Gout is a common form of arthritis, affecting 2.5% of the UK population. Gout is characterised by flares of joint pain and swelling, which can require admission to hospital when severe. Hospital admissions due to gout have doubled in England over the last 15 years, many of which may have been preventable with better use of existing treatments. There are highly effective medications available to treat and prevent gout flares, yet previous studies have shown that gout is poorly managed in both community and hospital settings.
The objective of our study is to investigate gout care in the community and in hospitals in England and Wales using CPRD with linked hospital data. We will describe the use of guideline-recommended treatments after new diagnoses of gout, and assess care before and after hospital admissions for gout flares. We will study predictors of hospital admission and sub-optimal care.
Our findings will inform the development of a strategy to improve care for patients with gout. This will directly benefit patients through fewer episodes of pain and reduced disability; it will enable doctors and nurses to provide more joined-up, high quality care for patients with gout; and produce cost savings for the NHS through fewer hospital admissions.
Background: Gout is the most common form of inflammatory arthritis, with a rising incidence and prevalence worldwide. There are highly effective medications available to treat and prevent gout flares, yet previous research has shown that the management of gout in primary and secondary care is poor. One consequence of this is recurrent hospital admissions, which have doubled in England over the last 15 years. Many gout admissions are likely to be preventable with more widespread use of existing treatments.
Objectives: To describe the management of gout in primary and secondary care in England and Wales, including analyses of individual and structural predictors of hospitalisation and sub-optimal care.
Methods: The study population of interest is patients aged 18 years and above with index gout diagnoses between 2004 and 2021. We will describe the number and proportion of patients who are commenced on urate-lowering therapy (e.g. allopurinol) within 12 months of diagnosis. We will describe the pattern of serum urate monitoring and the proportion of patients who achieve target serum urate levels. We will use multi-level logistic regression to analyse individual and structural predictors associated with adherence to recommendations in national gout management guidelines. Through linkage with NHS Digital Hospital Episode Statistics Admission and A&E datasets, we will analyse predictors of hospitalisation and emergency department attendances for gout flares, and investigate post-discharge management, including time to first urate-lowering therapy prescription and/or re-admission, using Cox proportional hazards models.
Public health benefits: Our analyses will inform the development of a strategy to improve gout management in primary and secondary care in England and Wales; the impact for patients will be reduced morbidity, with fewer painful gout flares and reduced disability; the impact for NHS clinicians will include improved integration of care; and for commissioners, the impact will include reduced costs of unplanned admissions.
Co-primary outcomes: Initiation of urate-lowering therapy (ULT); attendance at emergency departments (ED) for gout flares; admission to hospital for gout flares.
Key secondary outcomes: Target serum urate level attainment; treat-to-target monitoring and uptitration of ULT.
James Galloway - Chief Investigator - King's College London (KCL)
Mark Russell - Corresponding Applicant - King's College London (KCL)
Abdel Douiri - Collaborator - King's College London (KCL)
Martin Gulliford - Collaborator - King's College London (KCL)
HES Accident and Emergency;HES Admitted Patient Care