Alice Goodman

November 25, 2014

BOSTON — Inefficient or inadequate clinical care led to unnecessary hospitalizations in 89% of patients with gout, according to a retrospective review conducted at the Geisinger Health System in Central Pennsylvania.

"Most of these hospitalizations could have been avoided with a consult with a rheumatologist," said Thomas Olenginski, MD, from the Geisinger Medical Center in Danville, Pennsylvania.

In fact, the hospitalizations were often the result of failure to follow the guidelines of the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR), hospitalizing patients who present to the emergency department for care, and noncompliance with prescribed medications.

However, rheumatologists "were rarely asked to see the patients once they were admitted," he explained.

"Because patients presented so often to the emergency department rather than their doctor's office and were in pain with other comorbidities, admission may have seemed to be the correct medical care decision," Dr. Olenginski said during a press conference here at the ACR 2014 Annual Meeting.

"Gout is a misunderstood disease, and not considered to be a condition that can lead to complications. Gout attacks are preventable. In 2014, deposition of crystals on the joint should not occur. When the patient comes in, it is critical to make the diagnosis by aspirating fluid and defining crystals under the microscope," he emphasized.

"Gout patients are problematic," he continued. "Even before we undertook this study, we suspected that gout was not being properly managed, and not just by primary care providers. We expected to find preventable hospital admissions and patients who could have had shorter hospital stays."

Most of these hospitalizations could have been avoided with a consult with a rheumatologist.

Dr. Olenginski and his team retrospectively reviewed the cases of 56 hospitalized adults with a primary discharge diagnosis of gout from 2009 to 2013. Of these hospital admissions, 50 (89%) were considered to be preventable, defined as a primary diagnosis of gout with no concomitant illness at presentation that required hospitalization.

Of the 50 patients with preventable admissions, 21 (42%) had three or more risk factors for gout, such as diabetes, chronic kidney disease, cardiovascular disease, malignancy, diuretic use, and low-dose aspirin use.

On admission, cellulitis was suspected in 8% of the patients, inflammatory polyarthritis in 14%, and septic arthritis in 76%. Two-thirds of patients underwent arthrocentesis, 73% of which were performed in the emergency department.

"One thing that was not considered was whether this was gout," said Dr. Olenginski.

Of the 35 patients with a history of gout, only nine (26%) were managed by a rheumatologist. Of the 26 (74%) managed by a primary care physician, eight (31%) were receiving urate-lowering therapy and five (19%) were receiving colchicine prophylaxis.

During the year after hospitalization, 18 of 23 serum uric acid levels recorded were not at goal (<6 mg/dL).

Of the 15 patients prescribed long-term gout treatment, five were not compliant with their medications. The three patients who underwent orthopedic procedures (1 toe amputation and 2 debridements) were subsequently diagnosed with gout.

Expensive Oversight

The total cost related to the management of these 50 patients was $208,000, or an average of $4160 per preventable admission. These patients stayed a total of 171 days in the hospital (mean, 3.4 days per patient).

"With appropriate management, this considerable amount of money and considerable amount of time in the hospital could be reduced," Dr. Olenginski explained.

This study, which was funded by Geisinger as a quality initiative in the department of rheumatology, was part of a system-wide revamping designed to improve the value of care and reduce costs.

"Following the ACR and EULAR guidelines could reduce hospitalizations," said Monique Hinchcliff, MD, from the Northwestern University Feinberg School of Medicine in Chicago. "If a rheumatologist were consulted at presentation and involved in emergency department assessment, admissions could be prevented."

"We need to do a better job of putting patients on urate-lowering therapy and colchicine, an inexpensive drug, at the first sign of a gout flare to avoid full fire in the joint," she explained. "This would take a combination of involving rheumatologists in the care of these patients and educating patients."

Dr. Hinchcliff said that an emergency physician could consult a rheumatologist by pager after a patient comes in, and the rheumatologist could ascertain at that time whether joint aspiration had been performed.

"If there is no inflammation, septic arthritis and gout can be ruled out. The patient could remain in the emergency department for 12 hours. There is no reason for a patient to be admitted for 4 days for a gout attack. That is just wasteful," she said.

Dr. Olenginski and Dr. Hinchcliff have disclosed no relevant financial relationships.

American College of Rheumatology (ACR) 2014 Annual Meeting. Abstract 2322. Presented November 16, 2014.


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