While hospitalizations related to rheumatoid arthritis have dropped considerably over the past two decades, hospitalizations primarily associated with gout have increased dramatically. These results of a study described in a research letter in the June 7 issue of JAMA reflect improved management of rheumatoid arthritis patients and both an increased prevalence and persistent suboptimal care of gout.
“Our findings provide a remarkably encouraging benchmark for the improvement in rheumatoid arthritis care in recent years,” says Hyon K. Choi, MD, DrPH, of the MGH Division of Rheumatology, Allergy and Immunology, senior author of the JAMA report. “However, they also highlight the critical need to improve gout management in the U.S. and beyond.”
Gout and rheumatoid arthritis are the two most common inflammatory joint disorders worldwide, but long-term data reflecting hospitalizations for these conditions has not been available. Choi explains that such information can improve our understanding of the extent of the conditions and the quality of care provided. To conduct their analysis, he and his colleagues gathered data from the Nationwide Inpatient Sample compiled by the Agency for Healthcare Research and Quality, covering the years 1993-2011. They investigated overall rates of hospitalizations, rates of surgery related to either condition and inflation-adjusted hospital costs.
While the rate of hospitalizations for rheumatoid arthritis dropped by 67 percent – from 13.9 to 4.6 per 100,000 in the U.S. population – the rate for gout doubled from 4.4 to 8.8 per 100,000. Surgical hospitalizations for rheumatoid arthritis dropped by 75 percent from 8.4 to 2.1 per 100,000, whereas those for gout remained practically unchanged (from 0.09 to 0.17 per 100,000). Inflation-adjusted annual costs for rheumatoid arthritis hospitalizations dropped by 33 percent from $83,101 in 1993 to $55,988 per 100,000 in 2011; in the same period inflation-adjusted annual hospitalization costs for gout rose by 68 percent from $34,457 to $58,003.
Choi explains that widespread use of effective medications for rheumatoid arthritis – including methotrexate and the newer, genetically engineered biologics – along with better management and earlier treatment, have contributed to a reduced incidence of complications requiring hospitalizations, including those for systemic complications and major joint surgeries. Western lifestyle factors – including consumption of meats, fats, sugary sodas , and alcohol – and risk factors including obesity, hypertension and chronic kidney disease all contribute to the increased frequency of gout, which now affects more than 8 million in the U.S.
“A recent study found that up to 89 percent of hospitalizations for gout were preventable, owing to inadequate or inefficient care,” he explains. “While many patients are candidates for uric-acid-lowering medications, only a small proportion receive treatment. In fact, many physicians are not even measuring uric acid levels for their patients who do receive uric-acid-lowering prescriptions. Most importantly, few patients receive personalized lifestyle advice to reduce risk factors and complications or clear education about the essentially curable nature of this disease. That has led to very poor treatment adherence among patients, with one study finding adherence among gout patients to be the worst among seven chronic conditions.”
A professor of Medicine at Harvard Medical School, Choi adds, “Advanced gout can be quite debilitating, as it leads to joint destruction and deformity, and acute gout flares are one of the most painful conditions experienced by humans. The pathogenesis of gout is well understood and effective treatments are available, but the care of gout remains remarkably suboptimal due to a lack of proper patient education and treatment mismanagement.”
The lead author of the JAMA letter is Sian Yik Lim, MD, MGH Division of Rheumatology, Allergy and Immunology. Additional co-authors are Na Lu, MPH, Amar Oza, MD, and Mark Fisher, MD, MPH, MGH Rheumatology, Allergy and Immunology; Mariano Menendez, MD, MGH Department of Orthopædic Surgery, and Sharan Rai, Arthritis Research Canada. The study was supported by National Institute of Arthritis and Musculoskeletal and Skin Diseases grant R01 AR065944.
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals, earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service and returned to the number one spot on the 2015-16 U.S. News & World Report list of "America's Best Hospitals."
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