1.1.4.1. Included studies

No relevant clinical studies comparing follow-up care strategies were identified.

See also the study selection flow chart in Appendix C.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G

Economic

• No relevant economic evaluations were identified.

1.1.11.1. The outcomes that matter most

The committee considered the following outcomes as important for decision making: health-related quality of life (e.g. as described by SF-36, Gout Assessment Questionnaire (GAQ) and the Gout Impact Scale (GIS) or other validated gout-specific HRQoL measures, frequency of flares, patient global assessment of treatment success (response to treatment) (e.g. Likert scales, visual analogue scales (VAS), numerical ratings scales (NRS)), proportion of people with gout using ULT, patient awareness of their condition/treatment, serum urate levels, admissions (hospital and A&E/urgent care) and GP visits.

The committee considered the impact on the patient’s health-related quality of life to be particularly important for this question because the aim of providing follow-up is to improve quality of care for the patient by increasing awareness of their condition and treatments available to prevent another flare in the future. Outcomes reporting whether follow-up would improve the person’s serum urate levels or made any impact on admissions or frequency of G.P appointments after flares would also aid the committee’s decision making.

To help guide recommendations the committee were interested in the frequency and duration of follow-up reported and decided to categorise time-points reported in the included studies by short-term (less than three months), medium-term (three to 12 months) and long-term (more than 12 months).

1.1.11.2. The quality of the evidence

No evidence was identified for this question. The committee were particularly interested in evidence that addressed different forms of follow-up strategies, including the frequency and duration of follow-up, who should provide it and in which setting. The committee therefore agreed to make a consensus recommendation based on their clinical experience.

Given the lack of evidence and the importance of this area of practice the committee agreed to make a research recommendation on what is the clinical and cost-effectiveness and acceptability of different approaches of follow-up after a gout flare including provision of information? The committee acknowledged provision of information on self-management and prevention of flares was variable, and further research would facilitate the optimum timing and delivery of information.

1.1.11.3. Benefits and harms

The committee discussed that in current practice offering a follow-up appointment to people after a gout flare is variable and it would be more typical for any follow-up to be initiated by the patient themselves. The committee agreed that whether a follow-up appointment was offered or not was often dependent on the health care practitioner’s knowledge of gout and gout flares. The committee considered that making a specific recommendation for follow up following a gout flare was helpful as this will promote practitioners and patients understanding of the long-term nature of gout and the need for proper evaluation of a patient who presents with a gout flare. A gout flare can be very painful and distressing and the immediate requirement is for appropriate pain relief. A follow up appointment allows an opportunity to provide information, make a more comprehensive assessment of the person’s co-morbidities and explore the person’s concerns and expectations. The committee considered these advantages would outweigh any costs associated with follow up. Many people also self-manage gout and consult infrequently so presentation with a flare is an opportunity to review understanding and optimise care.

The committee considered that a follow-up appointment would enable the clinician to provide the person with information about gout and how to reduce the risk of future flares. This could include a discussion about lifestyle factors such as diet and exercise and how people can self-manage flares if they occur again using pharmacological and non-pharmacological methods. The committee noted it would be an optimum time for a serum urate level measurement to be taken, and a review of medication including discussion of the possible benefits of long-term urate lowering therapy (ULT). This is currently under-prescribed (31.8% of people with gout are currently prescribed ULT)⁶ and committee experience is that people have many pre-conceptions about gout so a recent flare is a good opportunity to provide information about short and long term issues including the potential use of ULT. Assessment of co-morbidities is particularly important both to assess any comorbidities that could impact on gout and how it is treated, such as cardiovascular risk factors or renal function. The committee noted CKD as a significant risk factor as the prevalence of CKD is recognised to be higher in people with gout. The committee agreed all these elements should be considered by the health professional when following up a person who has had a flare and included these in the recommendation.

The committee discussed when a follow-up appointment should take place and agreed that when a person is in pain it is hard to take in any information, therefore the optimum time would be after the flare has resolved. The committee discussed the time-efficiency of arranging testing of serum urate levels before a follow-up appointment took place, because having the results at the time of the appointment would provide an opportunity to discuss with the person about their serum urate level, treatments and self-managing the condition. The committee concluded the logistics of arranging this would not be practical but agreed the appointment should take place after a person’s flare has settled and included this within the recommendation.

The review question was not only looking at whether follow-up was clinically and cost-effective but also specifically which follow-up strategies would be most effective, including which frequency and duration of follow-up, which healthcare professionals should lead the follow-up and in what settings (community versus secondary/hospital-based care). As no evidence was found, the committee decided to include a research recommendation to investigate the clinical and cost-effectiveness and acceptability of different approaches of follow-up for gout flares.

Overall, the committee agreed that there were no harms in following-up a person who has had an acute gout flare. Based on their clinical experience they agreed there were substantial benefits to be gained if these measures were put in place to ensure people were receiving optimum medication and provided with information on how best to self-manage their gout, which would lead to improvements in the overall health of the person and help prevent further flares. In the long-term this could also reduce the number of GP appointments made. How follow up is organised could be negotiated with individual people so that some follow up could happen by telephone or in person.

1.1.11.4. Cost effectiveness and resource use

No published health economic evidence was identified for this review question. Unit costs associated with follow-up appointments following a gout flare were presented to the committee to aid consideration of cost-effectiveness. The unit cost of a primary care practice nurse was £42 per hour and the cost per 9.22 min consultation with a GP was £37. In addition, the costs of blood tests (excluding the time to take the blood) were presented and estimated to be between £3 and £4.

In current practice, generally little-to-no follow-up is offered to people after a gout flare. However, the committee noted that follow-up after an initial gout flare provides an opportunity for health care professionals to assess and review a person’s medication or initiate ULT. In addition, follow-up appointments provide clinicians the opportunity to provide a person with gout additional information such as, diet and lifestyle advice and information on how to reduce the risk of future flares. Although no clinical or health economic evidence was identified for this review question the committee concluded follow-up appointments after an initial flare would likely result in people experiencing a higher health-related quality of life in the long-term as people would likely initiate ULT sooner compared to what is currently observed in clinical practice. Therefore, ultimately people would experience fewer flares by achieving target serum urate levels sooner as a result of initiating ULT.

The committee acknowledged it may not be appropriate for all people to initiate ULT after an initial gout flare but providing people information about gout and the best course of treatment dependent on the severity of a person’s gout would result in better health outcomes for people. The committee noted that in current practice a high proportion of people with gout may only ever seek treatment with a GP once because they are not fully informed of the treatment options available to them. As a result of follow-up appointments people with gout will be better equipped to manage their gout flares as they will have been provided information on the preventative measures people can take to minimise their chances or recurrent gout flares.

Overall, the committee discussed that the benefits and downstream cost savings associated with follow-up appointments would outweigh the costs of follow-up appointments. The committee acknowledged that one follow-up appointment would cost between £10.50 (assuming 15 minutes of nurse time) and £37 dependent on the health care professional conducting the appointment. The cost of a gout flare is estimated to be £27.19 – £55.60 (See Evidence review G: Which ULTs). Based on their clinical experience, the committee concluded the care and information provided to people in a follow-up appointment after a gout flare could prevent two flares, on average, over a person’s lifetime and therefore be cost saving. To put this into context a trial by Doherty et al 2018³ found that in the usual care arm, which is considered by the committee to be a conservative representation of people with gout in current practice, 80% and 35% had two or more and four or more flares in the past year respectively. People will also experience improved quality of life from experiencing fewer flares which the committee noted are very painful and can sometimes be debilitating. Overall, as no clinical or health economic evidence was identified for this review question, the committee made a consensus recommendation to consider follow-up after a gout flare.

If implemented, this recommendation is likely to be a change in practice for many and will affect a large proportion of the gout population. However, the committee agreed that it is likely that this recommendation would be cost saving or at least cost neutral in terms of resource impact, as a follow up appointment may prevent up to two flares over a lifetime.

1.1.11.5. Other factors the committee took into account

The committee agreed that it would be appropriate to cross refer to the NICE guideline Medicines adherence (CG76) and Shared decision making (ng197) when reviewing a person’s medication for gout and having a discussion with the person about considering urate lowering therapies and the possibility of flares when initiating treatment. The committee agreed cross reference should also be made to the Chronic Kidney Disease in adults (CG182) and Cardiovascular disease risk assessment (CG 181) for recommendations on risk assessment and managing medicines in these populations.