2025 Southeastern Residency Conference

Title: Improving Compliance with Gout Management Guidelines: Implementing a Standardized Order Menu for HLA-B*58:01 Testing in Veterans

Authors: Roslyn Mays; Mary Kalyn Pounders

Background/Purpose: 
Gout is a common and significant health issue among veterans, particularly in those with comorbid conditions like chronic kidney disease and cardiovascular disease. Allopurinol, the first-line recommended treatment for gout, carries the rare risk of a severe adverse hypersensitivity reaction, allopurinol hypersensitivity syndrome (AHS). The risk of AHS is higher in those with the HLA-B*58:01 allele, which is most prevalent in African American and Asian populations. The American College of Rheumatology (ACR) 2020 Gout Management Guidelines recommend routine genetic testing for HLA-B*58:01 in these higher-risk ethnicity groups before initiation of allopurinol. As of July 2024, preliminary data from the Atlanta VA revealed significant noncompliance with these guideline recommendations. This project aimed to improve compliance with the ACR allele testing recommendations by implementing a standardized order menu with prompts for allele testing in recommended patient groups, thus in hopes of reducing the risk of AHS in at-risk veterans.

Methods: 
This was a single-site, retrospective quality improvement project designed to evaluate the impact of a standardized HLA-B*58:01 allele order menu on compliance with the ACR 2020 gout management guideline recommendations. Eligible participants included veterans aged 18 or older prescribed allopurinol for non-hematologic or oncologic indications within the timeframe both prior to and following the implementation of the order menu in July 2024. Eligible patients were identified using the VA National Quality Enhancement Research Initiative (QUERI) Gout Safety Dashboard. Patients prescribed allopurinol for conditions other than gout, such as tumor lysis syndrome, were excluded using prescriber data. Baseline data was collected on key variables such as race/ethnicity, urate-lowering therapy (ULT) status, HLA-B*5801 allele testing results, and the type of prescribing provider (primary care physician or rheumatologist). The primary endpoint was the percentage of new ULT users prescribed allopurinol who received guideline-recommended HLA-B*58:01 testing before and after introducing the standardized order menu. Statistical analysis was used to compare testing compliance rates before and after the intervention. Upon data review, the impact of the order menu on allele testing was assessed to identify specific areas needing improvement, allowing for future targeted interventions in areas of continued non-compliance.

Results:
Upon review, after the implementation of the order menu, the percentage of new ULT users with guideline recommended HLA-B*58:01 test results increased by 5.2%. The total number of patients with an HLA-B*58:01 test result increased from 3.6% to 5.1%. The percentage of African American (AA) patients tested for the allele rose by 2.2%, while Asian patients demonstrated a 3.9% increase. While these changes are encouraging with a new ULT non-compliance rate decrease from 96.7% to 91.6%, more than 90% of at-risk patients remained untested, indicating that more targeted interventions may be necessary to achieve substantial improvements.

Conclusion:
The introduction of a standardized HLA-B*58:01 allele testing order menu resulted in a modest increase in testing compliance for new ULT users. While this increase is a positive step, the continued rate of non-compliance suggests the need for further refinements in the intervention. Potential future directions for this project include enhancing provider education, incorporating automated reminders, and exploring other interventions or tools to further enhance facility compliance. Continued monitoring and refinement of this intervention will be essential to achieving better compliance rates to the ACR 2020 gout guideline recommendations, and thus, a further reduction in risk for AHS development in at-risk veteran groups.