consultation is a key challenge to the optimal management of gout in primary care [
16]. Given that medicines are a key feature of gout management and that GP consultation time constraints are unlikely to be easily overcome, a multidisciplinary team approach to care via primary care gout clinics including pharmacist input has been recently reported [
32].
Acknowledgments
The data archived in the Applied Research on Communication in Health Group (ARCH) Corpus of Health Interactions were originally collected as part of research projects funded by the New Zealand Health Research Council, the Royal Society of New Zealand Marsden Fund, the New Zealand Lotteries Health Research Fund and the University of Otago Research Committee. The authors thank all participants for generously allowing their consultations to be recorded and archived, and acknowledge the input of Lesley Gray, Rachel Tester and other colleagues and research assistants from the ARCH Group, Kevin Dew, another member of the ARCH group, from the School of Social and Cultural Studies, Victoria University of Wellington, New Zealand and Barbara Docherty, Devi-Ann Hall, Timothy Kenealy, Debbie Raphael and Nicolette Sheridan from the Faculty of Medical and Health Sciences, The University of Auckland, New Zealand