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Kurajoh M, Akari S, Nakamura T, Ihara Y, Imai T, Morioka T, Emoto M. Seasonal variations for newly prescribed urate-lowering drugs for asymptomatic hyperuricemia and gout in Japan. Front Pharmacol 2024; 15:1230562. [PMID: 38292940 PMCID: PMC10825023 DOI: 10.3389/fphar.2024.1230562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/08/2024] [Indexed: 02/01/2024] Open
Abstract
Background: Urate-lowering drugs (ULDs) have been approved for treatment of asymptomatic hyperuricemia and gout in Japan. Although serum urate levels and rates of gout onset are known to have seasonal variations, no survey results regarding the seasonality of ULD prescriptions for asymptomatic hyperuricemia and gout have been reported. Methods: A large-scale database of medical claims in Japan filed between January 2019 and December 2022 was accessed. In addition to total size of the recorded population for each month examined, the numbers of patients every month with newly prescribed ULDs for asymptomatic hyperuricemia and gout were noted, based on the International Classification of Diseases, 10th Revision, codes E79.0 and M10. Results: The results identified 201,008 patients with newly prescribed ULDs (median age 49.0 years, male 95.6%). Of those, 64.0% were prescribed ULDs for asymptomatic hyperuricemia and 36.0% for gout. The proportion of new ULD prescriptions was seasonal, with that significantly (p < 0.001) higher in summer (June-August) [risk ratio (RR) 1.322, 95% CI 1.218 to 1.436] and autumn (September-November) (RR 1.227, 95% CI 1.129-1.335) than in winter (December-February), whereas the proportion in spring (March-May) was not significantly different from winter. There was no significant difference after stratification by drug type (uric acid production inhibitor/uricosuric agent) or size of the medical institution, nor subgrouping by age or sex (p for interaction = 0.739, 0.727, 0.886, and 0.978, respectively). On the other hand, the proportions of new ULD prescriptions for asymptomatic hyperuricemia were significantly lower and for gout significantly higher in spring than winter, while those were similar in summer and autumn for both groups (p for interaction<0.001). Conclusion: The present findings indicate that new prescriptions for ULDs to treat asymptomatic hyperuricemia or gout in Japan show seasonal differences, with higher rates noted in summer and autumn as compared to winter.
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Affiliation(s)
- Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Seigo Akari
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Nagoya, Aichi, Japan
| | - Takashi Nakamura
- Medical Affairs Department, Sanwa Kagaku Kenkyusho Co., Ltd., Nagoya, Aichi, Japan
| | - Yasutaka Ihara
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Wu ZD, Yang XK, He YS, Ni J, Wang J, Yin KJ, Huang JX, Chen Y, Feng YT, Wang P, Pan HF. Environmental factors and risk of gout. ENVIRONMENTAL RESEARCH 2022; 212:113377. [PMID: 35500858 DOI: 10.1016/j.envres.2022.113377] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 06/14/2023]
Abstract
Gout is a chronic disease with inflammatory arthritis caused by monosodium urate (MSU) crystals deposition, an elevated serum urate level (hyperuricaemia) is the critical factor leading to MSU crystals deposition and promoting the progression of gout. The onset and development of gout is generally the result of multiple factors, such as diet, heredity and environmental factors. Although genetics and diet are thought to play as major factors, a growing body of research evidence has highlighted that environmental factors also play a significant role in the onset and exacerbation of gout. Recent studies have shown that air pollutants such as particulate matter, sulfur dioxide (SO2) and carbon monoxide (CO) may increase the risk of hospitalizations for gout, and that the changes in temperature and humidity may affect uric acid (UA) levels. There is also seasonal trend in gout. It has been demonstrated that environmental factors may induce or accelerate the production and release of pro-inflammatory mediators, causing an unbalance oxidative stress and systemic inflammation, and then participating in the overall process or a certain link of gout. Moreover, several environmental factors have shown the ability to induce the production urate and regulate the innate immune pathways, involving in the pathogenesis of gout. Nevertheless, the role of environmental factors in the etiology of gout remains unclear. In this review, we summarized the recent literatures and aimed to discuss the relationship between environmental factors (such as microclimate, season, ambient/indoor air pollution and extreme weather) and gout. We further discussed the inflammatory mechanisms of environmental factors and gout and the comprehensive effects of environmental factors on gout. We also made a prospect of the management and treatment of gout, with special consideration to environmental factors associated with gout.
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Affiliation(s)
- Zheng-Dong Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Xiao-Ke Yang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yi-Sheng He
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Jing Ni
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Jie Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Kang-Jia Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Ji-Xiang Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Yue Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Ya-Ting Feng
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China
| | - Peng Wang
- Teaching Center of Preventive Medicine, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China.
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, China.
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Affiliation(s)
- Desmond O'Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin, Ireland
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Hwang SM, Hwang SH. Association of nationwide insurance data and Google Trends for seasonality of gout in South Korea. THE EGYPTIAN RHEUMATOLOGIST 2021. [DOI: 10.1016/j.ejr.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ahmed F, Tscharke B, O'Brien JW, Zheng Q, Thompson J, Mueller JF, Thomas KV. Wastewater-based prevalence trends of gout in an Australian community over a period of 8 years. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 759:143460. [PMID: 33234275 DOI: 10.1016/j.scitotenv.2020.143460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 06/11/2023]
Abstract
Gout is a rheumatic arthritis disease which poses a health burden. Monitoring the prevalence of gout is key to reduce the community burden of gout disease and associated health costs. Allopurinol has been used as a first line gout preventive medication in Australia which is metabolised into oxypurinol and excreted in urine. Wastewater-based epidemiology (WBE) was applied to estimate temporal trends of gout prevalence in an Australian community over eight-years via the quantification of oxypurinol in wastewater. A total of 180 wastewater samples collected between 2012 and 2019 were analysed for oxypurinol to estimate allopurinol consumption in a community in South East Queensland, Australia. Annual gout prevalence was estimated by daily defined doses (DDD) consumed and ranged from 24 to 32 DDD/day/1000, an equivalent gout prevalence of 2.3 to 3.2% over the eight-year period. A statistically significant increase in allopurinol consumption was observed over the period (Slope = 0.094, p = 0.0001), equating to year-on-year increases in gout prevalence of 3.6% per year. To the best of our knowledge, this is the first long-term gout prevalence study using wastewater, adding epidemiological and public health insights in the gout research field.
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Affiliation(s)
- Fahad Ahmed
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia.
| | - Benjamin Tscharke
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Jake W O'Brien
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Qiuda Zheng
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Jack Thompson
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Jochen F Mueller
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Kevin V Thomas
- Queensland Alliance for Environmental Health Sciences (QAEHS), The University of Queensland, Woolloongabba, Brisbane, QLD 4102, Australia
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The impact of adoption of a new urate-lowering agent on trends in utilization and cost in practice. PLoS One 2019; 14:e0221504. [PMID: 31449565 PMCID: PMC6709886 DOI: 10.1371/journal.pone.0221504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/13/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Changes in treatment choice of therapy and size of treated population that can lead to under- or overestimate of payer's budget are less likely to be reassured after reimbursement adoption of a new drug. The aim of this study was to evaluate the effects of febuxostat introduction and the modifications in its insurance coverage on the utilization and expenditure of urate-lowering therapy (ULT). METHODS Electronic medical records for adults patients prescribed any ULT during 2010-2015 was derived from the largest medical organization in Taiwan. Aggregated estimates of ULT use and costs were assessed per 3-month and per patient per month (PPPM). Factors associated with total ULT expenditure were assessed using a time series design with factored Autoregressive Integrated Moving Average (ARIMA) models. RESULTS ULT prevalent users increased 34.1% from 2010 to 2015 and a 123% increase in total ULT expenditure. Numbers on allopurinol and sulfinpyrazone both declined 31%, and on benzbromarone and febuxostat gradually increased to 38.21% and 22.89% of all users in 2015. Insurance payments PPPM ($4.44 to $9.22) and total monthly ULT cost ($32,946 to $ 85,732) growth more than doubled in 6 years, trend changes generated mostly by individuals switching to febuxostat. CONCLUSIONS ULT use moved to favor benzbromarone and febuxostat; greater expensive uptake for febuxostat led to a rapid rise in ULT cost. Marginal values of increasing access to febuxostat for asymptomatic hyperuricemia should be focus on future studies to facilitate drug prices negotiation and ensure appropriate ULT use.
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Kardeş S. Seasonal variation in the internet searches for gout: an ecological study. Clin Rheumatol 2018; 38:769-775. [DOI: 10.1007/s10067-018-4345-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/13/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022]
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Abhishek A, Valdes AM, Jenkins W, Zhang W, Doherty M. Triggers of acute attacks of gout, does age of gout onset matter? A primary care based cross-sectional study. PLoS One 2017; 12:e0186096. [PMID: 29023487 PMCID: PMC5638318 DOI: 10.1371/journal.pone.0186096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/25/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To determine the proportion of people with gout who self-report triggers of acute attacks; identify the commonly reported triggers, and examine the disease and demographic features associated with self-reporting any trigger(s) of acute attacks of gout. METHODS Individuals with gout were asked to fill a questionnaire enquiring about triggers that precipitated their acute gout attacks. Binary logistic regression was used to compute odds ratio (OR) and 95% confidence intervals (CI) to examine the association between having ≥1 self-reported trigger of acute gout and disease and demographic risk factors and to adjust for covariates. All statistical analyses were performed using STATA. RESULTS 550 participants returned completed questionnaires. 206 (37.5%) reported at least one trigger of acute attacks, and less than 5% reported >2 triggers. Only 28.73% participants reported that their most recent gout attack was triggered by dietary or lifestyle risk factors. The most frequently self-reported triggers were alcohol intake (14.18%), red-meat or sea-food consumption (6%), dehydration (4.91%), injury or excess activity (4.91%), and excessively warm or cold weather (4.36% and 5.45%). Patients who had onset of gout before the age of 50 years were significantly more likely to identify a trigger for precipitating their acute gout attacks (aOR (95%CI) 1.73 (1.12-2.68) after adjusting for covariates. CONCLUSION Most people with gout do not identify any triggers for acute attacks, and identifiable triggers are more common in those with young onset gout. Less than 20% people self-reported acute gout attacks from conventionally accepted triggers of gout e.g. alcohol, red-meat intake, while c.5% reported novel triggers such as dehydration, injury or physical activity, and weather extremes.
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Affiliation(s)
- Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham, United Kingdom
- * E-mail:
| | - Ana M. Valdes
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham, United Kingdom
| | - Wendy Jenkins
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham, United Kingdom
| | - Weiya Zhang
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham, United Kingdom
| | - Michael Doherty
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham, United Kingdom
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Park KY, Kim HJ, Ahn HS, Yim SY, Jun JB. Association between acute gouty arthritis and meteorological factors: An ecological study using a systematic review and meta-analysis. Semin Arthritis Rheum 2017; 47:369-375. [PMID: 28583691 DOI: 10.1016/j.semarthrit.2017.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/26/2017] [Accepted: 05/16/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aims of this study were as follows: (1) to analyze the literature systematically regarding the seasonal and monthly variation of the occurrence of episodes of acute gouty arthritis, and (2) to investigate the relationship between the occurrence of episodes of acute gouty arthritis and meteorological parameters. METHODS The present authors systematically reviewed databases for articles published before November 2015. Studies with quantitative data on episodes of acute gouty arthritis by months and/or seasons were included. Meteorological data such as the highest temperature, lowest temperature, diurnal temperature range, change in mean temperature between neighboring days, relative humidity and wind speed for the geographic place(s), and study period where and when each study took place were obtained from meteorological websites. RESULTS Ten studies published between 1920 and 2015 were included. A meta-analysis by season showed that acute gouty arthritis occurred significantly more frequently in spring than in other seasons. Analysis by month showed an increase in episodes of acute gouty arthritis from March to July, being the highest in July. The trend reversed, and episodes of acute gouty arthritis started decreasing from July to September, being the lowest in September. The change in mean temperature between neighboring days was the only meteorological parameter that was significantly correlated with the number of monthly episodes of acute gouty arthritis. CONCLUSIONS Acute gouty arthritis seems to develop more frequently during the period in which the temperature increases significantly between neighboring days: spring by season and between March and July by month in the northern hemisphere.
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Affiliation(s)
- Kyu Yong Park
- Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Worldcup-ro 164, Yeongtong-gu, Suwon, Republic of Korea 16499
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Anam-ro 145, Seongbuk-gu, Seoul, Republic of Korea 02841
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Anam-ro 145, Seongbuk-gu, Seoul, Republic of Korea 02841
| | - Shin-Young Yim
- Department of Physical Medicine and Rehabilitation, Ajou University School of Medicine, Worldcup-ro 164, Yeongtong-gu, Suwon, Republic of Korea 16499.
| | - Jae-Bum Jun
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Wangsimni-ro 222-1, Seongdong-gu, Seoul, Republic of Korea 04763.
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Åkerblom A, Helmersson-Karlqvist J, Weitoft T, Larsson A. Seasonal variations of urate in a Swedish adult population. Clin Rheumatol 2017; 36:1595-1598. [PMID: 28283767 PMCID: PMC5486493 DOI: 10.1007/s10067-017-3591-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/20/2017] [Accepted: 02/22/2017] [Indexed: 11/29/2022]
Abstract
Seasonality in the incidence and prevalence of gout has previously been reported but the cause of this seasonality in gout is not explained. The aim of this study was to evaluate possible seasonal variations of urate in a large unselected Swedish adult population. We analyzed 170,915 urate test results from patients at a tertiary care hospital between 2000 and 2016. The results were divided according to sex and sampling month of the year. The median urate values were overall higher in males compared to females and both males and females had peak urate concentrations in the summer months (June–August). There is a seasonal pattern for urate concentrations in a large Swedish population similar to the previously reported seasonality for gout. This may be clinically important and could contribute to the circannual variation of gout. The seasonal pattern should be recognized when evaluating patient results both in clinical practice and in research studies.
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Affiliation(s)
- Axel Åkerblom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Tomas Weitoft
- Section of Rheumatology, Center of Research and Development, Uppsala University/Region of Gävleborg, Gävle, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden.
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Singh JA, Yu S. Gout-related inpatient utilization: a study of predictors of outcomes and time trends. Arthritis Res Ther 2016; 18:57. [PMID: 26935737 PMCID: PMC4774040 DOI: 10.1186/s13075-016-0936-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/18/2016] [Indexed: 02/06/2023] Open
Abstract
Background To assess inpatient healthcare burden of gout in the USA after an Emergency Department (ED) visit and the predictors of gout-related hospitalizations. Method We used the 2009, 2010 and 2012 US National ED Sample (NEDS) data to examine the time trends in inpatient visits with gout as the primary diagnosis. We used the 2012 NEDS data to assess multivariable-adjusted predictors of length of hospital stay, discharge to home (versus other) and total charges for gout-related inpatient visits. Results Of the 205,152 ED visits for gout as the primary diagnosis in 2012, 7.7 % resulted in hospitalization. In 2009, 2010 and 2012, 63 %, 63 % and 64.5 % of hospitalized patients were discharged home; respective durations of hospital stay were 4.15, 4.00 and 3.86 days. Older age 50 to <65 years (ref <50), renal failure, heart failure, osteoarthritis and diabetes were associated with a longer hospital stay and self-pay/uninsured status, hospital location in the Midwest or Western USA with a shorter hospital stay for gout. Similar factors were associated with total charges for gout-related admissions. Older age (65 to <80 and ≥80, relative to <50 years), diabetes, self-pay/no charge insurance status, metropolitan area residence, and a longer length of hospital stay were associated with lower odds of discharge to home; and self-pay/no charge (uninsured) status was associated with higher odds of discharge to home, compared to Medicare coverage. Conclusions Using a national sample, we noted declining duration of hospital stay and identified factors associated with the length of hospital stay, discharge to home and charges for gout hospitalization following an ED visit. Future studies should examine whether better management of comorbidities in patients with gout can further reduce utilization and cost of gout-related hospitalizations.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, 700 South 19th Street, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), 1705 University Boulevard, Birmingham, AL, 35233, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN, 55905, USA.
| | - Shaohua Yu
- Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama at Birmingham (UAB), 1705 University Boulevard, Birmingham, AL, 35233, USA.
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