The implementation of a treat-to-target (T2T) approach has been widely recommended for achieving optimal outcomes in gout treatment, as substantiated by a wealth of compelling evidence. However, a paucity of knowledge exists regarding the barriers hindering effective T2T management in China. This study seeks to investigate the factors contributing to treatment failure within the context of the T2T strategy. A cross-sectional, multi-center investigation was conducted, involving the completion of electronic questionnaires by outpatients undergoing urate-lowering treatment for a duration exceeding 6 months. These questionnaires encompassed demographic information, disease-related conditions, comorbid conditions, and management. The study analyzed factors associated with serum uric acid levels exceeding 360 µmol/L, poor disease control, and poor medication adherence. A total of 425 valid questionnaires were collected, representing 90.8% of the patients. The T2T implementation rate was 26.82% (n = 114). Factors linked to serum uric acid levels surpassing 360 µmol/L included moderate medication adherence (odds ratio (OR) = 2.35; 95% confidence interval (CI) 1.17-4.77; P = .016), poor medication adherence (OR = 4.63; 95% CI 2.28-9.51; P < .001), and management by general practitioners (OR = 0.60; 95% CI 0.37-0.97; P = .036). The rate of well-controlled patients was 14.35% (n = 61). Predictors of not well controlled encompassed the presence of tophi (OR = 2.48; 95% CI 1.17-5.61; P = .023), general medication adherence (OR = 2.78; 95% CI 1.28-6.05; P = .009), poor medication adherence (OR = 6.23; 95% CI 2.68-14.77; P < .001), and poor patient's perception of gout (OR = 4.07; 95% CI 1.41-13.91; P = .015). A poor medication adherence rate of 55.29% (n = 235) was observed, with lower rates of poor medication adherence associated with the use of febuxostat (OR = 0.35; 95% CI 0.14-0.83; P = .02), uric acid levels exceeding 360 µmol/L (OR = 3.05; 95% CI 1.84-5.12; P = .00), moderate patient education (OR = 2.28; 95% CI 1.29-4.15; P = .01), moderate diet control (OR = 1.98; 95% CI 1.17-3.41; P = .01), and poor diet control (OR = 3.73; 95% CI 1.26-12.83; P = .02). The rate of T2T implementation in China is notably low among patients undergoing urate-lowering treatment of gout beyond 6 months. Importantly, medication adherence demonstrates a significant association with T2T outcomes.Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.