Background/Purpose: Hospital admissions for gout flares have increased dramatically in recent years. Strategies to reduce hospitalizations and improve uptake of urate-lowering therapy (ULT) are needed. We performed an in-depth review of gout hospitalizations at our centre, incorporating stakeholder input and process mapping, to identify strategies to prevent admissions.

Methods: We retrospectively reviewed all emergency department (ED) attendances and hospital admissions for gout flares at two large hospitals in London, UK, from 1st October 2020 to 31st December 2020. Primary and secondary admission diagnoses of gout were included. Data on multiple aspects of hospital and post-discharge care were analysed, including ULT initiation/uptitration, discharge delays and re-admission rates. A process map of the inpatient journey was constructed with input from multiple stakeholders, including patients and clinicians, and strategies to address care barriers were identified.

Results: Detailed case reviews were performed on 68 ED attendances or hospital admissions for gout flares. There was initial diagnostic uncertainty in 32 patients (47%); however, specialist input was rarely sought in ED, and joint aspiration was performed in only 9 patients, with a median delay of 3 days. For the 22 admitted patients, the median length of stay was 11 days (8 days for primary admissions; 17 days for secondary admissions). 18 patients (82%) had discharge delays, including delays in seeking rheumatology input and treatment of comorbid conditions. Forty patients (59%) had pre-existing gout, of whom 25% were on ULT at presentation (mean serum urate level, 6.6 mg/dL). ULT initiation and/or uptitration occurred in 7 patients (10%) during admission or in ED. Of 60 patients with post-discharge follow-up data available, 20 (33%) initiated and/or uptitrated ULT within 6 months (median delay, 32 days), 35 patients (58%) remained on no ULT, and only 2 patients (3%) achieved target serum urate levels. Seven patients (10%) re-presented to hospital within 6 months of discharge.

Through iterative process mapping and stakeholder input, strategies to address care barriers observed during gout hospitalizations were identified. Strategies included initiation of ULT during flares, treat-to-target ULT uptitration coordinated between secondary and primary care, provision of disease-specific patient education and flare management packs, and timely specialist input with joint aspiration and steroid injection as indicated.

Conclusion: We identified multiple barriers to optimal hospitalized gout care and strategies to address them. Effective implementation of evidence-based interventions during hospitalizations for gout could transform care for patients, reduce length of stay, and prevent re-admissions.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/process-mapping-gout-hospitalizations-a-deep-dive-into-an-avoidable-epidemic/