Knowledge and Practice of Primary Health Care Providers in the Management of Asymptomatic Hyperuricemia and Gout in the Qassim Region of Saudi Arabia

Introduction & Aim The most prevalent type of inflammatory arthritis is gout. It develops because of hyperuricemia, which makes monosodium urate (MSU) crystals accumulate in the joints. However, hyperuricemia does not always cause gout. Methodology The following is a cross-sectional study conducted in the Qassim region of Saudi Arabia. 133 PHPs in this region were given a self-administered questionnaire through an online survey. The questionnaire included four sections: Demographic data (i.e., age, gender, years of experience) Knowledge of asymptomatic hyperuricemia; Management practices of asymptomatic hyperuricemia; Knowledge and practice of gout management Results One hundred thirty-three primary healthcare providers took part (males 63.9%; females 36.1%). The proportion of PHPs who attended continuing medical education (CME) on AH or gout was 32.3%. Moreover, 67.7% already knew the guidelines for managing AH or gout. PHPs’ level of knowledge regarding the management of AH and gout was good (45.9%), but their level of practice was poor (23.3%). Greater experience and CME attendance on AH and gout contributed to better understanding and higher practice scores. Conclusion Although PHPs’ knowledge of managing AH and gout was adequate, this did not reflect in their practice. Physicians with more years of experience who attended CME on AH and gout demonstrated better knowledge and practice than the rest of the PHPs. It is necessary to address the gaps in the practice of our PHPs, which could be done through in-depth training about AH and gout. Our study could guide other researchers to assess the gaps in other clinical practices that PHPs face.


Introduction
The most prevalent type of inflammatory arthritis is gout, which is more common in men than women. Gout prevalence varies worldwide depending on the demographic analyzed and the research methods utilized, ranging from <1% to 6.8%. Thus, PHPs must know how to diagnose and manage it [1], Dehlin et al., 2020. Gouty arthritis results from monosodium urate (MSU) crystal deposition in the joints due to high plasma uric acid levels by Bardin & Richette, 2014 [2]. A serum urate level greater than 6.8 mg/dL is considered hyperuricemia Martillo et al., 2013 [3].
Asymptomatic hyperuricemia (AH) is a form of hyperuricemia where symptoms of gout do not occur. It constitutes 90% of patients who have hyperuricemia. Therefore, only some hyperuricemia patients are gout patients. However, AH is considered the first stage of advanced gout, which may last more than ten years before the flares develop [2], Bardin & Richette, 2014. Although AH is not a disease, it can predict the risk of cardiovascular disease and experiencing flares in the next five years [4], Mandell, 2008. The uric acid level depends on the balance between endogenous purine production and excretion via the kidneys. In 90% of patients, underexcretion on behalf of the kidneys caused their gout. On the other hand, 10% of the patients developed gout due to over-production by Ragab et al., 2017) [5].
Studies involving 838 primary care physicians have shown that a small percentage (11.8%) of participants stated that they were aware of gout therapy recommendations. Regarding the management of acute gout, when there is an acute flare, 84% of physicians stated that they would not aspirate the affected joint, and 86.6% would order a serum urate level test. 58.8% suggested colchicine for acute gout management, and 50.5% would use non-steroidal anti-inflammatory drugs (NSAIDs This study will evaluate the knowledge and practice among primary healthcare physicians in the Qassim region. It will specifically assess the management of gout and asymptomatic hyperuricemia. This will include the restriction of physicians to the current guidelines, considering patient history to diagnose gout, and deciding when to start ULT. These objectives have yet to be investigated in the Qassim region.

Study Design
This study was held in the Qassim region. This study followed a cross-sectional survey-based method. The study population includes primary healthcare physicians, from those specializing in family medicine to general practitioners. PHPs outside of the Qassim region, rheumatologists, and internal medicine physicians (including residents and specialists) were excluded from our research. The PHPs in the Qassim region were all eligible to participate in the study and the physicians' responses to the questionnaire constituted our study population.

Data Collection Plan
The questionnaire for the study was a modified self-designed electronic questionnaire. It was adapted from similar studies performed elsewhere and formulated according to the recent guidelines to address our study objective. The data will be managed and analyzed by the 24th version of IBM SPSS statistics software.

Ethical Considerations
The informed consent document indicated the purpose of the study and the rights of the participant for confidentiality. It also explained that they could withdraw at any moment with no commitment to the study team and to contact the study team if they had any queries. By giving each participant a code number just for analysis, we were able to ensure their privacy. Participants received no incentives or benefits. Approval from the institutional review board (IRB) was obtained prior to beginning this study.
This study obtained ethical approval from Qassim Regional Research Ethics Committee (Number 1443-880505)

Scoring
Five questions determined the overall knowledge of PHPs regarding managing AH and gout. The correct answers were coded with "1" and the incorrect answers with "0". Question 5 was a multiple response answer with three correct answers, giving a total knowledge of 7 items. The total knowledge score was obtained by adding all 7 items and a total score range from 0 to 7 has been generated which generally means that the higher the score the higher the knowledge toward the management of asymptomatic hyperuricemia and gout. A cutoff point of the total score determined the overall level of knowledge; a score of less than 50% showed poor knowledge, between 50%-75% demonstrated moderate knowledge, and more than 75% was a marker of a good level of knowledge.
Determining the practice of PHPs toward managing AH and gout was obtained from 8-item questionnaires, where the correct answers were coded with "1" and the incorrect answers with "0". Item 2 (three correct answers) and item 3 (three correct answers) gave a total practice item of 12. The total practice score was acquired by adding all 12 items, generating a score range from 0 to 12. Therefore, the greater the score, the greater the practice of managing AH and gout. A cutoff point of the total score determined the level of practice; a score of less than 50% showed a poor level of practice, between 50%-75% demonstrated moderate practice, and more than 75% was a marker of good practice.

Statistical Analysis
Mean ± standard deviation were used to present quantitative variables and quantitative variables were displayed using percentages and numbers.

Results
This cross-sectional survey recruited 133 PHPs.  The assessment of PHPs' knowledge in managing AH and gout is presented in Table 2. It was revealed that the overall mean knowledge score was 5.18 (SD 1.39), with poor, moderate, and good knowledge levels detected among 13.5%, 40.6%, and 45.9% of the participants, respectively.

N (%)
Which of the following values is correct regarding asymptomatic hyperuricemia (AH)?  * Indicates correct answer.
Regarding PHPs' practice in managing AH and gout, the poor practice was observed regarding the preferred treatment to perform during the acute setting of the first gouty attack, as only 22.6% indicated joint aspiration. Nearly two-thirds (65.4%) of the PHPs were correct in saying that less than 6 mg/dl was the target serum uric acid after starting ULT. Moreover, 36.8% knew that anti-inflammatory prophylaxis could last from 3 to 6 months, while nearly half (46.6%) believed that anti-inflammatory prophylaxis is not mandatory. Nearly all PHPs (90.2%) knew that allopurinol was the preferred form of ULT. Most PHPs understood the importance of discussing diet and lifestyle modifications in the case of gout/hyperuricemia at the clinic (96.2%). Accordingly, the overall mean practice score was 7.00 (SD 2.04), with poor, moderate, and good practices being determined in 23.3%, 63.9%, and 12.8% of the participants, respectively.

Statement N (%)
Which of the following would you prefer to perform in the acute setting of the first gouty attack? †   * Indicates correct answer. Figure 1 shows an association between the practice score and the knowledge score. A significantly positive correlation between the knowledge and practice score (r=0.351; p<0.001) can be observed. Therefore, this indicates that the practice score is likely to rise whenever the knowledge score does.

FIGURE 1: Correlation (Pearson-r) between knowledge score and practice score
When measuring the differences in the knowledge and practice scores, according to the socio-demographic characteristics of the PHPs (Table 4), it was found that a participant more likely acquired a higher knowledge score in the >45 years old group (Z=20.517; p<0.001). It is also more likely to be a participant with more than 10 years of experience (H=21.005; p<0.001) and one who attended CME on AH or gout (Z=3.594; p<0.001). Further, a higher practice score was more likely obtained by a participant in the >45 years old group (H=10.819; p=0.004) with more than 10 years of expression (H=5.740; p=0,057) and who attended CME on AH or gout (Z=2.357; p=0.018). Other variables, such as medical specialty, reading about AH or gout, and awareness of guidelines on the management of AH or gout (p>0.05), did not show significant differences in the knowledge and practice scores.
level of knowledge, but only 13.5% were considered to have a poor level of knowledge. The overall level was poor among 23.3%, and 63.9% possessed reasonable practice. Nevertheless, only 12.8% were considered to have a good practice. Consistent with these findings, Alharthi [9],2021, found that nearly all (86.6%) physicians possessed a good knowledge of managing AH at the primary health centers in the Bisha Province. However, their level of practice was a cause for concern, as only 43.9% had good practice, and just 27.4% of the physicians had attended CME on either gout or AH. In China [10], Liu et al., 2021, general practitioners' knowledge regarding gout were lower than our PHPs. Findings indicated that the overall rate of a good understanding of gout was only 6.5%. The basic knowledge level was 55.6%, and the understanding of gout diagnosis and treatment was only 11.1%. Data in this study revealed that the older age group (&gt;45 years) who regularly attended CME for AH/gout exhibited significantly better knowledge and practice scores than the remaining groups. This almost concurred with the study of Liu et al. [10], 2021, whose findings suggested that general practitioners' knowledge and management of gout was higher among those who understood basic concepts related to gout. It also states that CME could improve their understanding of gout diagnosis and treatment. Further education about the causes and risks of AH and gout among healthcare providers may bridge the gaps in their knowledge and practice, ultimately leading to better management.
Moreover, increasing years of experience was associated with increased knowledge scores. However, this correlation did not extend to the practice scores, as we found no significant differences between years of experience and the level of practice. In contrast, Alharthi [9], 2021, found that years of experience and reading about AH in the last 12 months were predictors of good practice.
When we compared the knowledge and practice of the medical field of each participant, we learned that the knowledge and practice of general practitioners and family physicians were not significantly different. However, we predicted that female PHPs were more likely to exhibit better practice than male PHPs, but such gender differences were not proven through literature. Thus, further investigation is needed to establish its credibility.
Interestingly, we found a significant positive correlation between the knowledge score and the practice score. Similarly, Alharthi [9], 2021, states that information based on guideline recommendations will provide better patient management plans. The prevalence of PHPs who attended CME on the subject of AH and gout was 32.3%. This figure was lower than those who read about AH or gout in the last year (70.7%) and those who were aware of the guidelines for managing AH or gout (67.7%). However, reading or awareness of such guidelines does not have a relevant effect on either knowledge or practice. This is inconsistent with the paper by Furlan et al. [7], 2021. Based on their reports, PHPs who read at least one scientific paper on hyperuricemia in the past year scored significantly higher in the knowledge test. Additionally, a study conducted by Liu et al. [10], 2021 documented that a large percentage of the general practitioners in the Tongzhou district of Beijing, China, had received CME about gout (71.8%), while more than half (54.6%) were aware of its treatment. However, despite these statistics, the author emphasized that there were severe deficits among general practitioners in understanding gout, wherein quality CME is needed to improve their management of gout.

Conclusions
Although PHPs' knowledge of managing AH and gout was adequate, this did not reflect in their practice. Physicians with more years of experience who attended CME on AH and gout demonstrated better knowledge and practice than the rest of the PHPs. It is necessary to address the gaps in the practice of our PHPs, which could be done through in-depth training about AH and gout. While having a good understanding of the management of hyperuricemia and gout could be an advantage, this has to be translated into real cases to decrease the risk of malpractice and the costly treatments of these conditions. Our study could guide other researchers to assess the gaps in other clinical practices that PHPs face.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Regional Research Ethics Committee, Registered at National Committee of Bio & Med.Ethics (NCBE) issued approval 1443-880505. We are pleased to inform you that the local research ethics committee had approved your research,Your efforts to meet the criteria requested by NCBE are highly appreciated. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.