Background Despite increasing prevalence of gout in the UK (1), a variety of barriers result in suboptimal care (1,2) with only 40% of gout patients receiving urate-lowering therapy (ULT), usually at fixed dose without titration to a serum uric acid (SUA) target (1,2). Nurses successfully manage many chronic diseases in the community, and we have shown that when people with gout are fully informed and involved in management decisions uptake of ULT is high and subsequent adherence under nurse-led care is excellent (3).
Objectives To directly compare nurse-led care to general practitioner (GP) care of people with gout in a 2 year randomised controlled trial (NIHR CRN Portfolio No.12943)
Methods 517 participants with acute gout in the previous year were identified from 56 local GP practices and randomised to nurse-led or continuing GP care. The nurses were trained about gout and its management according to recommended best practice (EULAR and BSR guidelines) involving full information, addressing illness perceptions, and involving patients in management decisions. Assessments were undertaken at 1 and 2 years. Analysis was intention to treat (last observation carried forward).
Results Nurse (n=255) and GP (n=262) groups were well matched at baseline for mean age (62 v 64yrs), sex (90% v 89% men), mean disease duration (11.6 v 12.7yrs), mean gout attack frequency in prior year (4.2 v. 3.8), tophi (13.7% v. 8.8%), mean SUA (443 v. 439 μmol/L), mean eGFR (71.5 v. 70.2) and ULT use (40% v. 39%) (all p>0.05). By 2yrs, 22 (8.6%) and 54 (20.6%) participants had discontinued the nurse and GP groups (p<0.001), including 2 v. 8 deaths respectively. Comparing nurse and GP groups at 2yrs: 95% v. 29% had SUA <360 μmol/L (primary outcome); 88% v. 16% had SUA <300 μmol/L; mean (SD) SUA was 252±73 v. 418±106; 97% v. 54% were on ULT; and mean (SD) dose of allopurinol was 470 (140) v. 240 (107) mg/day (all p<0.001). Mean (SD) attack frequency during the 2nd year was 0.33 (0.93) in the nurse v. 0.94 (2.03) in the GP group (p<0.001), and at 2yrs tophi were present in 2.6% (reduced) v. 9.6% respectively (p<002). Although equivalent at baseline, mean (SD) SF-36 norm-based physical component scores were better at 2yrs in the nurse group (41.31 (16.76) v. 37.87 (14.31); p<0.05).
Conclusions Nurse-led care of people with gout in the UK community can result in high uptake and excellent adherence to ULT over a 2yr period, achievement of target SUA in >9/10 cases and consequent improvements in patient-centred outcomes and quality of life. This study reinforces the benefits of “treat-to-target”. Compared to standard GP care this model is likely to be cost effective long-term and merits further consideration.
Doherty M. et al. Ann Rheum Dis 2012;71:1765–70.
Kuo C-F. et al. Ann Rheum Dis 2015;74:661–7.
Rees F. et al. Ann Rheum Dis 2013:72:826–30.
Acknowledgements Arthritis Research UK (Award No.19703) funded this study.
Disclosure of Interest M. Doherty Grant/research support from: AstraZeneca, Consultant for: AstraZeneca, Grunenthal, Mallinckrodt and Roche, W. Jenkins: None declared, H. Richardson: None declared, A. Abhishek Grant/research support from: AstraZeneca, D. Ashton: None declared, C. Barclay: None declared, L. Duley: None declared, H. Jones: None declared, M. Santarelli: None declared, A. Sarmanova: None declared, M. Stevenson: None declared, W. Zhang Consultant for: AstraZeneca and Grunenthal