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Research ArticleGout

Hospitalizations for Acute Gout: Process Mapping the Inpatient Journey and Identifying Predictors of Admission

Mark D. Russell, Deepak Nagra, Benjamin D. Clarke, Sathiyaa Balachandran, April Buazon, Amy Boalch, Katie Bechman, Maryam A. Adas, Edward G. Alveyn, Andrew I. Rutherford and James B. Galloway
The Journal of Rheumatology July 2022, 49 (7) 725-730; DOI: https://doi.org/10.3899/jrheum.211203
Mark D. Russell
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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  • ORCID record for Mark D. Russell
  • For correspondence: mark.russell@kcl.ac.uk
Deepak Nagra
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Benjamin D. Clarke
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Sathiyaa Balachandran
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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April Buazon
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Amy Boalch
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Katie Bechman
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Maryam A. Adas
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Edward G. Alveyn
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Andrew I. Rutherford
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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James B. Galloway
1M.D. Russell, MBBChir, Doctoral Research Fellow, D. Nagra, MD, Clinical Research Fellow, B.D. Clarke, MSc, Clinical Research Fellow, S. Balachandran, MBBS, Clinical Research Fellow, A. Buazon, MSc, Clinical Research Fellow, A. Boalch, MBBS, Clinical Research Fellow, K. Bechman, PhD, Clinical Lecturer, M.A. Adas, MBBS, Clinical Research Fellow, E.G. Alveyn, BMBCh, Clinical Research Fellow, A.I. Rutherford, MSc, Consultant Rheumatologist, J.B. Galloway, PhD, Reader in Rheumatology, Centre for Rheumatic Diseases, King’s College London, London, UK.
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Abstract

Objective. To identify predictors of admission following emergency department (ED) attendances for gout flares and to describe barriers to optimal inpatient gout care.

Methods. ED attendances and hospital admissions with primary diagnoses of gout were analyzed at 2 UK-based hospitals between January 1, 2017, and December 31, 2020. Demographic and clinical predictors of ED disposition (admission or discharge) and reattendance 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 to identify strategies to optimize care.

Results. Of 1220 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 (SU), higher C-reactive protein, and higher total white cell count at presentation. Detailed case note reviews showed that only 22.6% of patients with preexisting gout were receiving urate-lowering therapy (ULT) at presentation. Initial diagnostic uncertainty was common, yet rheumatology input and synovial aspirates were rarely obtained. By 6 months postdischarge, 43.6% were receiving ULT; however, few patients had treat-to-target dose optimization, and only 9.1% achieved SU levels ≤ 360 μmol/L.

Conclusion. We identified multiple predictors of hospitalization for acute gout. Treat-to-target optimization of ULT following hospitalization remains inadequate and must be improved if admissions are to be prevented.

Key Indexing Terms:
  • allopurinol
  • gout
  • healthcare costs
  • hospitalization
  • hyperuricaemia
  • patient education
  • Accepted for publication March 2, 2022.
  • Copyright © 2022 by the Journal of Rheumatology
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1 Jul 2022
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Hospitalizations for Acute Gout: Process Mapping the Inpatient Journey and Identifying Predictors of Admission
Mark D. Russell, Deepak Nagra, Benjamin D. Clarke, Sathiyaa Balachandran, April Buazon, Amy Boalch, Katie Bechman, Maryam A. Adas, Edward G. Alveyn, Andrew I. Rutherford, James B. Galloway
The Journal of Rheumatology Jul 2022, 49 (7) 725-730; DOI: 10.3899/jrheum.211203

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Hospitalizations for Acute Gout: Process Mapping the Inpatient Journey and Identifying Predictors of Admission
Mark D. Russell, Deepak Nagra, Benjamin D. Clarke, Sathiyaa Balachandran, April Buazon, Amy Boalch, Katie Bechman, Maryam A. Adas, Edward G. Alveyn, Andrew I. Rutherford, James B. Galloway
The Journal of Rheumatology Jul 2022, 49 (7) 725-730; DOI: 10.3899/jrheum.211203
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Keywords

ALLOPURINOL
GOUT
HEALTHCARE COSTS
HOSPITALIZATION
hyperuricaemia
PATIENT EDUCATION

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Keywords

  • allopurinol
  • gout
  • healthcare costs
  • hospitalization
  • hyperuricaemia
  • PATIENT EDUCATION

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