Gout-related inpatient utilization: a study of predictors of outcomes and time trends

Gout increases length of stay in patients hospitalized for heart failure exacerbation

Background:

It is unclear whether patients with a history of gout have longer hospitalizations in general, or only when suffering a flare. This study examines the effect of gout diagnosis and gout flare on the length of stay (LoS) in patients admitted for heart failure (HF) exacerbation.

Methods:

We conducted a matched retrospective cohort study and searched electronic medical records for patients admitted for HF with a prior diagnosis of gout from 1 July 2012 to 30 June 2017 and matched them to patients admitted for HF without gout. Cases who had a gout flare during the admission were identified. The log of the length of stay (log LoS) was utilized for normalization of the data. We used a linear mixed-effect model to compare the adjusted LoS of gout patient with flare, gout patient without flare, and controls.

Results:

A total of 978 admissions for HF exacerbation in 738 patients, including 246 individual with gout and 492 matched controls, were identified and included in the analysis. The log LoS was significantly longer in cases (1.86 ± 0.95) compared with controls (1.72 ± 0.94; p = 0.0278). The log LoS was significantly longer in those with gout who flared (2.41 ± 0.96) compared to those without gout (1.72 ± 0.94, p < 0.0001). After adjusting for potential confounders, the log LoS of patients who flared (p < 0.0001) remained significantly longer than controls, as well as those who did not flare (p = 0.042), but to a lesser extent.

Conclusion:

HF patients with gout had significantly longer hospitalizations than those without gout, a finding driven primarily by gout flare during hospitalization.

Trends in hospital visits and healthcare costs of gout and seropositive rheumatoid arthritis in Korea from 2010 to 2017 using National Healthcare Claims

BACKGROUND/AIMS

We examined temporal trends in the rate of gout and seropositive rheumatoid arthritis (RA) hospital visits and healthcare costs in Korea.

METHODS

We conducted a serial cross-sectional analysis of Korean national healthcare claims. We calculated the annual increase in hospital visits (emergency department [ED] visits, outpatient visits, and hospitalizations) and total healthcare costs per visit.

RESULTS

From 2010 to 2017, the annual rates of ED visits, outpatient visits, and hospitalizations for gout increased from 6.28 to 21, from 638.38 to 1059.55, and from 12.37 to 15.6 per 100,000 persons, respectively. Before 2013, ED visits for gout were most common in patients over 70 years old, but they were most common in those aged between 30 and 49 years after 2013. The number of patients with ED visits, outpatient visits, and hospitalizations for RA from 2010 to 2017 increased from 1.25 to 1.87, from 219.04 to 307.49 and from 8.44 to 12.32 per 100,000 persons, respectively. However, there was no increase in the prevalence of ED visits for RA in any age group except for those older than 70 years. The cost per ED visit for gout significantly decreased from 496.3 to 273.6 US dollar during the study period. There was no significant change in the cost per ED visit for RA between 2010 and 2017.

CONCLUSION

There was a large increase in ED visits for gout during the study period. Further studies are needed to analyze the reason behind increased ED visits for gout and suggest ways on how to improve gout care.

Hospitalizations for acute gout: process mapping the inpatient journey and identifying predictors of admission

Objective

To identify predictors of admission following emergency attendances for gout flares, and describe barriers to optimal inpatient gout care.

Methods

Emergency department (ED) attendances and hospital admissions with primary diagnoses of gout were analyzed at two UK-based hospitals between 1st January 2017 and 31st December 2020. Demographic and clinical predictors of ED disposition (admission or discharge) and re-attendance for gout flares were identified using logistic regression and survival models, respectively. Case-note reviews (n=59), stakeholder meetings and process mapping were performed to capture detailed information on gout management and identify strategies to optimize care.

Results

Of 1,220 emergency attendances for gout flares, 23.5% required hospitalization (median length of stay: 3.6 days). Recurrent attendances for flares occurred in 10.4% of patients during the study period. In multivariate logistic regression models, significant predictors of admission from ED were older age, overnight ED arrival time, higher serum urate, higher CRP and higher total white cell count at presentation. Detailed case-note reviews showed that only 22.6% of patients with pre-existing gout were receiving urate-lowering therapy (ULT) at presentation. Initial diagnostic uncertainty was common, yet rheumatology input and synovial aspirates were rarely obtained. By six months post-discharge, 43.6% were receiving ULT; however, few patients had treat-to-target dose optimization, and only 9.1% achieved a urate ≤360 micromol/L.

Conclusion

We identified multiple predictors of hospitalization for acute gout. Prescription of ULT and treat-to-target optimization following hospitalization remain inadequate, and must be improved if admissions are to be prevented.

Serious Infections in Patients With Gout in the US: A National Study of Incidence, Time Trends, and Outcomes

OBJECTIVE

To study the epidemiology of serious infections in patients hospitalized with gout.

METHODS

We identified patients with gout hospitalized with a primary diagnosis of pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), or opportunistic infections (OIs) in a US National Inpatient Sample from 1998 to 2016 and examined factors associated with utilization and mortality.

RESULTS

We noted 1,140,085 hospitalizations of patients with serious infections and gout (11% of all hospitalizations of patients with gout; 1998-2000 [8.9%], 2015-2016 [14.5%]). Compared to patients without gout, patients with gout hospitalized with serious infections were older (median age 65 versus 74 years), more of them had a Charlson-Deyo comorbidity index score ≥2 (42% versus 65%), and fewer were female (53% versus 35%) or non-White (40% versus 35%), respectively. The most common infection was pneumonia (52%) in 1998-2000 and sepsis (52%) in 2015-2016. Median hospital charges and hospital stays were higher for patients with sepsis and OIs in 2015-2016 ($41,000-$42,000; 5.1-5.5 days) versus those with UTI, pneumonia, or SSTIs ($15,000-$17,000; 3.0-3.9 days). Compared to patients with sepsis, the multivariable-adjusted odds of health care utilization and in-hospital mortality were significantly lower for patients with UTI, SSTIs, and pneumonia, and non-home discharge or in-hospital mortality were lower in patients with OIs. Among patients hospitalized with infections, older age, Medicaid coverage, a higher Charlson-Deyo comorbidity index score, Black race, and Northeast and nonrural hospital location were associated with significantly higher health care utilization and mortality, while female sex, Medicare insurance, and lower income were associated with higher utilization.

CONCLUSION

Given an increasing rate of serious infections, especially sepsis and pneumonia, in individuals with gout, development of effective interventions targeting factors associated with health care utilization and mortality will improve outcomes and reduce burden.

Healthcare-related impact of gout in hospitalized patients in Spain

To analyze the epidemiology, clinical features and costs of hospitalized patients with gout during the last decade in Spain. Retrospective observational study based on data from the Minimum Basic Data Set (MBDS) from the Spanish National Health Service database. Patients ≥ 18 years with any gout diagnosis at discharge who had been admitted to public or private hospitals between 2005 and 2015 were included. Patients were divided in two periods: p1 (2005-2010) and p2 (2011-2015) to compare the number of hospitalizations, mean costs and mortality rates. Data from 192,037 patients with gout was analyzed. There was an increase in the number of hospitalized patients with gout (p < 0.001). The more frequent comorbidities were diabetes (27.6% of patients), kidney disease (26.6%) and heart failure (19.3%). Liver disease (OR 2.61), dementia (OR 2.13), cerebrovascular diseases (OR 1.57), heart failure (OR 1.41), and kidney disease (OR 1.34) were associated with a higher mortality risk. Women had a lower risk of mortality than men (OR 0.85). General mortality rates in these hospitalized patients progressively increased over the years (p < 0.001). In addition, costs gradually rose, presenting a significant increase in p2 even after adjusting for inflation (p = 0.001). A progressive increase in hospitalizations, mortality rates and cost in hospitalized patients with gout was observed. This harmful trend in a preventable illness highlights the need for change and the search for new healthcare strategies.

Gout Flare Burden, Diagnosis, and Management: Navigating Care in Older Patients with Comorbidity

Gout is the most common form of inflammatory arthritis, and its incidence is highest in middle-aged and older patients. Adding to the diagnostic complexity, up to 50% of patients aged > 65 years present atypically, with subacute oligo- or polyarticular flares. Comorbidity and polypharmacy, common in older populations, affect real-world treatment decisions in gout management, and no specific guidelines are available to address these issues in these at-risk groups. Despite the growing public health burden posed by gout, suboptimal management has led to increased morbidity and substantial healthcare utilization and cost burden, as reflected by an increased incidence of emergency department visits and hospitalizations in recent years. Colchicine, nonsteroidal anti-inflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) should be considered as first-line agents for gout flare management. Urate-lowering therapy, with the goal of lowering and maintaining serum urate concentrations at < 6 mg/dL (< 360 μmol/L), is recommended to achieve optimal outcomes, including regression of tophi, reduction (or elimination) of flares, and reductions in total urate burden. In this review, we summarize the current burden posed by gout and discuss best practices in its diagnosis and management, focusing on best practices in the context of gout flare in older patients with comorbid conditions.

Quality of gout care in the emergency departments: a multicentre study

BACKGROUND

To report on prevalence of gout flare in emergency departments and to report the quality of gout care in emergency departments and causes of admission at emergency departments.

METHODS

A retrospective chart review of visits that had a primary diagnosis in gout by the International Classification of Diseases, the tenth revision, at emergency departments from 6 universities in Thailand over a 5 year period from 1 January 2012 to 31 December 2016.

RESULTS

Six hundred thirty-two visits were included to the study. Prevalence of gout flare in emergency departments was 0.04. Only 29.3% of the visits had arthrocentesis. 628/632 (99.4%) and 519/585 (88.7%) of the visits were prescribed medications in emergency departments and had home medications, respectively. Although all visits that were prescribed colchicine in emergency departments received adequate doses of colchicine, it was also found that more than 2.4 mg/day of colchicine was prescribed (3/394, 0.8%) for home medications. In addition, 183/343 (53.4%) of the visits with normal renal function were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). However, prescribed NSAIDs in abnormal renal function (42/343, 12.2%) was also found. The interruption of dosing, including increase, decrease, addition or discontinuance of urate lowing therapy in a gout flare period was 42/632 (6.6%). The most common cause of admission was acute gouty arthritis (31/47, 66.0%).

CONCLUSIONS

Quality of gout care in the emergency departments was not good. Inappropriate management of gout flare in emergency departments was demonstrated in our study, particularly with regard to investigations and pharmacological management. Gaps between clinicians and guidelines, the knowledge of clinicians, and overcrowding in emergency departments were hypothesized in the results.

Impact of gout on in-hospital outcomes of acute coronary syndrome-related hospitalizations and revascularizations: Insights from the national inpatient sample

BACKGROUND

Previous studies have established a role of gout in predicting risk and prognosis of cardiovascular diseases. However, large-scale data on the impact of gout on inpatient outcomes of acute coronary syndrome (ACS)-related hospitalizations and post-revascularization is inadequate.

AIM

To evaluate the impact of gout on in-hospital outcomes of ACS hospitalizations, subsequent healthcare burden and predictors of post-revascularization inpatient mortality.

METHODS

We used the national inpatient sample (2010-2014) to identify the ACS and gout-related hospitalizations, relevant comorbidities, revascularization and post-revascularization outcomes using the ICD-9 CM codes. A multivariable analysis was performed to evaluate the predictors of post-revascularization in-hospital mortality.

RESULTS

We identified 3144744 ACS-related hospitalizations, of which 105198 (3.35%) also had gout. The ACS-gout cohort were more often older white males with a higher prevalence of comorbidities. Coronary artery bypass grafting was required more often in the ACS-gout cohort. Post-revascularization complications including cardiac (3.2% vs 2.9%), respiratory (3.5% vs 2.9%), and hemorrhage (3.1% vs 2.7%) were higher whereas all-cause mortality was lower (2.2% vs 3.0%) in the ACS-gout cohort (P < 0.001). An older age (OR 15.63, CI: 5.51-44.39), non-elective admissions (OR 2.00, CI: 1.44-2.79), lower household income (OR 1.44, CI: 1.17-1.78), and comorbid conditions predicted higher mortality in ACS-gout cohort undergoing revascularization (P < 0.001). Odds of post-revascularization in-hospital mortality were lower in Hispanics (OR 0.45, CI: 0.31-0.67) and Asians (OR 0.65, CI: 0.45-0.94) as compared to white (P < 0.001). However, post-operative complications significantly raised mortality odds. Mean length of stay, transfer to other facilities, and hospital charges were higher in the ACS-gout cohort.

CONCLUSION

Although gout was not independently associated with an increased risk of post-revascularization in-hospital mortality in ACS, it did increase post-revascularization complications.

Managing Gout Flares in the Elderly: Practical Considerations

Gout is common in the elderly, affecting an estimated 4.7 million people aged > 60 years in the USA alone. The incidence and prevalence of gout increases, and male predisposition to gout reduces, with increasing age. The elderly have more comorbidities, and gout manifests differently, with more frequent involvement of knees, ankles, and wrists at disease onset, systemic upset, and tophi. Comorbidities and polypharmacy make the management of gout flares challenging in this population. Intra-articular corticosteroid injection remains the treatment of choice for accessible joints, oral prednisolone is preferred over low-dose colchicine, and non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided. Xanthine oxidase inhibitors (XOI) remain the first-line treatment for hyperuricemia in the elderly. Arhalofenate, an emerging uricosuric anti-inflammatory drug, prevents gout flares while reducing serum urate. It may be particularly relevant in the treatment of gout in the elderly as they are unable to tolerate long-term colchicine for flare prophylaxis and frequently have contraindications to corticosteroids and NSAIDs. However, given its modest urate-lowering effect, it can only be used in combination with an XOI, and the safety and efficacy of this drug has not been examined in the elderly or in those with chronic kidney disease. Diuretics and beta-blockers should be discontinued where feasible, whereas low-dose aspirin can be continued if otherwise indicated.

Gout and comorbidity: a nominal group study of people with gout

BACKGROUND

Comorbidities are common in patients with gout, yet qualitative research is lacking. The study objective was to examine the impact of gout on comorbidities.

METHODS

Nine nominal groups were conducted. Patients with gout discussed and rank-ordered their concerns in response to the question, "How does gout or its treatment affect your other conditions and their treatment?"

RESULTS

Nine nominal groups had 45 gout patients, with mean age 61 years (standard deviation (SD) 10.7) and mean gout duration 14.9 years (SD 12). Of these, 62% were men, 45% African-American, 51% married and 63% were currently using allopurinol. The most frequently cited highly ranked concerns among the nine nominal groups were: (1) interaction of gout medication with medications for other medical conditions (three groups); (2) worsening of other medical comorbidities, including hospitalizations (seven groups); (3) worsening of anxiety and depression (three groups); (4) significant dietary changes for gout that contrasted with diet for other conditions (three groups); (5) new diseases diagnosed due to gout (three groups); (6) irreversible joint damage (three groups); (7) inability to exercise and weight gain (four groups); and (8) gout misdiagnosed as another health condition (three groups). Other domains ranked highly were: (1) impact of gout on daily life and activities, including the ability to work and social activities (six groups); (2) medication side effects, real and perceived (nine groups); (3) weight loss due to gout related to frequent flares (one group); and (4) cost and burden (three groups).

CONCLUSIONS

Gout and the medications used for its treatment have a significant effect on comorbidities and their management. These findings provide insights into potential targets for improving outcomes in patients with gout.

Emergency Department and Inpatient Healthcare utilization due to Hypertension

Background

Hypertension is one of the commonest chronic diseases, yet limited data are available for related health care utilization. Our study objective was to describe the emergency department (ED) and subsequent hospitalization related health care utilization and charges due to hypertension in the U.S.

Methods

We used the National ED sample (NEDS) to study hypertension-related utilization and charges. Multivariable-adjusted linear or logistic regression was used to assess hypertension-associated ED and hospitalization outcomes (disposition, length of stay, charges), adjusted for patient demographic, comorbidity and hospital characteristics.

Results

There were 0.92, 0.97 and 1.04 million ED visits (0.71–0.77 % of all ED visits) with hypertension as the primary diagnosis in 2009, 2010 and 2012, respectively; 23 % resulted in hospitalization. ED charges were $2.00, $2.27 and $2.86 billion, and for those hospitalized, total charges (ED plus inpatient) were $6.62, $7.09 and $7.94 billion, in 2009, 2010 and 2012, respectively. Older age (50 to 65 years), female sex, metropolitan area residence, South or West U.S. hospital location, private insurance and the presence of congestive heart failure were each associated with higher charges for an ED visit with hypertension as the primary diagnosis. Younger age, metropolitan residence, Medicaid insurance, hospital location in the Northeast and co-existing diabetes, gout, coronary heart disease, chronic obstructive pulmonary disease, hyperlipidemia and osteoarthritis were associated with higher risk, whereas male sex was associated with lower risk of hospitalization after ED visit for hypertension. In 2012, 71.6 % of all patients hospitalized with hypertension as the primary diagnosis were discharged home. Older age, metropolitan residence and most comorbidities were associated with lower odds, whereas male sex, payer other than Medicare, South or West U.S. hospital location were associated with higher odds of discharge to home.

Conclusions

Hypertension is associated with significant healthcare burden in the U.S. Future studies should assess strategies to reduce hypertension-associated cost and health care burden.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1563-7) contains supplementary material, which is available to authorized users.