Of the 331,664 patients included in the study, 138,068 (42%) were uncontrolled and 193,596 (58%) were controlled. Both groups were predominantly white non-Hispanic (58% and 70%) and male (99% and 99%). The uncontrolled group was younger (mean age 64 vs. 70 years, p < 0.01), had more Black non-Hispanic patients (27% vs. 17%, p < 0.01), renal disease (29% vs. 21%, p < 0.01), and obese patients (BMI ≥ 30 kg/m2; 50% vs. 43%, p < 0.01) (Table 1, Fig. 3).

Age distribution in Veterans Affairs patients with uncontrolled and controlled gout. aSD standard deviation

Patients with uncontrolled gout saw specialists more often during follow-up: podiatry (38% vs. 30%, p < 0.01), rheumatology (24% vs. 9%, p < 0.01), and nephrology (24% vs. 12%, p < 0.01). During follow-up, patients who were grouped as uncontrolled gout were significantly more likely to have sUA levels above 6 mg/dl (92% vs. 54%, p < 0.01) and 8 mg/dl (74% vs. 3%, p < 0.01), and had more healthcare utilization in the emergency room (55% vs. 38%, p < 0.01) and hospital (47% vs. 37%, p < 0.01) (Tables 2 and 3).

Overall, patients with uncontrolled gout in the VA were primarily prescribed allopurinol, of which use increased from 60% in 2016 to 70% in 2022 and febuxostat where use decreased from 7% in 2016 to 4% in 2022. (Figs. 4, 5, and 6) We did not collect medication doses and therefore cannot speak to whether or not ULT dosing was optimized.

Therapies for Veterans Affairs patients with uncontrolled gout: All lines, n = 138,068. aPatients might have received multiple therapies each year, either concurrently or consecutively. bSulfinpyrazone, pegloticase, and pegloticase + methotrexate were not given during study period

Therapies for Veterans Affairs patients with uncontrolled gout: First-line, n = 138,068. aPatients might have received multiple therapies each year, either concurrently or consecutively. bSulfinpyrazone, pegloticase, and pegloticase + methotrexate were not given during study period

Most prescribed medications for Veterans Affairs patients with uncontrolled gout in 2016 and 2022

Multivariable logistic regression models were used to determine if gout severity (uncontrolled vs. controlled) was associated with healthcare utilization and health outcomes at 12 months. The covariates were selected based on prior literature, which suggested differences in gout control based on these characteristics [2, 3, 7, 14], and included patient age (< 65 vs. ≥ 65 years), sex (male vs. female), diabetes with complications (presence vs. absence), and renal disease (presence vs. absence). Results reflect adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) (Table 4).

Patients with uncontrolled gout had more primary care visits (OR: 1.14, 1.08–1.20), podiatry visits (1.32, 1.30–1.35), rheumatology visits (2.93, 2.86–3.00), nephrology visits (2.05, 1.99–2.10), ER visits (1.73, 1.64–1.71), urgent care visits (1.47, 1.42–1.52), and hospital visits (1.30, 1.28–1.33), as well as experience more gout flares (3.10, 2.98–3.23), amputations (1.13, 1.00–1.28), and a higher mortality (1.17, 1.12–1.22). All reported values were statistically significant.

Younger patients (< 65 years) had more follow up (2.39, 2.25–2.54), primary care visits (OR: 2.03, 1.91–2.17), rheumatology visits (1.22, 1.19–1.25), nephrology visits (1.22, 1.18–1.26), urgent care visits (1.26, 1.21–1.31), ER visits (1.42, 1.40–1.45), gout flares (1.84, 1.77–1.91), amputations (1.30, 1.13–1.49), and a higher mortality (3.15, 2.93–3.38). Older patients (65 +) had more hospital visits (0.97, 0.95–0.99) and podiatry visits (0.91, 0.89–0.93). All reported values were statistically significant.

Men with uncontrolled gout, compared to women, were more likely to undergo amputation (OR: 2.82, 1.38–7.12), had more primary care visits (2.96, 2.56–3.40). Women were more likely to have rheumatology visits (0.51, 0.48–0.56), podiatry visits (0.71, 0.66–0.76), nephrology visits (0.60, 0.54–0.66), hospital visits (0.81, 0.75–0.87), and ER visits (0.75, 0.71–0.80). All reported values were statistically significant.

Renal disease was also associated with higher odds of amputation (OR: 2.05, 31.80–2.34) and more rheumatology visits (1.48, 1.45–1.52), nephrology visits (21.23, 20.6–21.93), urgent care visits (1.10, 1.05–1.14), and ER visits (1.67, 1.64–1.71). All reported values were statistically significant.

Finally, diabetes with complications was associated with higher odds of podiatry visits (4.36, 4.27–4.45), rheumatology visits (1.18, 1.15–1.22), nephrology visits (2.18, 2.12–2.24), ER visits (1.74, 1.71–1.78), urgent care visits (1.40, 1.33–1.46), hospital visits (2.16, 2.11–2.20), gout flares (1.16, 1.10–1.21), and amputations (9.92 (8.61–11.45). All reported values were statistically significant.

An alternate multivariable logistic regression model, Table 5, was used to determine if gout severity (uncontrolled vs. controlled) was associated with healthcare utilization and health outcomes at 12 months. For this analysis, more variables from Table 1 were included as covariates in the model. The overall conclusions were consistent for eight of ten dependent variables. Namely, patients with uncontrolled gout had more podiatry visits (1.23, 1.20–1.25), rheumatology visits (2.78, 2.71–2.85), nephrology visits (1.72, 1.67–1.77), ER visits (1.58, 1.55–1.61), urgent care visits (1.35, 1.30–1.40), and hospital visits (1.18, 1.15–1.21), as well as experienced more gout flares (2.84, 2.72–2.97) and a higher mortality (1.18, 1.12–1.25). Two of the dependent variables were no longer statistically significant in the alternate model: primary care visits (OR: 1.05, 0.98–1.13) and amputations (0.99, 0.86–1.13).

Supplementary Table S1 contains an alternate model (bivariate regression) to compare demographics for VA Patients with uncontrolled and controlled gout. All conclusions from the alternate model were consistent with those reported above.

The complete table of Table 5 can be found in the supplementary material in Table S2, with all estimates, odds ratios, and confidence intervals for all covariates.