Nurse-led gout care doubles rate of patients achieving target urate, improves continuance
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Key takeaways:
- Patients in a nurse-led gout care program achieved target plasma urate levels at twice the rate of a control group.
- More patients in the nurse-led group continued treatment at 2 years.
A nurse-led gout care program nearly doubled the rate of patients achieving low plasma urate levels and resulted in greater continuance of urate-lowering therapy vs. general practice care, according to data published in RMD Open.
“Despite the clear recommendations for urate-lowering therapy in patients with established gout, studies in both primary and secondary care have revealed that less than half of the patients receive ULT, and when prescribed, the doses are often fixed without appropriate titration to achieve target plasma urate concentrations,” Claus Rasmussen, MD, of the North Denmark Regional Hospital in Hjorring, Denmark, and colleagues wrote. “Additionally, treatment adherence has been shown [to be] poor.”
To follow up on a previous randomized assessment in which nurse-led gout care outperformed that from general practitioners, Rasmussen and colleagues conducted a real-life, prospective cohort study. Specifically, the researchers set up a nurse-led gout clinic in June 2017 at the North Denmark Regional Hospital and tracked patients’ outcomes over 2 years, including their transition to care from general practice.
The cohort included 114 patients referred to a year of nurse-led care, followed by a year of care from a general practitioner. The nurse-led care consisted of a structured treatment plan featuring eight scheduled contacts over 1 year, a patient leaflet, telephone contact, allopurinol titration and lab monitoring. Meanwhile, 172 patients underwent usual care by physicians in general practice, rheumatology and other departments.
The primary outcome was the achievement of a target plasma urate level of 0.36 mmol/L or less 2 years after diagnosis. Continuation of treatment at 2 years was additionally analyzed as a secondary outcome. Results of patients in the nurse-led care group were compared with the control group of patients who underwent usual care.
According to the researchers, 83% of patients who received nurse-led care achieved target plasma urate levels vs. 44% in the usual-care group. Urate-lowering therapy was continued at 2 years by 98% of patients in the nurse-led care group, compared with 73% of those receiving usual care.
On average, the nurse-led care program consisted of two visits and three telephone contacts across 336 days. At the last visit, patients received a letter for their general practitioner outlining their treatment plan. The transfer process appeared to be “effective,” as at 2 years, according to the researchers. “Nearly all patients had been cared for the second year” in general practice, they wrote.
“This study strongly reaffirms the importance of education and engagement of patients in disease management, the usefulness of a treat-to-target strategy and collaborative involvement of [general practitioners] in long-term care,” Rasmussen and colleagues wrote. “Our study demonstrates that a low-cost, nurse-led gout clinic, primarily based on telephone interventions for 1 year, can be highly successful in achieving a clinically relevant reduction in [plasma urate] levels. This reduction significantly decreases the risk of disease progression, complications and potentially even mortality rates.
“As health care costs continue to rise, coupled with an increasing incidence of gout and physician shortages, there is a growing need for more efficient strategies to manage common yet costly diseases,” they added. “Given the effectiveness and affordability of treatments like allopurinol, nurse-led care initiated in a rheumatology clinic emerges as a promising avenue.”
Perspective
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David E. Bacha, MD, FACP, FACR
What can be done to optimize the treatment of gout and patients’ adherence to treatment? The authors of the article would suggest that nurse-led clinics dedicated to the treatment of gout may provide a potential answer to this question. The nurse-led model highlighted in this article incorporates a treat-to-target approach to the management of gout combined with education and telephone contacts.
Gaps in gout care have plagued both rheumatologists and primary care physicians in clinical practice. The 2020 American College of Rheumatology guidelines for the management of gout recommend a treat-to-target strategy using urate lowering therapy to achieve a serum uric acid of less than 6 mg/dl. Despite these recommendations, a treat-to-target strategy has not been completely embraced and incorporated into practice by all clinicians.
Patient adherence to urate lowering therapy is also problematic. Patients with gout who start urate lowering therapy commonly discontinue or are nonadherent to ongoing treatment. Reasons for nonadherence vary, but it ultimately contributes to the inadequate or suboptimal treatment of gout patients.
Pharmacist-led, nurse-led and rheumatology assisted gout services are interventions that have been reported to improve patient adherence to urate lowering therapy. Patient education and telephone reminders are key components to these strategies. Education of gout patients can reduce some of the barriers to the optimal management of gout.
Nurse-led clinics for gout treatment are not a new tactic. However, this real-world strategy has been shown to be effective in improving not only the treatment of gout, but also patient adherence to urate lowering therapy. Additional options to improve the treatment of gout and patient adherence, such as nurse-led clinics, are needed and welcome.
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