To directly compare nurse–led care to standard general practitioner (GP) care of people with gout, 517 participants with acute gout in the previous year, identified from 56 local GP practices, were randomised to receive either one or the other type of care in a 2–year controlled trial.

After receiving full information about gout almost all participants in the nurse–led group wanted ULT. Comparing the nurse and GP groups at 2 years: 95% vs. 29% achieved a target serum uric acid (SUA) <360 mumol/L (primary outcome); 88% vs. 16% an SUA <300 mumol/; and the mean (±SD) SUA was 252±73 mumol/L vs. 418±106 mumol/L respectively (all three measures p<0.001).

In terms of the patients in the nurse and GP groups receiving treatment at 2 years, 97% vs. 54% were on ULT; with the mean (±SD) dose of allopurinol 470 (±140) vs. 240 (±107) mg/day respectively (again both measures p<0.001).

The mean (±SD) gout attack frequency during the 2nd year was 0.33 (±0.93) in the nurse vs. 0.94 (±2.03) in the GP group (p<0.001) and, at 2 years, tophi were present in 2.6% (reduced from 13.7%) vs. 9.6% (increased from 8.8%) respectively (p<002).

Although equivalent at baseline, there was a significantly better physical component score on the SF–36 health survey questionnaire among the nurse group at 2 years: mean (±SD) of 41.31 (±16.76) vs. 37.87 (±14.31); p<0.05.

"Patients in the nurse–led group did significantly better in terms of achieving their target uric acid level and excellent adherence to ULT," said lead author Professor Michael Doherty from University of Nottingham, UK. "Our findings confirm the importance of patient education in successful management of gout and reinforce the benefits of a 'treat–to–target' strategy to achieve significant improvements in patient–centred outcomes, such as gout attack frequency, reduction in tophi and quality of life. Compared to standard GP care, adopting additional nurse support is likely to be cost effective in the long–term and certainly merits further consideration," Professor Doherty concluded.

Despite increasing prevalence of gout in the UK, a variety of barriers result in suboptimal care with only 40% of gout patients receiving ULT, usually at a fixed dose without titration to an SUA target. Nurses successfully manage many chronic diseases in the community, and a previous preliminary "proof–of–concept" study in Nottingham, UK had shown that, when people with gout are fully informed and involved in management decisions, uptake of ULT is high, and subsequent adherence at one year under nurse–led care is excellent. The current larger randomised controlled trial confirmed these findings over a two year period.

Nurses in the current study were trained about gout and its management according to recommended best practice (EULAR and BSR guidelines) including providing full information, addressing illness perceptions, and involving patients in management decisions. GP follow up was based on the usual standard of care. Assessments were undertaken at 1 and 2 years. Analysis was intention to treat (with the last observation carried forward). The nurse (n=255) and GP (n=262) patient groups were well matched at baseline for mean age (62 vs. 64 years), sex (90% vs. 89% men), mean disease duration (11.6 vs. 12.7 years), mean gout attack frequency in prior year (4.2 vs. 3.8), presence of tophi (13.7% vs. 8.8%), mean serum uric acid (443 vs. 439 mumol/L), mean eGFR (71.5 v. 70.2) and use of ULT (40% v. 39%) (all p>0.05).

After 2 years, 22 (8.6%) compared to 54 (20.6%) of the participants had discontinued attending the nurse and GP groups (p<0.001), including 2 vs. 8 deaths respectively.