medwireNews: Nurse-led care involving patient education and engagement increases the likelihood of achieving target serum urate levels among individuals with gout, findings from a UK randomized controlled trial suggest.
As reported in The Lancet, Michael Doherty (City Hospital, Nottingham) and fellow researchers randomly assigned 517 patients who had experienced a gout flare in the previous year to receive 2 years of individualized nurse-led care with allopurinol (100 mg/day followed by dose increases of 100 mg every 3–4 weeks according to serum urate concentrations) recommended as the first-line treatment, or to receive usual care led by their primary care physician.
“The key differences from usual care in the nurse-led approach in this study were the time spent explaining gout and making the explanations individualised and easy to understand, addressing illness perceptions, and involving patients in shared decision making,” explain Doherty and colleagues.
At the 2-year follow-up, 95% of participants in the nurse-led group achieved a serum urate level below 360 µmol/L compared with just 30% of those in the usual care group, translating into a significant risk ratio (RR) of 3.18.
The researchers report that “a similar difference” was seen at the 1-year follow-up, and average serum urate concentrations were significantly lower in patients receiving nurse-led compared with usual care at both 1 and 2 years (250.56 vs 427.87 µmol/L and 251.52 vs 421.13 µmol/L, respectively).
Moreover, the use of urate-lowering therapy (ULT) increased from baseline to years 1 and 2 in both groups, but a significantly higher proportion of patients in the nurse-led group were taking ULT at both follow-up times, at 97% and 96% versus 47% and 56% in the usual care group, respectively. At baseline, approximately 40% of patients in both groups were taking ULT.
Patients receiving nurse-led care also experienced significantly fewer flares and tophi at 2 years on average, as well as significantly greater improvements in self-reported physical health, than those given usual care.
Doherty and colleagues calculated that the cost of the nurse-led intervention per quality-adjusted life–year gained was £ 5066 (US$ 6598; € 5764) at 2 years, which “was far below” the threshold of £ 20,000 ($ 26,048; € 22,755) as recommended by the UK National Institute for Health and Care Excellence, and projected that the intervention would be cost-saving after 5 years.
Writing in an accompanying commentary, Tuhina Neogi (Boston University School of Medicine, Massachusetts, USA) and Nicola Dalbeth (University of Auckland, New Zealand) say that these findings “show a path forward for improved gout outcomes, demonstrating a package of care that leads to sustained adherence and clinical benefits.”
They add that “[h]ighly efficacious and cost-effective gout management can be readily achieved by educating and spending time with patients.”
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