Gout - View Improvement Plan


1. Measures Selected from Report:

MEASURE:

1. IF a gout patient is receiving an initial prescription for allopurinol and has significant renal impairment (defined as a serum creatinine level ≥ 2 mg/dl or measured/estimated creatinine clearance ≤ 50 ml/min), THEN the initial daily allopurinol dose should be < 300 mg/day.
 
Gout
Patients receiving an initial prescription for allopurinolQI
n
%
Goal
 Patients receiving an initial prescription for allopurinol
14
67
 
 INITIALLY PRESCRIBED BY YOU:
 Patients receiving an initial prescription for allopurinol
13
62
 
 Patients receiving an initial prescription for allopurinol having significant renal impairment
3
23
 Patients receiving an initial prescription for allopurinol having significant renal impairment and initial daily allopurinol dose less than 300 mg/day
1
33
 INITIALLY PRESCRIBED BY OTHER PHYSICIAN:
 Patients receiving an initial prescription for allopurinol
1
5
 
 Patients receiving an initial prescription for allopurinol having significant renal impairment
1
100
 Patients receiving an initial prescription for allopurinol having significant renal impairment and initial daily allopurinol dose less than 300 mg/day
0
0

2. IF a patient with tophaceous gout is given an initial prescription for a urate-lowering medication and lacks both 1) significant renal impairment (a serum creatinine level ≥ 2 mg/dl or measured/ estimated creatinine clearance ≤ 50 ml/min and 2) peptic ulcer disease, THEN a prophylactic agent (colchicine or NSAID) should be given concomitantly.
 
Gout
Anti-inflammatory agents with initiation of urate-lowering agentsQI
n
%
Goal
 Patients with tophaceous gout
16
76
 
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication
11
69
 
 INITIALLY PRESCRIBED BY YOU:
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication
10
0
 
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease
1
10
 
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease given a prophylactic agent concomitantly
0
0
 INITIALLY PRESCRIBED BY OTHER PHYSICIAN:
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication
1
0
 
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease
0
0
 
 Patients with tophaceous gout given an initial prescription for a urate-lowering medication lacking both significant renal impairment and peptic ulcer disease given a prophylactic agent concomitantly
0
0

3. IF a gout patient has either 1) a history of nephrolithiasis or 2) significant renal insufficiency (defined as a serum creatinine level ≥ 2 mg/dl or measured/estimated creatinine clearance ≤ 50 ml/min) THEN a xanthine oxidase inhibitor should be started as the initial urate-lowering medication rather than a uricosuric agent.
 
Gout
Apropriate urate-lowering agentQI
n
%
Goal
 Patients with a history of nephrolithiasis OR significant renal insufficiency
15
71
 
 Patients with a history of nephrolithiasis OR significant renal insufficiency with a xanthine oxidase inhibitor started as the initial urate-lowering medication rather than a uricosuric agent
11
0
 Patients with a history of nephrolithiasis OR significant renal insufficiency with a uricosuric agent started
3
20

4. IF a patient has hyperuricemia and gouty arthritis characterized by any of the following clinical characteristics 1) tophaceous deposits, 2) gouty erosive changes on radiographs, or 3) gout attack of twice or more per year, THEN the patient should be offered therapy with a urate lowering drug unless contraindicated.
 
Gout
Initiation of urate-lowering therapyQI
n
%
Goal
 Patients with hyperuricemia and gouty arthritis
19
90
 
Patients with hyperuricemia and gouty arthritis where a urate-lowering drug is NOT prescribed due to:
    Not Indicated
1
5
    Contraindicated
2
11
    Patient Refused
0
0
    Other Reason
0
0
 Patients with hyperuricemia and gouty arthritis offered therapy with a urate-lowering drug
16
84

1. IF a patient is newly prescribed any of the following drugs: NSAIDs (selective or non-selective), DMARDs, glucocorticoids or narcotics, THEN a discussion with the patient about the risks of the chosen therapy should be documented.

 
Drug Safety
Informing patients about risksQI
n
%
Goal
INITIALLY PRESCRIBED BY YOU:
 Number of patients newly prescribed allopurinol
4
19
 For patients newly prescribed allopurinol, a documented discussion was held with the patient about the risks of the chosen therapy
3
75
 Number of patients newly prescribed probenicid
5
23
 For patients newly prescribed probenicid, a documented discussion was held with the patient about the risks of the chosen therapy
4
80
 Number of patients newly prescribed colchicine
4
19
 For patients newly prescribed colchicine, a documented discussion was held with the patient about the risks of the chosen therapy
3
75
 Number of patients newly prescribed a NSAID
5
23
 For patients newly prescribed a NSAID, a documented discussion was held with the patient about the risks of the chosen therapy
2
40
 Number of patients newly prescribed a glucocorticoid
2
9
 For patients newly prescribed a glucocorticoid, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
 Number of patients newly prescribed a narcotic
0
0
 For patients newly prescribed a narcotic, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
  
INITIALLY PRESCRIBED BY OTHER PHYSICIAN:
 Number of patients newly prescribed allopurinol
0
0
 For patients newly prescribed allopurinol, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
 Number of patients newly prescribed probenicid
0
0
 For patients newly prescribed probenicid, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
 Number of patients newly prescribed colchicine
0
0
 For patients newly prescribed colchicine, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
 Number of patients newly prescribed a NSAID
1
4
 For patients newly prescribed a NSAID, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
 Number of patients newly prescribed a glucocorticoid
2
9
 For patients newly prescribed a glucocorticoid, a documented discussion was held with the patient about the risks of the chosen therapy
1
50
 Number of patients newly prescribed a narcotic
0
0
 For patients newly prescribed a narcotic, a documented discussion was held with the patient about the risks of the chosen therapy
0
0
  

2. IF a patient is treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin, AND the patient has risk factors for upper gastrointestinal bleeding, THEN the patient should be treated concomitantly with either misoprostol or a proton pump inhibitor unless patient refuses.

Prophylaxis for patients at risk for gastrointestinal bleedingQI
n
%
Goal
 Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin
10
48
 
 Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin with risk factors
0
0
 
 Number of patients treated with 1) a non-selective NSAID or 2) a COX-2 selective NSAID plus aspirin with risk factors for upper gastrointestinal bleeding treated concomitantly with either misoprostol or a proton pump inhibitor
0
0
  

3. IF a patient is treated with daily NSAIDs (selective or non-selective) and the patient has risk factors for gastrointestinal bleeding, THEN a hemoglobin or hematocrit should be performed at baseline and during the first year after initiating therapy.

Lab monitoring - gastrointestinal bleeding QI
n
%
Goal
 Number of patients treated with a non-selective NSAID
10
48
 Number of patients treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding
0
0
 Number of patients DIAGNOSED BY YOU treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding
0
0
 Number of patients DIAGNOSED BY YOU treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding with hemoglobin or hematocrit performed at baseline and during the first year after initiating therapy.
0
0
 Number of patients DIAGNOSED BY OTHER PHYSICIAN treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding
0
0
 Number of patients DIAGNOSED BY OTHER PHYSICIAN treated with a daily NSAID (selective or non-selective) with risk factors for upper gastrointestinal bleeding with hemoglobin or hematocrit performed at baseline and during the first year after initiating therapy.
0
0

4. IF a patient is treated with daily NSAIDs (selective or non-selective) AND the patient has risk factors for developing renal insufficiency** THEN a serum creatinine should be assessed at baseline, within the first 3 months, and then at least annually thereafter.

Lab monitoring - renal insufficiency QI
n
%
Goal
 Number of patients treated with daily NSAIDs (selective or non-selective)
10
48
 Number of patients treated with daily NSAIDs with risk factor for developing renal insufficiency
8
80
 Number of patients DIAGNOSED BY YOU treated with daily NSAIDs with risk factor for developing renal insufficiency
3
30
 Number of patients treated DIAGNOSED BY YOU with daily NSAIDs with risk factor for developing renal insufficiency with a serum creatinine assessed at baseline, within the first 3 months
0
0
 Number of patients DIAGNOSED BY other treated with daily NSAIDs with risk factor for developing renal insufficiency
5
50
 Number of patients treated DIAGNOSED BY other with daily NSAIDs with risk factor for developing renal insufficiency with a serum creatinine assessed at baseline, within the first 3 months
0
0
 Number of patients treated with daily NSAIDs with risk factor for developing renal insufficiency with a serum creatinine performed in the last 12 months
0
0

6. IF a patient has established treatment with a DMARD or glucocorticoids, THEN monitoring for drug toxicity should be performed. (SEE Table 2)


Monitoring for drug toxicity QI
n
%
Goal


2. Why did you choose this measure(s)?
test8

3. What is your plan to improve performance on the measure(s) chosen?
follow the helpful hints Monitir creatinine closely while patient started on allopurinol

4. How will you implement your quality improvement plan?
check labs regularly

5. Who will be involved in implementing your improvement plan and what will their roles be?
my nursing staff and myself

6. What, if any, tools do you intend to use to bring about improvement?
introduced new form flow sheets for lab documentation

7. Why did you choose this approach?
easy to implement and effective

8. Did you consider other approaches?
Yes
No
Comments:
no

9. When will you begin your quality improvement plan?
Month: Year:

10. When do you plan to remeasure?
Month: Year:

11. What is your plan for remeasurement?


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