Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial

Abstract

SummaryBackgroundIn the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community.MethodsResearch nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346.Findings517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42–4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years.InterpretationNurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes.FundingArthritis Research UK.

Management of patients with gout and achievement of target serum urate levels at a tertiary rheumatology service in Australia

“…The larger subsequent follow on study (n = 517) showed that 95% of patients with nurse led care and only 30% of those managed by their GP reached their SU target. 17 Pharmacist-led models have also shown some potential, with a randomised control study in California showing that over 26 weeks 35% of patients reached target SU when managed solely by a clinical pharmacist, while only 13% reached target when managed by their usual primary physician, 18 and another study set in a community rheumatology clinic showing that 82% of patients that underwent management and education by a clinical pharmacist reached target SU over a mean of 48 weeks. 19 Given these positive findings, further research into designing effective alternative models of care, and feasibility and cost-effectiveness of training nurses and pharmacists in gout care would be useful.…”

Review of gout clinic in a tertiary hospital setting

“…16 In TQEH Gout Clinic, the aim is to see patients every month until target serum urate is reached. 18,19 This clinic also provided a popular platform for teaching of physician trainees and medical students, and an educative information source for general practitioners. We have shown that scheduled visits at a rheumatology gout clinic resulted in successful reduction in serum urate levels, and that patients seen monthly reached target significantly faster.…”

“…Although we did not measure cost-effectiveness, some studies suggested that treating to target can be cost-effective as this prevents loss of income, emergency room presentation and hospitalisation. 18,19 This clinic also provided a popular platform for teaching of physician trainees and medical students, and an educative information source for general practitioners. It was identified that despite the specialised clinic, the rate of withdrawal was considerable.…”

The Supply of Rheumatology Specialist Care in Real Life. Results of a Nationwide Survey and Analysis of Supply and Needs

“…In addition, incorporation of Health professionals (HP) in medical information, treatment and surveillance of patients with inflammatory rheumatic diseases will improve rheumatology care and, indirectly, possibly reduce the need for rheumatologists. There is data to show that, at least in gout, nurses can be much better at providing T2T (4) treatment than GPs (16). Most of the rheumatology units work already together with qualified HPs.…”