Background/Purpose: ACR/EULAR guidelines have been published on the management of gout. Despite these guidelines, many patients with gout suffer recurrent flares and hospitalizations resulting in poor disease control and increased health care utilization. We aim to analyze the hospitalizations related to gout, determine whether these admissions were preventable and calculate imputed hospitalization costs.

Methods: A retrospective cohort of adult patients hospitalized at our institution with a primary discharge diagnosis of gout (defined as ICD-9 274, 275 or 712) from 01/01/2009 to 12/31/2013 was constructed (n=79). The primary diagnoses were validated and preventable admissions ascertained on chart review. A preventable admission was defined as an admission where the primary admitting diagnosis was a mono or polyarthritis subsequently diagnosed as gout on hospitalization and without any concomitant illness on presentation warranting admission. We reported demographic characteristics, including clinical diagnosis on admission, prior history of gout, possible risk factors for gout (Diabetes, Cardiovascular disease, chronic kidney disease, diuretic or low dose aspirin use), gout medications, serum uric acid levels within 1 year prior to admission, timing of arthrocentesis, if done, surgical procedures performed and hospitalization costs.

Results: Fifty six (56) of 79 patients were found to have adjudicated primary diagnosis of gout. Of these 56 gout admissions, 50 (89%) met the definition of preventable admission. On admission, the clinical diagnosis was septic arthritis (76%), inflammatory polyarthritis (14%) or cellulitis (8%). Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the Emergency Room.  Thirty-five (35) patients (70%) had a previous history of gout and 21 (42%) had ≥3 risk factors for gout. Of the 35 patients with a prior history of gout, 74% were managed by primary care, whereas 26% were being managed by rheumatology. Of the 26 patients managed by family physicians, 8 (31%) were on urate lowering therapy (ULT) and 5 (19%) were on colchicine prophylaxis.  Twenty three serum uric acid levels within 1 year of the date of hospitalization were recorded of which 18 (78%) were not at goal of <6 mg/dL. Of 15 patients on long term gout treatment, 33% were non-compliant. Three (3) patients underwent orthopedic procedures: toe amputation (1), arthroscopic debridement (2) and were subsequently diagnosed as gout.

Total additive length of stay for the preventable admissions was 171 days (mean 3.42 days). Total hospitalization-related-costs were $208,000 with average cost per admission of $4160.

Conclusion: We conclude that 89% of the hospitalizations with primary diagnosis of gout were preventable. Defined gaps in clinical care include: ACR/EULAR guidelines not followed, lack of crystal-confirmed diagnoses, patients presenting to emergency room for care, and medication non-compliance. Consequently, this population incurred unnecessary health care costs in the emergency room and costly and preventable admission care expenditures. Steps to reassess the care of gout at our institution have begun as a direct result of these study findings.