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

Lancet. 2018 Oct 20;392(10156):1403-1412. doi: 10.1016/S0140-6736(18)32158-5.

Abstract

Background: In 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.

Methods: Research 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.

Findings: 517 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.

Interpretation: Nurse-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.

Funding: Arthritis Research UK.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Allopurinol / administration & dosage
  • Cost-Benefit Analysis
  • Disease Management
  • England
  • Female
  • General Practice / methods
  • Gout / drug therapy
  • Gout / economics*
  • Gout / nursing*
  • Gout Suppressants / administration & dosage
  • Humans
  • Longitudinal Studies
  • Male
  • Medication Adherence / statistics & numerical data
  • Middle Aged
  • Practice Patterns, Nurses'*
  • Quality-Adjusted Life Years*
  • Surveys and Questionnaires
  • Uric Acid / blood*

Substances

  • Gout Suppressants
  • Uric Acid
  • Allopurinol

Associated data

  • ClinicalTrials.gov/NCT01477346