Full Disclosure: Health System Learns High Cost of Non-Referrals for Gout

November 17, 2014

(ACR2014) These researchers learned what is actually happening to many gout patients who flare, and offer powerful reasons for its doctors to do better.

Sharma TS, Harrington TM, Olenginski TP. Aim for Better Gout Control: A Retrospective Analysis of Preventable Hospital Admissions for Gout.Arthritis & Rheumatism. 2014;66(11)-Supplement:S1014. ACR 2014, Abstract #2322.

A new study from Geisinger Health System reveals what often happens when gout patients are treated in primary care rather than rheumatology, and the results point powerfully to the bottom line. Many patients with painful flares end up in emergency rooms rather than the office, and are then admitted to the hospital, according to a small study presented at the 2014 meeting of the American College of Rheumatology here.

Retrospective analysis of hospital data for 56 gout patients between 2009 and 2013 from Geisinger Health System in Danville PA showed that 89% met the study's criteria for preventable admission: a primary diagnostic code of mono- or poly-articular arthritis, with gout diagnosed only after hospital admission. 

While 70% of the patients had a previous history of gout and almost half had risk factors for gout, most (74%) were being managed by their primary care physician rather than by a rheumatologist. This showed in the measures reflecting guidelines-based care: Only 23 patients had serum uric acid levels recorded within the past year, and 78% of those on long-term gout therapy had serum uric acid values above target levels (below 6 mg/dL).

Evidently many primary care doctors are referring patients with gout flares to the emergency room (ER), said Geisinger rheumatologist Thomas Olenginski, MD, the study’s lead author, speaking at the American College of Rheumatology's annual meeting in Boston. Most presented with pain, and were initially suspected of having septic arthritis, inflammatory polyarthritis, or cellulitis. To rule out infection, doctors in the ER did athrocentesis, but they did not examine the aspirated fluid immediately for microscopic urate crystals (which would have revealed the gout).

They referred to the hospital’s rheumatology department only after the patient had been admitted and diagnosed with gout. There were other significant gaps in care, Olenginski noted.

“A third of the patients were not taking their medications,” Oleginski observed. “The guidelines for gout are very straightforward, but clearly doctors are not following them. We need to do a better job with this,” he says.

Gout patients spent a mean of 3.4 days in the hospital, for total hospital-related costs of $208,000 per admission, the study found.

"All of us have to be more sensitive to costs. Unless you really look at that issue, you don't really know,” Oleginski conceded during an interview with Rheumatology Network. “With the results of our study in our system, I know that over time we will do better in the future.”

As an alternative to hospital admission, once you've ruled out septic arthritis and related conditions, you do need to put a patients under observation, Olenginki suggested, to determine the appropriate dose of urate-lowering therapy.

“During a flare, urate can actually be lower than usual, so we need to find out what level of urate-lowering drugs to give," Oleginsky said. "There’s a misperception that there’s a ‘standard dose’ of allopurinol. There isn’t. We may have to re-set their dose, set the target level lower."