VIENNA — To maintain gout in remission, nurses in a rheumatology service do better than doctors in implementing a straightforward treat-to-target (T2T) strategy, according to a randomized study that showed a consistent advantage across subgroups.
"Our study provides evidence that nurse-led therapy for gout leads to better uric acid control, which is an important consideration with the increasing incidence and the increasing costs of managing this condition," said Jesper W. Larsen, a registered nurse affiliated with the Department of Rheumatology at North Denmark Regional Hospital, Hjørring, Denmark. He presented the study at the European Alliance of Associations for Rheumatology (EULAR) 2024 Annual Meeting.
The advantage of nurse-led care was seen across every subgroup evaluated. Moreover, more patients in the nurse-led group than in the usual care group remained on urate-lowering therapy at the end of the 2-year study.
The optimal management of gout is based on the treatment goal of lowering serum uric acid (sUA) to below the physiologic level of 0.36 mmol/L (6 mg/dL), a strategy called T2T that is endorsed by both EULAR and the American College of Rheumatology.
"This target can be reached in most patients with commonly used therapies, including allopurinol, which is relatively inexpensive," Larsen said. Given that disease control and sustained remission are largely based on this target, he and his colleagues tested the hypothesis that nurses working in a rheumatology service could provide efficient and cost-effective care.
A total of 286 patients with gout defined by microscopy who were treated between 2015 and 2021 were enrolled in the study. Of these, 100 patients who had been enrolled before the introduction of nurse-led care received and were maintained on usual care, which generally included diagnosis by an orthopedist, an emergency room physician, or an internist, with subsequent treatment and follow-up with a general practitioner.
Of 186 patients treated after nurse-led care was implemented, 72 were transitioned to usual care, and the remaining 114 continued receiving nurse-led care over the next 2 years of follow-up. In the nurse-led care arm, nurses who specialized in rheumatology and were trained in gout management monitored a structured T2T strategy. They were available for consultation, provided patient education, and followed laboratory values, including sUA, which they used to adjust treatments.
Except in the case of complications, "there was no more contact with physicians" once care was transferred to the nurse, Larsen said. Most of the nurse management was based on sUA laboratory values and performed by telephone.
At 2 years, 112 patients in the nurse-led care group were compared with the 144 in the usual care group. Two of the 114 patients who entered the nurse-care cohort and 28 of the 172 in the usual care cohort died before the study ended.
At 2 years, the proportion of patients maintained at the target sUA was almost twice as great in the nurse-led arm (83% vs 44%). This was also true of patients aged 70 years or older (84% vs 45%), patients with tophi (60% vs 33%), and patients with sUA > 0.5 mmol/L at baseline (84% vs 44%). Nurse-led care also kept a greater proportion of patients at target who entered the study with an estimated glomerular filtration rate < 60 mL/min/1.73 m2 (84% vs 52%) or were taking diuretics (89% vs 52%). All differences reached statistical significance (P < .05).
The reason for the lower mortality at 2 years in the nurse-led group (4% vs 23%; P < .001) is unclear, according to Larsen. In addition to a selection bias that might have channeled patients with more severe disease to usual care, he and his coinvestigators are considering whether the lower rates of sUA control in the usual care group might have led to a higher rate of cardiovascular events.
Because of some baseline imbalances, a selection bias cannot be ruled out, but the imbalances did not uniformly favor nurse-led care. For example, the proportion of patients with diabetes (23% vs 13%) or a baseline cancer diagnosis (11% vs 5%) was higher in the nurse-led care group. The proportion of patients with atrial fibrillation (45% vs 35%) or on diuretics (47% vs 33%) at baseline was higher in the usual care group.
The median age of 69 years was the same in the two groups, although the nurse-led group included a higher proportion of men than women (86% vs 76%).
Within a T2T strategy, nurses focused on reaching the target might do a better job than physicians in consistently monitoring and adjusting therapies as needed, but Larsen also speculated that nurses might offer a more collaborative approach and provide greater support through patient education and regular telephone contact.
Potential Advantages of Nurse-Led Care
Clinicians concerned about nurses missing nuances in disease progression or being slow to recognize complications might be surprised to learn about the advantage of nurse-led care, but Mwidimi Ndosi, PhD, an associate professor in rheumatology nursing at the University of the West of England Bristol, was not.
"There is quite a large literature to show that nursing care is often superior to physician-led patient management in the appropriate circumstances," Ndosi said. In this specific instance of gout management, he said that the treatment target is clear, and nurses are often able to devote more time to a specific goal, like T2T, than clinicians balancing more priorities.
"In this trial, the care was administered by nurse specialists who presumably are skilled in this disease and know their limitations if a consultation with a physician is needed," he said.
Ndosi, like Larsen, considers it likely that nurse-led programs for a T2T gout protocol will be implemented elsewhere. Ndosi pointed out that patients who are concerned about the quality of nurse-led care are generally convinced of its merits over time.
Because of factors such as nurses' ability to spend more clinical time with patients and greater willingness to engage in resolving obstacles to self-care, compared with physicians, "there are many studies to show that patients are often more satisfied with care provided by nurses," he said.
Larsen and Ndosi reported no potential conflicts of interest.
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