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

Doherty, Michael; Jenkins, Wendy; Richardson, Helen; Sarmanova, Aliya; Abhishek, Abhishek; Ashton, Deborah; Barclay, Christine; Doherty, Sally; Duley, Leila; Hatton, Rachael; Rees, Frances; Stevenson, Matthew; Zhang, Weiya

Abstract

Background: In the UK gout management is suboptimal, only 40% of patients receiving urate-lowering therapy (ULT), usually without titration to a target serum urate (SU) level. Nurses successfully manage many diseases in primary care. This trial compared nurse-led care to usual (general practitioner-led) care for people with gout.

Methods: Research nurses were trained in best practice management of gout, including full individualised patient information and engagement in shared decision-making. Adults experiencing a gout flare in the previous year were randomised (1:1) to nurse-led or continuing usual care in the community. Assessments were at baseline, one and two years. The primary outcome was percentage of participants achieving SUA [less than] 360μmol/L at two years. Secondary outcomes were flare frequency in year two, presence of tophi, quality of life (SF-36, Gout Impact Scale) and cost per quality-adjusted life year (QALY) gained. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated based on intention to treat with multiple imputation.

Findings: Of 517 participants, 255 were assigned nurse-led care and 262 usual care. Nurse-led care associated with high uptake and adherence to ULT, and comparing nurse-led to usual care groups at two years 95% versus 30% had SU [less than] 360μmol/L (RR 3∙18, 95%CI 2∙42 to 4∙18, p [less than] 0∙0001). At two years all patient-centred clinical outcomes were statistically in favour of the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at two years, and modelled to be £286 at three years and cost-saving at five years.

Interpretation: Nurse-led gout care is clinically effective and cost-effective compared to usual care. These findings illustrate the benefits of patient education and engagement in gout management, and reaffirm the importance of a treat-to-target ULT strategy to improve patient-centred outcomes.

Citation

Doherty, M., Jenkins, W., Richardson, H., Sarmanova, A., Abhishek, A., Ashton, D., …Zhang, W. (2018). Efficacy and cost-effectiveness of nurse-lead 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, 392(10156), 1403-1412. https://doi.org/10.1016/S0140-6736%2818%2932158-5

• Journal Article Type: Article
• Acceptance Date: Aug 30, 2018
• Online Publication Date: Oct 20, 2018
• Publication Date: Oct 20, 2018
• Deposit Date: Oct 16, 2018
• Publicly Available Date: Oct 22, 2018
• Journal: Lancet
• Print ISSN: 0140-6736
• Electronic ISSN: 1474-547X
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 392
• Issue: 10156
• Pages: 1403-1412
• DOI: https://doi.org/10.1016/S0140-6736%2818%2932158-5
• Public URL: https://nottingham-repository.worktribe.com/output/1168915
• Publisher URL: https://www.sciencedirect.com/science/article/pii/S0140673618321585?via%3Dihub
• Additional Information: This article is maintained by: Elsevier; Article Title: 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; Journal Title: The Lancet; CrossRef DOI link to publisher maintained version: https://doi.org/10.1016/S0140-6736(18)32158-5; CrossRef DOI link to the associated document: https://doi.org/10.1016/S0140-6736(18)32415-2; Content Type: article; Copyright: © 2018 The Author(s). Published by Elsevier Ltd.
• Contract Date: Oct 22, 2018