Dr. Singh replies

To the Editor:

I appreciate the letter by Drs. Therán-León and Otero-Rueda¹ that further discusses the key issues from the editorial,² in depth. They raised 2 critical questions: (1) How can the care be improved from the current poor quality of care for long-term hyperuricemia management for gout in primary care to optimal gout care? (2) Who will provide the treat-to-target (T2T) approach with the use of urate-lowering therapy (ULT) in primary care, where the majority of patients with gout are managed? These are million-dollar questions.

The UK nurse-led program was phenomenally successful in managing gout.³ So, why was it so successful? The nurse-led program included a face-to-face nurse visit with the patient, educating the patient about gout and its management, providing them with a gout brochure, frequent laboratory monitoring to check serum urate levels, titration of the ULT dose to achieve T2T, and follow-up patient visits as frequently as needed (in-person or at-home visits, or phone calls), all completed by a trained nurse. Frequent serum urate testing and ULT titration helped patients to achieve T2T in gout, and, as a result, reduced the risk of gout flares, improved quality of life, and lowered the cost of care for gout.³ Such a program can directly address the quality-of-care gaps in gout by helping to achieve T2T in people with gout in a primary care setting.

Additional evidence from other chronic conditions further supports this concept. A recent systematic review of nurse-led intervention trials that included 22 trials concluded that nurse-led interventions, in particular face-to-face visits with nurses, were effective at improving medication adherence in chronic medical conditions.⁴ In a randomized trial, a nurse-led, household-based clinical practice model increased coronavirus disease 2019 (COVID-19) testing in an underserved, minoritized community, compared to the standard of care.⁵ Another systematic review that included 40 trials showed that nurse-led remote digital support interventions significantly improved self-management capacity, clinical health outcomes, healthcare resource use, and patient satisfaction with care.⁶ Most trials targeted diabetes or cardiovascular disease, and most used websites or mobile applications.⁶ In a systematic review that included 26 trials, nurse-led telerehabilitation programs were beneficial to patients with chronic disease in the community.⁷ Thus, evidence from trials supports the positive impact of nurse-led programs on medication adherence and other relevant clinical outcomes in chronic diseases, using a combination of platforms.

The UK nurse-led gout program meets all the principles of shared decision making, personalized medicine, and continuity of care. It also enables a medical team member to take ownership and help comanage patients with a chronic medical condition. A nurse or advanced practice provider (APP) can likely serve this role in a routine outpatient primary care practice. The UK nurse-led model in primary care³ is certainly practical and feasible in the UK and similar settings, and it follows the path of least resistance. Similar models, with some modifications, may also be practical for other countries and scenarios, as well as for other models of healthcare delivery.

Now that the evidence exists, how can we implement it in primary care? Implementation requires training, capacity, compensation, and interest from stakeholders (nurses and primary care providers). The healthcare systems must train nurses and APPs to manage chronic disease, as well as ensure enough capacity, and payers must compensate providers for these services.

How can a limited number of nurses reach thousands of patients with gout, coordinate the optimal use of ULT medications, and help them achieve T2T serum urate in gout? It remains to be seen whether nurse-led chronic disease management services such as these can be billed at levels that will incentivize practices and motivate primary care practitioners. Policymakers should make a case for these programs to payers since downstream expenses can be saved with such programs by avoiding emergency room visits and hospitalizations for acute gouty flares. Payers can start by offering incentives for a nurse-led, telemedicine-enabled gout management program for better disease outcomes. Since the nurse-led model was tested in the UK, payers may demand initial evidence in the US setting on a real-world platform with a pilot, before national implementation. This would be reasonable. The use of artificial intelligence (AI) should further enhance the scale-up ability of nurse-led programs, with the use of new tools, technology, and AI assistants.^8,9 In this new era of AI, a nurse-led gout program may finally become a reality.

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