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Most gout hospitalizations are preventable with better clinical care

Date:
November 16, 2014
Source:
American College of Rheumatology (ACR)
Summary:
Better clinical care and compliance might prevent most gout cases that require hospitalization, according to new research. Gout is a chronic disease that involves painful joint swelling and redness. Gout often strikes joints in the feet and ankles, especially the big toe. Gout occurs when excess uric acid (a normal waste product) collects in the body, and needle‐like urate crystals deposit in the joints. This may happen due to an increase in uric acid production, or more often, the kidneys cannot sufficiently remove uric acid from the body.
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Better clinical care and compliance might prevent most gout cases that require hospitalization, according to new research findings presented at the American College of Rheumatology Annual Meeting in Boston.

Gout is a chronic disease that involves painful joint swelling and redness. Gout often strikes joints in the feet and ankles, especially the big toe. Gout occurs when excess uric acid (a normal waste product) collects in the body, and needle‐like urate crystals deposit in the joints. This may happen due to an increase in uric acid production, or more often, the kidneys cannot sufficiently remove uric acid from the body.

Researchers at Geisinger Health System in Danville, Penn., analyzed retrospective data on 56 patients admitted to their hospital with a primary diagnosis of gout from 2009-2013. The researchers' goal was to determine how many of these hospitalizations were preventable with better interventions and clinical management. Preventing hospitalizations for gout might also translate to lower health care costs.

They defined a hospital admission as preventable in cases where the primary admitting diagnosis was a mono or polyarthritis, and the patient was subsequently diagnosed as gout on hospitalization and had no concomitant illness on presentation warranting admission. They also analyzed demographic characteristics, including clinical diagnosis on admission, prior history of gout, possible risk factors for gout (such as diabetes, cardiovascular disease, chronic kidney disease and diuretic or low-dose aspirin use), gout medications, serum uric acid levels within one year prior to admission, timing of arthrocentesis (if done), surgical procedures performed and hospitalization costs.

"Because rheumatology sees these patients in hospital consultation, we hypothesized that many of these gout admissions were unnecessary. Because the patient presented so often to the emergency room rather than their doctor's office and were in pain with other co-morbidities, admission seemed the correct medical care decision," said Thomas Olenginski, MD of the Geisinger Health System and a lead author of the study. "We felt that the results might spur interest in a system-wide effort to create a gout initiative or a multi-pronged approach to better address this perceived problem within our health care system."

Out of the 56 gout admissions to their hospital, the Geisinger researchers found that 50 (89 percent) met the study's definition of a preventable admission. The clinical diagnoses included 76 percent septic arthritis, 14 percent inflammatory polyarthritis and eight percent cellulitis. Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the Emergency Room.

Thirty-five (70 percent) of the patients had a previous history of gout, and 21 (42 percent) had three or more risk factors for gout. Of the 35 patients with a prior history of gout, 74 percent were managed by their primary-care physician, and 26 percent were being managed by a rheumatologist. Of the 26 patients managed by family physicians, eight (31 percent) were on urate-lowering therapy and five (19 percent) were on colchicine prophylaxis. There were 23 patients whose serum uric acid levels were recorded within one year of their hospitalization, and 18 (78 percent) of these patients did not reach the goal of <6 mg/dL. Of 15 patients on long-term gout treatment, 33 percent were non-compliant with their treatment plans. Three patients in the study had undergone orthopedic procedures, including one toe amputation and two arthroscopic debridements, and were subsequently diagnosed as having gout.

The total additive length of stay for the preventable gout admissions was 171 days (a mean of 3.42 days). Total hospitalization-related costs related to these admissions were $208,000, with an average cost per admission of $4,160.

The study's authors concluded that 89 percent of the hospitalizations with a primary diagnosis of gout were preventable. They noted several key gaps in clinical care, including ACR/EULAR guidelines not being followed, lack of crystal-confirmed diagnoses, patients presenting to the emergency room for care and medication non-compliance. They noted that people with gout incur unnecessary health care costs in the emergency room and costly, preventable admission care expenditures.

"Too many of these admissions were indeed preventable, but most of the time, the rheumatology department was called in after the patient had already been admitted to the hospital. To effectively deal with this problem in a busy emergency room, a collaborative approach between the ER, rheumatology, orthopedics and internal medicine is necessary," said Dr. Olenginski. "The solution is quick assessment of the patient, prompt diagnostic aspiration of affected joints (to make a diagnosis of gout and/or consider the possibility of joint infection), prompt initiation of systemic anti-inflammatory therapy, and then adequate and close outpatient follow-up. Additionally, a patient with gout needs definitive uric acid-lowering therapy as long-term maintenance therapy. We can and will address this problem and fix it."


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Materials provided by American College of Rheumatology (ACR). Note: Content may be edited for style and length.


Cite This Page:

American College of Rheumatology (ACR). "Most gout hospitalizations are preventable with better clinical care." ScienceDaily. ScienceDaily, 16 November 2014. <www.sciencedaily.com/releases/2014/11/141116094052.htm>.
American College of Rheumatology (ACR). (2014, November 16). Most gout hospitalizations are preventable with better clinical care. ScienceDaily. Retrieved March 27, 2024 from www.sciencedaily.com/releases/2014/11/141116094052.htm
American College of Rheumatology (ACR). "Most gout hospitalizations are preventable with better clinical care." ScienceDaily. www.sciencedaily.com/releases/2014/11/141116094052.htm (accessed March 27, 2024).

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