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.”
This study was performed as a Quality Initiative within the Department of Rheumatology at Geisinger Health System with no additional funding.
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The American College of Rheumatology is an international professional medical society that represents more than 9,500 rheumatologists and rheumatology health professionals around the world. Its mission is to Advance Rheumatology! The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. For more information about the meeting, visit http://www.acrannualmeeting.org/ or join the conversation on Twitter by using the official #ACR14 hashtag. Paper Number: 2322
Aim for Better Gout Control: A Retrospective Analysis of Preventable Hospital Admissions for Gout
Tarun S. Sharma1, Thomas M. Harrington2 and Thomas P. Olenginski2, 1Geisinger Medical Center, Danville, PA, 2Geisinger Health System, Danville, PA
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. Disclosures:T. S. Sharma, NoneT. M. Harrington, NoneT. P. Olenginski, None
Meeting Link: American College of Rheumatology Annual Meeting
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