Title: The PREVENT Study: Preventing hospital admissions attributable to gout
Funder: Department of Health and Social Care

Abstract: Research question Can we improve care for patients admitted to hospital with gout, and reduce hospital re-admissions, using a treat-to-target strategy integrated between primary and secondary care? Background Gout is the most common form of inflammatory arthritis, with a rising incidence and prevalence worldwide. My previous research has demonstrated that hospital admissions due to acute gout have increased by 58% in England since 2006, accounting for 350,000 NHS bed-days, at a cost of up to 5,662 per admission. Gout is inherently curable, yet poorly managed, and many of these admissions are avoidable. We urgently need a strategy to reduce hospitalisations and improve care for patients admitted with gout. Aims and objectives My research plan has 3 phases: To describe the current epidemiology of admitted gout care, including identification of individual and structural predictors of hospitalisation; To develop a gout care pathway at the primary/secondary care interface that can be implemented during an acute admission, with the aim of improving care and reducing future hospitalisations; To evaluate the implementation of this strategy in patients admitted with gout at three local hospitals over a 12-month period.Methods (timelines for delivery) Phase 1 (0-9 months): Using the Royal College of General Practitioners Research and Surveillance Centre and Hospital Episode Statistics datasets, I will analyse hospital admissions due to gout in England between 2004 and 2020. I will examine the use of urate-lowering therapy and treat-to-target optimisation. Statistical modelling will be employed to identify individual and structural characteristics predicting hospitalisation and sub-optimal care. Phase 2 (9-14 months): I will process map the admitted patient journey in a retrospective sample of patients hospitalised for gout. I will work with stakeholders to identify barriers and facilitators of optimal admitted gout care, and adapt an evidence-based intervention for implementation during acute admissions. This will incorporate treat-to-target optimisation of urate-lowering medications and self-management approaches, embedded at the primary/secondary care interface. Phase 3 (14-36 months): I will prospectively evaluate the implementation of the intervention I have developed in Phase 2 in patients admitted with acute gout exacerbations at three local hospitals over a 12-month period. I will adopt a hybrid type 3 effectiveness-implementation study design, with outcome measures including: re-admission rates, intervention uptake and acceptability, and health resource utilisation. Anticipated impact and dissemination My research proposal will inform a UK-wide clinical trial to improve admitted gout care and reduce hospitalisations. The impact of my research for patients will be reduced morbidity, with fewer painful gout attacks and reduced accumulation of disability. The impact for the NHS will include reduced costs of unplanned admissions, and improved integration of care for clinicians managing this chronic disease. I will disseminate my findings through publications, presentations, public engagement events, and implementation recommendations.

Lay abstract: Background Gout is a common form of arthritis, affecting 2.5% of the UK population. It is characterised by recurrent attacks of severe joint pain and swelling. Left untreated, gout can lead to permanent joint damage and health problems, such as kidney disease. Highly effective, low-cost medications are available to treat and prevent attacks of gout in people with the condition. However, previous studies have shown that we do not use preventative medications as frequently as we should, or at effective doses. The problem In patients with undertreated gout, severe attacks of joint pain can require admission to hospital. My research has shown that hospital admissions due to gout have increased by nearly 60% in England over the last decade. Hospital admissions are unpleasant for patients and costly for the NHS. Many of these admissions could be prevented with improved treatment. Aims of my research I will develop a strategy to: Prevent unnecessary hospital admissions due to gout; Improve care and follow-up for patients admitted to hospital with gout.The goals of my research are to: Improve quality of life for patients with gout and their carers, including reduced pain and disability; Enable doctors and nurses to provide joined-up, high quality care for their patients; Produce cost savings for the NHS, through fewer hospital admissions.Design and methods My research will be in 3 phases: Phase 1: I will investigate gout care in England using a large patient database. I will describe the number of hospital admissions due to gout, the characteristics associated with hospital admissions, and the quality of care provided to patients when compared to national guidelines. Phase 2: I will review the medical records of patients previously admitted to local hospitals with gout to identify areas of good care and areas where improvement is needed. I will work with patients, carers, GPs, and hospital specialists to develop a strategy to improve care for patients admitted with gout and reduce hospital admissions. This will combine individualised education with the effective use of gout medications, and will integrate hospital and GP care services. Phase 3: I will evaluate the strategy developed in Phase 2 in three local hospitals over a 12-month period. Patients admitted with gout will be offered the intervention and followed up to assess: The number of patients who require re-admission to hospital with gout; The use of preventative gout medications after discharge from hospital; The acceptability of the intervention to patients and clinical staff.Patient and public involvement I have worked closely with patients to understand the negative impact gout can have on their lives. I have interviewed patients who have been admitted with gout to explore barriers to better care. Poor follow-up after discharge from hospital and a lack of guidance on how to manage future gout attacks are areas I will specifically target for improvement. Patients and carers will be closely involved in the design and evaluation of my strategy to improve gout care and prevent hospitalisations. This will include participation in stakeholder meetings and regular Patient and Public Involvement meetings. Dissemination I will communicate my research findings to patients and the wider population using several approaches: Plain English summaries of all publications; Social media summaries of outputs, including podcasts; Public engagement events; Newsletters.I will present my findings at conferences and publish in academic journals to ensure a range of health professionals can access my research findings. I will produce national recommendations for my strategy. Our self-management and information packs will be made freely available via a website.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL