Background/Purpose: Despite available effective treatment options and published guidelines for gout management, many patients suffer from recurrent gout attacks. Increases in gout prevalence and continued suboptimal gout care result in an increase in hospitalizations and health care utilization. We analyzed admissions due to gout in a community teaching hospital in order to ascertain whether these hospitalizations were preventable and to identify deficits in care prior to admission.

Methods:

We identified adult patients hospitalized at our institution from 01/01/2011 to 12/31/2014 with a primary discharge diagnosis of gout. A preventable admission was defined as a final diagnosis of gout without any coexisting conditions on presentation warranting admission, determined by chart review. We reviewed demographic characteristics, diagnosis on admission, prior history of gout, risk factors for gout, gout medication use prior to hospitalization, serum uric acid levels on admission, date and time of admission including overnight and weekend admissions, history of outpatient follow-up for treatment of gout, use of arthrocentesis, and duration of inpatient stay.

Results:

Ninety one patients were discharged with a primary diagnosis of gout, 71 (78%) of whom met criteria for preventable admission. Diagnosis on admission included pain 27 (38%), pain and joint swelling 4 (5%), joint effusion 4 (5%), acute gouty arthritis 26 (36%), cellulitis 10 (14%), osteomyelitis 2 (3%), and one patient was admitted to rule out deep vein thrombosis. Twenty four patients underwent arthrocentesis, but only 5 of these procedures were done in the Emergency Department (ED) prior to admission. Fifty patients (70%) had a prior history of gout, although 35 (70%) of them had no documentation of any outpatient provider managing their gout. 12 (23%) were managed by primary care providers, 3 (5%) by a rheumatologist. Risk factors for gout included hypertension 63 (88%), chronic kidney disease 27 (38%), aspirin therapy 34 (47%), and diuretic therapy 46 (64%). 20 (28%) were receiving urate lowering therapy (ULT), and 8 (11%) chronic colchicine. Seventeen (85%) of the patients treated with allopurinol received no prophylactic therapy. Only 10 (14%) had serum uric acid levels at target of <6 mg/dL, 27 (59%) had a uric acid level between 8-10 mg/dL, and 15 (21%) above 10 mg/dL. Ten (14%) had no documentation of their uric acid level. Twenty (28%) of the admissions were during the weekend, and 33 (46%) were admitted between the hours of 5pm and 7am. Overall aggregate length of stay for the preventable admissions was 179 days (mean 2.59 days).

Conclusion: Our findings demonstrate that 78% of the hospitalizations with a primary discharge diagnosis of gout were preventable. Lapses in the outpatient management of gout were apparent, as most of the patients did not have ongoing outpatient gout management, and few received concomitant prophylactic therapy when treated with ULT or had serum uric acid levels at target. A significant number of patients were admitted via the ED at night and on weekends. Arthrocentesis appeared to be underutilized in the ED. Interventions to address gaps in outpatient and ED care for gout are needed to prevent unnecessary admissions and decrease hospitalization-related costs.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/breaking-the-cycle-analyzing-preventable-hospital-admissions-due-to-gout/