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Diagnostic accuracy and trajectories of referrals for gout to rheumatology
Timothy Sh Kwok1, Sangeeta Bajaj2, Tripti Papneja2
1Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Holland Bone & Joint Program, Toronto, Canada; Division of Rheumatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
Insights
Referring physicians accurately diagnosed gout in most cases, with accuracy highest among internists and ER doctors. Focus quality improvement efforts on post-diagnosis gout care gaps.
Area of Science:
- Rheumatology
- Internal Medicine
- Diagnostic Accuracy
Background:
- Gout diagnosis can be challenging, impacting patient care trajectories.
- Accurate diagnosis is crucial for effective gout management and preventing complications.
Purpose of the Study:
- To evaluate the diagnostic accuracy of gout referrals to rheumatology.
- To identify factors associated with accurate gout diagnoses.
Main Methods:
- Retrospective cohort study of 4315 patient referrals to 4 rheumatology clinics (December 2019-January 2023).
- Diagnostic accuracy assessed against rheumatologist diagnosis; multivariable logistic regression used to identify predictive factors.
Main Results:
- Of 191 gout referrals, 159 (83.2%) had confirmed gout. Referring physicians demonstrated high sensitivity (73.6%) and specificity (99.2%).
- Accuracy was highest for internists and emergency room physicians. Factors predicting gout diagnosis included male sex, high serum urate, lower extremity monoarthritis, and short symptom duration.
Conclusions:
- Referring providers exhibit reasonable accuracy in diagnosing gout.
- Gout care gaps likely occur post-diagnosis; quality improvement should target treatment-associated issues.
Objectives:
To evaluate diagnostic accuracy and trajectories of gout referrals to rheumatology including factors associated with an accurate diagnosis.
Methods:
We performed a retrospective cohort study of referrals at 4 rheumatology clinics in Brampton, Canada from December 2019 to January 2023. We assessed gout diagnostic accuracy referenced to the rheumatologist's "gold standard" diagnosis, describing alternative final diagnoses. Using multivariable logistic regression, we identified factors associated with an accurate gout diagnosis.
Results:
Among 4315 patients, 216 were diagnosed with gout. Of 191 gout referrals (mean (SD) age 58.4 (15.4) years; 77.0% male), the diagnosis was unchanged in 159 (83.2%) patients with alternative diagnoses comprising osteoarthritis, autoimmune inflammatory arthritis and calcium pyrophosphate deposition disease. Referring physicians had moderate-to-high sensitivity (73.6%, 95% CI: 67.2-79.4), specificity (99.2%, 95% CI: 98.9-99.5), positive predictive value (83.2%, 95% CI: 77.2-88.2), negative predictive value (98.6%, 95% CI: 98.2-99.0) and inter-rater reliability (Cohen's kappa: 0.77, 95% CI: 0.72-0.82). Accuracy was highest amongst internists and emergency room physicians. Male sex (OR 14.32, 95% CI: 4.44-46.17), serum urate ≥500μmol/L (OR 9.10, 95% CI: 2.19-37.78), lower extremity monoarthritis (OR 5.08, 95% CI: 1.59-16.27) and symptom duration ≤2weeks (OR 3.87, 95% CI 1.23-12.21) were predictive of a final gout diagnosis.
Conclusions:
Referring providers had reasonably high accuracy in diagnosing gout. Traditional risk factors were associated with concordance with the consultant rheumatologist. Suboptimal gout care likely does not stem at point-of-diagnosis and quality improvement efforts should be focused on mitigating treatment-associated care gaps.
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