Abstract
BackgroundGout is the most common form of inflammatory arthritis, affecting 1 in 40 people in the UK. Despite highly effective treatments, hospital admissions for gout flares have doubled in England over the last 20 years. Many of these admissions may have been prevented if optimal gout management had been delivered to patients.
Objectives
1. Describe the epidemiology of gout management in primary and secondary care in the UK.
2. Develop an intervention package for implementation during hospitalisations for gout flares, with the aim of improving care and reducing hospitalisations.
3. Implement and evaluate this intervention in people hospitalised for gout.
Methods
I used population-level health datasets (CPRD, OpenSAFELY, NHS Digital Hospital Episode Statistics) to evaluate outcomes for people with incident gout diagnoses over a 20-year period. I used multivariable regression and survival modelling to analyse factors associated with outcomes, including: i) initiation of urate-lowering therapies (ULT); ii) attainment of serum urate targets; and iii) hospitalisations for gout flares.
With extensive stakeholder input, I developed an evidence-based intervention package to optimise hospital gout care. This incorporated the findings of a systematic literature review and process mapping of the admitted patient journey in a cohort of hospitalised gout patients. My intervention consisted of a care pathway, based upon British (BSR), European (EULAR) and American (ACR) gout management guidelines, which encouraged ULT initiation prior to discharge, followed by a nurse-led, post-discharge review to facilitate handover to primary care. I implemented this intervention in patients hospitalised for gout flares at King’s College Hospital over a 12-month period, and evaluated outcomes including ULT initiation, urate target attainment and re-admission rates.
Results
In the UK, between 2004 and 2020, I showed that only 29% of patients with gout were initiated on ULT within 12 months of diagnosis, while only 36% attained urate targets. No significant improvements in these outcomes were observed after publication of updated BSR and EULAR gout management guidelines. Comorbidities, including chronic kidney disease, heart failure and obesity, associated with increased odds of ULT initiation but decreased odds of attaining urate targets.
For patients who were diagnosed with gout during the COVID-19 pandemic, I showed that ULT initiation improved modestly, relative to before the pandemic, while urate target attainment trends were similar. Underlying these trends was a 31% decrease in incident gout diagnoses in England during the first year of the pandemic.
Using linked primary and secondary care data, I showed that the risk of hospitalisations for gout flares is greatest within the first 6 months after diagnosis. ULT initiation is associated with more hospitalisations for flares within the first 6 months of diagnosis, but a reduced risk of hospitalisations beyond 12 months; particularly when urate targets are attained.
After process mapping the admitted patient journey and systematically appraising the evidence base, I developed and implemented a multi-faceted intervention at King’s College Hospital, with the aim of improving hospital gout care. Following implementation of this intervention, the proportion of hospitalised gout patients who initiated ULT increased from 49% to 92%; more patients achieved serum urate targets; and there were 38% fewer repeat hospitalisations for gout flares.
Conclusions
At a population level, ULT initiation and urate target attainment remain sub-optimal for people with gout in the UK, despite updated management guidelines. Initiation of ULT is associated with long-term reductions in hospitalisations for flares; however, only a minority of patients hospitalised for gout flares are initiated on ULT. After designing and implementing a strategy to optimise hospital gout care, over 90% of patients were initiated on ULT, urate target attainment improved, and repeat hospitalisations decreased. My findings suggest that improved primary-secondary care integration is essential if we are to reverse the epidemic of gout hospitalisations.
| Date of Award | 1 Jan 2024 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | James Galloway (Supervisor), Andrew Cope (Supervisor) & Joanna Hudson (Supervisor) |