Novel Quality Index Linked to Reduced Hospital Admissions for Gout

Manjari Lahiri, MD

Credit: ResearchGate

New research is calling attention to the potential utility of a novel quality index, the Urate-Lowering Therapy (ULT) to Acute Treatment Ratio (ULTrA), for reducing gout-related hospital admissions.¹

Findings from the retrospective study were presented at the American College of Rheumatology (ACR) Convergence 2024, in Washington, DC, and suggest use of the index may help improve gout management.¹

“Gout is sub-optimally managed with under-prescribed urate-lowering therapy (ULT) leading to frequent flares, increased healthcare utilization, and cost,” Manjari Lahiri, MD, an adjunct associate professor of medicine at the National University of Singapore and a senior consultant in the divisions of rheumatology and advanced internal medicine at the National University Hospital, and colleagues wrote.¹

The most common type of inflammatory arthritis, gout is characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in 1 or more joints. It is caused by a buildup of urate crystals due to high levels of uric acid in the blood and can be treated with anti-inflammatory drugs and ULT.² Despite the availability of these treatments, their clinical use in gout management is limited.

Investigators conducted a retrospective study leveraging electronic health records from January 1, 2022, to December 31, 2023, from the National University Health System Value Driven Outcomes database, integrating both clinical and administrative data. Patients ≥ 21 years of age from 3 public acute hospitals and 7 public primary care clinics in western Singapore were included in the study. Patients with ≥ 1 gout-related healthcare encounter in 2022 and with ≥ 1 year of follow-up formed the derivation cohort, while those with a first encounter in 2023 formed the validation cohort.¹

An emergency department visit was defined by an International Classification of Diseases 10th Edition or SNOMED diagnosis of gout as well as a prescription of acute anti-inflammatory drugs, including nonsteroidal anti-inflammatory drugs, colchicine and/or glucocorticoids. An inpatient or outpatient encounter was included in the study if gout was the primary or secondary diagnosis.¹

In 2022, 12,314 unique patients were identified. Among this cohort, 83.1% were male and the median age was 64 (interquartile range [IQR, 51-73) years. Serum uric acid was measured ≥ twice per year in 3539 (28.7%) patients. Of 7355 patients with serum uric acid measured ≥ once, 2910 (39.6%) achieved target serum uric acid ≤360 µmol/L ≥ once.¹

Investigators noted 5673 (46.1%) patients were prescribed ULT, including allopurinol, febuxostat, probenecid, or benzbromarone ≥ once. The mean ULTrA index was 0.68 (Standard deviation [SD], 1.01). In total, 916 (7.4%) patients had emergency department visits for gout and 1408 (11.4%) were hospitalized for a median of 7 (IQR, 3-14) days. The annual cost of gout care from the healthcare systems’ perspective was $1882 per patient – specifically, $13,667 per patient for those hospitalized versus $278 for others.1

In 2023, among 12,789 unique patients, 4669 were new, with more women, fewer ULT prescriptions, more emergency department visits, and more frequent hospitalizations. The ULTrA index for these newly presenting patients was lower at 0.22 (0.56).¹

Investigators noted older age (≥65 years), female sex, and sUA indicator were associated with increased hospitalization. Importantly, the ULTrA index was inversely associated with hospitalization for prevalent patients in 2022 (odds ratio [OR], 0.94; 95% CI, 0.93-0.95; P <.001) and for incident patients in 2023 (OR, 0.98; 95% CI, 0.97-0.99; P = .02) after adjusting for age and sex.¹

“The ULTrA is an easy-to-measure index which was inversely associated with hospital admissions,” investigators concluded.¹ “This is unlikely to be solely explained by the higher number of acute prescriptions in patients who are hospitalized, as the association was weaker in the 2023 incident cohort with more frequent hospitalizations. The impact of real-time visualization of ULTrA on prescriber behavior and hospitalization should be studied.”

References

1. ^{Tang M, Tay F, Santosa A, et al. Urate Lowering Therapy to Acute Treatment Ratio (ULTrA) Index – a Novel Quality Indicator Associated with Reduced Hospital Admissions for Gout. Arthritis Rheumatol. https://acrabstracts.org/abstract/urate-lowering-therapy-to-acute-treatment-ratio-ultra-index-a-novel-quality-indicator-associated-with-reduced-hospital-admissions-for-gout/}
2. ^{Mayo Clinic. Gout. November 16, 2022. Accessed November 22, 2024. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897}