Implementing treat-to-target urate-lowering therapy during hospitalizations for gout flares

Russell, Mark D; Ameyaw-Kyeremeh, Louise; Dell'Accio, Flora; Lapham, Heather; Head, Natalie; Stovin, Christopher; Patel, Vishit; Clarke, Benjamin D; Nagra, Deepak; Alveyn, Edward; Adas, Maryam A; Bechman, Katie; de la Puente, María A; Ellis, Benjamin; Byrne, Corrine; Patel, Rina; Rutherford, Andrew I; Cantle, Fleur; Norton, Sam; Roddy, Edward; Hudson, Joanna; Cope, Andrew P; Galloway, James B

Abstract

Objectives
To evaluate a strategy designed to optimize care and increase uptake of urate-lowering therapy (ULT) during hospitalizations for gout flares.

Methods
We conducted a prospective cohort study to evaluate a strategy that combined optimal in-hospital gout management with a nurse-led, follow-up appointment, followed by handover to primary care. Outcomes, including ULT initiation, urate target attainment and re-hospitalization rates, were compared between patients hospitalized for flares in the 12 months post-implementation and a retrospective cohort of hospitalized patients from 12 months pre-implementation.

Results
One hundred and nineteen and 108 patients, respectively, were hospitalized for gout flares in the 12 months pre- and post-implementation. For patients with 6-month follow-up data available (n = 94 and n = 97, respectively), the proportion newly initiated on ULT increased from 49.2% pre-implementation to 92.3% post-implementation (age/sex-adjusted odds ratio [aOR] 11.5; 95% CI 4.36, 30.5; P < 0.001). After implementation, more patients achieved a serum urate ≤360 μmol/l within 6 months of discharge (10.6% pre-implementation vs 26.8% post-implementation; aOR 3.04; 95% CI 1.36, 6.78; P = 0.007). The proportion of patients re-hospitalized for flares was 14.9% pre-implementation vs 9.3% post-implementation (aOR 0.53; 95% CI 0.22, 1.32; P = 0.18).

Conclusion
Over 90% of patients were initiated on ULT after implementing a strategy to optimize hospital gout care. Despite increased initiation of ULT during flares, recurrent hospitalizations were not more frequent following implementation. Significant relative improvements in urate target attainment were observed post-implementation; however, for the majority of hospitalized gout patients to achieve urate targets, closer primary–secondary care integration is still needed.

Citation

Russell, M. D., Ameyaw-Kyeremeh, L., Dell'Accio, F., Lapham, H., Head, N., Stovin, C., Patel, V., Clarke, B. D., Nagra, D., Alveyn, E., Adas, M. A., Bechman, K., de la Puente, M. A., Ellis, B., Byrne, C., Patel, R., Rutherford, A. I., Cantle, F., Norton, S., Roddy, E., …Galloway, J. B. (in press). Implementing treat-to-target urate-lowering therapy during hospitalizations for gout flares. Rheumatology, https://doi.org/10.1093/rheumatology/kead574

• Journal Article Type: Article
• Acceptance Date: Aug 13, 2023
• Online Publication Date: Oct 31, 2023
• Deposit Date: Nov 27, 2023
• Journal: Rheumatology
• Print ISSN: 1462-0324
• Electronic ISSN: 1462-0332
• Publisher: Oxford University Press
• Peer Reviewed: Peer Reviewed
• DOI: https://doi.org/10.1093/rheumatology/kead574
• Keywords: gout; crystal arthritis; hospital; admissions; urate-lowering therapy; allopurinol
• Public URL: https://keele-repository.worktribe.com/output/645851