Graduation Date

Spring 5-7-2016

Document Type


Degree Name

Doctor of Philosophy (PhD)


Medical Sciences Interdepartmental Area

First Advisor

Ted R. Mikuls


Improving patient outcomes in chronic disease is of critical importance to the future of health care. Gout, affecting 4% of the US population, is a highly treatable chronic disease from which patients experience unnecessarily suboptimal outcomes. In this dissertation, I demonstrate how interrelated patient and provider factors affect patient outcomes in gout. First, I describe how only 14% of gout patients know their serum urate (SU) goal for urate lowering therapy (ULT) despite otherwise being knowledgeable about gout and its treatment. I then demonstrate the importance of multiple patient and provider factors in achieving SU goal. Specifically, I demonstrate that ULT medication adherence, ULT dose escalation and a high ULT starting dose are associated with SU goal attainment. However, I show that a high starting dose is also associated with worse SU goal attainment through its negative impact on medication adherence. These findings demonstrate not only the importance of patient and provider behaviors in achieving optimal outcomes, but also their interrelated nature. Finally, I report that there is no evidence from a large national study that ULT dose escalation reduces mortality among gout patients. In further analysis, I demonstrate that the lack of evidence could be due to inadequate final ULT doses observed even among patients receiving dose escalation. Importantly, the patient and provider factors I identify in this work are all modifiable. Future interventions should address the broad care context outlined in the Chronic Care Model to target these interrelated, modifiable factors and achieve optimal outcomes in gout.