Background/Purpose: Despite effective treatments, hospitalization due to acute gout is increasing and is financially burdensome. Prior studies have primarily attributed the increased rate of gout hospitalizations to physicians’ gaps in knowledge regarding gout management. However, these studies fail to address patient and systems factors which may be associated with this risk. Our aim was to assess the association between these factors and risk of hospitalization among patients visiting the emergency department (ED) using a statewide healthcare system.

Methods: Lifespan is the largest provider of healthcare in Rhode Island and has 3 EDs across the state. We identified gout patients 18 years of age or older who presented to the ED between 3/30/2015 and 9/30/2017 using ICD9 and ICD10 diagnostic codes. If the patient was seen more than once during this time only the first encounter was included. Outcome of interest was admission from ED to inpatient or observation. We collected information regarding: a) patients factors including demographics, medications and comorbidities assessed at presentation, b) clinical presentation of gout (single versus multiple joint involvement) and severity as assessed by the triage nurse on a 5-point ED severity scale (1 being the worst), and c) systems factors including time of day and time of year at presentation to the ED, and type of insurance (commercial versus state health agencies/governmental insurance). A multivariable logistic regression model was used to identify factors associated with hospitalization.

Results: A total of 458 patients (mean age 58.71 ± 16.36 years, 79.43% males) were included. Of these 458 patients, 51 patients (11.1%) were admitted; 29 (6.4%) to inpatient and 22 (4.8%) to observation. Older age, presence of comorbidities, pattern of joint involvement and severity and time of presentation to the ED were associated with increased odds of admission. In a multivariable model, older age [aOR 1.05 (1.01 to 1.08)], having oligo- or polyarticular gout [aOR 8.67 (3.50 to 21.48)], diabetes [aOR 4.74 (1.86 to 12.11)], history of inflammatory arthritis [aOR 5.83 (1.36 to 25.01)] and time of presentation to the ED between 8 AM–4 PM [aOR 5.92 (1.28 to 27.46)] and 4 PM–12 AM [aOR 7.04 (1.35 to 36.66)] continued to remain significant.

Conclusion: Our study demonstrates increased hospitalization rates among older patients, and those with comorbid diabetes or pre-existing inflammatory arthritis. This may be related to fear that these patients are at higher risk of joint infection. The study highlights increased odds of admission in patients presenting between 8 AM and midnight compared to those presenting between midnight and 8AM. It is likely that decision to admit in case of the latter is made during regular business hours. Hence, highlighting the need to improve systems for after hour care of gout patients.

Table 1: Baseline cohort characteristics

*  Represents statistically significant results (p <0.05)