番茄社区

BOSTON -- The majority of hospitalizations for gout were preventable, with considerable implications for cost, according to a retrospective study presented here.

Among 56 patients admitted to the hospital who were determined to have gout, 89% were considered preventable, and the result was a total of 171 in-hospital days -- a mean of 3.42 per patient -- and total hospitalization-related costs being $208,000, or more than $4,000 per admission, reported, of Geisinger Medical Center in Danville, Penn.

Both the and the (EULAR) have published guidelines on the management of gout. Nonetheless, poor disease control with recurrent flares and frequent hospitalizations are common among patients.

"Many patients have relapses that can become disfiguring and can lead to complications, and that shouldn't be happening in 2014," Olenginski said during a press conference at the American College of Rheumatology annual meeting.

To estimate the frequency of preventable admissions to the hospital with better management, Olenginski and colleagues reviewed the records of adults in their health system who had primary discharge diagnoses of gout between 2009 and 2013.

Preventable admissions were those in which the primary admission diagnosis was mono- or polyarthritis that was later determined to be gout, and no concomitant illness that would warrant hospitalization.

They also considered demographics, clinical and risk factors such as prior history of gout, risk factors for gout including diabetes, chronic kidney disease, cardiovascular disease, use of diuretics or low-dose aspirin, gout medications, and serum uric acid levels.

The 56 patients initially were thought to have septic arthritis in 76%, inflammatory polyarthritis in 14%, and cellulitis in the remainder.

Among the 50 patients whose admissions were preventable, 35 had a history of gout and 21 had three or more risk factors for gout. Only 26% were being treated by a rheumatologist, and the remainder were being seen in primary care.

Among the patients cared for by family physicians, only eight were on urate-lowering therapy and just five were taking colchicine prophylaxis.

And among the total 15 patients who had been prescribed long-term gout treatments, one-third reported nonadherence.

And for the 23 patients who had had a uric acid measurement within the previous year, 78% were not at the goal level of less than 6 mg/dL.

One-third of the patients underwent arthrocentesis, 24 of which took place in the emergency department. Moreover, one had a toe amputation and two others underwent arthroscopic debridement.

"Too many of these admissions were indeed preventable, but most of the time, the rheumatology department was called in after the patient had already been admitted to the hospital. To effectively deal with this problem in a busy emergency room, a collaborative approach between the emergency department, rheumatology, orthopedics, and internal medicine is necessary," said co-author , of Geisinger Health System, in an accompanying press release.

"Defined gaps in clinical care included the failure to follow ACR/EULAR guidelines when possible, inconsistent crystal-confirmed diagnoses, and overuse of the emergency department," Olenginski said.

"A major reason for admission was possible infection. We should be able to do that more quickly with joint aspiration and analysis of the aspirate to see if crystals or pathogens are present," he said.

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