Development and Validation of an Emergency Department Electronic Medical Record Gout Flare Alert

Abstract

Objective Patients with acute gout are frequently treated in the emergency department (ED) and represent a typically underresourced and understudied population. A key limitation for gout research in the ED is the timely ability to identify acute gout patients. Our goal was to refine a multicriteria, electronic medical record alert for gout flares and to determine its diagnostic characteristics in the ED. Methods The gout flare alert used electronic medical record data from ED nursing notes and was triggered by the term ‘gout’ preceding past medical history in the chief complaint, the term ‘gout’ and a musculoskeletal problem in the chief complaint, or the term ‘gout’ in the problem list and a musculoskeletal chief complaint. We validated its diagnostic properties to assess presence/absence of gout through manual medical record review using adjudicated expert consensus as the gold standard. Results In January 2020, we analyzed 202 patient records from 2 university‐based EDs; from these records, 57 patients were identified by our gout flare alert, and 145 were identified by other means as potentially having an acute gout flare. The gout flare alert's positive predictive value was 47% (95% confidence interval [95% CI] 34–60%), negative predictive value was 94% (95% CI 90–98%), sensitivity was 75% (95% CI 61–89%), and specificity was 82% (95% CI 76–88%). The diagnostic properties were similar at both institutions. Conclusion Our multicomponent gout flare alert had reasonable sensitivity and specificity, albeit a modest positive predictive value. An electronic gout flare alert may help enable the conduct of gout research in the ED setting.

An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture

“…Our study was challenged by several modifiable barriers that warrant particular note, some of which were related to the COVID-19 pandemic (e.g., low enrollment rate since patients with falls avoided ED during the study period) and have been reported for other preventative care studies in the ED. 23 A major barrier to enrollment included the EMR alert “firing” on week days before 8 a.m. or after 5 p.m. (40%) or during weekends (25%) when ED research study staff were not available to approach the patient. Recruitment improved following the expansion of sites to include UAB – University ED, such that by the study conclusion, research assistants had screened approximately two-thirds of all potential participants.…”

“…First, using an approach we previously developed for patients presenting with gout flares in the ED, 23 we developed an EMR alert to identify patients with high-risk of fragility fracture or high-risk of fall in the ED. At our institution, upon initial triage in the ED, the chief complaint is recorded by nursing staff and entered in the EMR.…”

“…A limitation in studying these adults is deploying effective methods to identify them in real-time, an issue that we aimed to address in this study using a novel electronic medical record (EMR) alert, an approach which has been used effectively in other disease states for this purpose. 23–25 …”

A multi-step approach to develop a “storytelling” intervention to improve patient gout knowledge and improve outpatient follow-up

“…When recruiting our storytellers we strongly considered the demographic characteristics of the recipients of the eventual behavioral intervention. In particular, since the majority of patients with gout seen in our ED are African American [ 22 ], we sought to include compelling African American storytellers as strong motivators of behavior change via homophily.…”

“…In addition, significant disparities exist in gout care, with African Americans having a higher prevalence of gout but are less likely to receive quality gout care [ 21 ]. This is particularly relevant in our geographic region where a majority of patients with gout are African American [ 22 ]. Behavioral interventions focusing on gout self-management, including adherence to gout therapy and appropriate follow-up care, may represent the cornerstone of gout management [ 23 ].…”