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

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

doi:10.1016/S0140-6736(18)32158-5

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

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

Bristol Medical School (PHS)

Research output: Contribution to journal › Article (Academic Journal) › peer-review

335 Citations (Scopus)

384 Downloads (Pure)

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.

Original language	English
Pages (from-to)	1403-1412
Number of pages	10
Journal	Lancet
Volume	392
Issue number	10156
Early online date	18 Oct 2018
DOIs	https://doi.org/10.1016/S0140-6736(18)32158-5
Publication status	Published - 20 Oct 2018

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This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

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Doherty, M., Jenkins, W., Richardson, H., Sarmanova, A., Abhishek, A., Ashton, D., Barclay, C., Doherty, S., Duley, L., Hatton, R., Rees, F., Stevenson, M., & Zhang, W. (2018). 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, 392(10156), 1403-1412. https://doi.org/10.1016/S0140-6736(18)32158-5

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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",

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.",

author = "Michael Doherty and Wendy Jenkins and Helen Richardson and Aliya Sarmanova and Abhishek Abhishek and Deborah Ashton and Christine Barclay and Sally Doherty and Lelia Duley and Rachael Hatton and Frances Rees and Matthew Stevenson and Weiya Zhang",

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Doherty, M, Jenkins, W, Richardson, H, Sarmanova, A, Abhishek, A, Ashton, D, Barclay, C, Doherty, S, Duley, L, Hatton, R, Rees, F, Stevenson, M & Zhang, W 2018, '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, vol. 392, no. 10156, pp. 1403-1412. https://doi.org/10.1016/S0140-6736(18)32158-5

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. / Doherty, Michael; Jenkins, Wendy; Richardson, Helen et al.
In: Lancet, Vol. 392, No. 10156, 20.10.2018, p. 1403-1412.

Research output: Contribution to journal › Article (Academic Journal) › peer-review

TY - JOUR

T1 - 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

T2 - a randomised controlled trial

AU - Doherty, Michael

AU - Jenkins, Wendy

AU - Richardson, Helen

AU - Sarmanova, Aliya

AU - Abhishek, Abhishek

AU - Ashton, Deborah

AU - Barclay, Christine

AU - Doherty, Sally

AU - Duley, Lelia

AU - Hatton, Rachael

AU - Rees, Frances

AU - Stevenson, Matthew

AU - Zhang, Weiya

PY - 2018/10/20

Y1 - 2018/10/20

N2 - 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.

AB - 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.

U2 - 10.1016/S0140-6736(18)32158-5

DO - 10.1016/S0140-6736(18)32158-5

M3 - Article (Academic Journal)

C2 - 30343856

SN - 0140-6736

VL - 392

SP - 1403

EP - 1412

JO - Lancet

JF - Lancet

IS - 10156

ER -

Doherty M, Jenkins W, Richardson H, Sarmanova A, Abhishek A, Ashton D et al. 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. Epub 2018 Oct 18. doi: 10.1016/S0140-6736(18)32158-5

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

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