BOSTON – Nearly all hospitalizations of people who were discharged with a primary diagnosis of gout were likely preventable, based on the results of a retrospective analysis of 79 cases at a single institution.
Because most of these patients presented to the emergency department rather than their doctor’s office, and were in pain and had other comorbidities, admission seemed the correct medical care decision, said Dr. Thomas Olenginski of the Geisinger Health System and one of the study’s lead authors. If the ED had gotten a rheumatology consult during the patients’ observation periods, however, the diagnosis could have been confirmed and most of these admissions would likely have been avoided, with a potential savings of over $200,000 in total hospitalization-related costs, Dr. Olenginski said at the annual meeting of the American College of Rheumatology.
Mary Jo Dales/Frontline Medical Media
Dr. Thomas Olenginski
Further, most of these patients were not adherent to their prescribed gout medications. Better clinical care and compliance with gout therapy might prevent most gout flareups that result in hospitalization, he added.
As a result of these findings, Geisinger has reassessed its approach to gout patients, especially those who present to the ED. For identified gout patients, they have ramped up efforts to make sure patients are adhering to therapy and are at goal, as well as educating them about their disease and how it can worsen without adherence. Rheumatologists are available to the ED by pager, encouraging arthrocentesis and crystal confirmation, thereby allowing the ED to focus on treating any associated skin infections and comorbidities, Dr. Olenginski said.
Of 56 gout-related admissions to their hospital, the Geisinger researchers found that 50 (89%) met the study’s definition of a preventable admission. A preventable admission was defined as one with a primary admitting diagnosis of mono- or polyarthritis subsequently diagnosed as gout and without any concomitant illness warranting admission on presentation.
The clinical diagnoses included 76% septic arthritis, 14% inflammatory polyarthritis, and 8% cellulitis.
Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the ED where the diagnosis could have been made based on crystal-confirmed diagnosis, he said.
Among the 35 patients with a prior history of gout, there were 23 patients whose serum uric acid levels were recorded within 1 year of their hospitalization, and 18 (78%) did not reach the goal of less than 6 mg/dL. Of 15 patients on long-term gout treatment, 5 (33%) were noncompliant with their treatment plans.
The total additive length of stay for the preventable gout admissions was 171 days with a mean stay of 3.42 days. Total hospitalization-related costs of these admissions were $208,000, with an average cost per admission of $4,160.
The study was performed as a quality initiative at Geisinger Health System. Dr. Olenginski had no relevant financial disclosures.